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ObjectivesCOVID-19 presents a risk for delays to stroke treatment. We examined how COVID-19 affected stroke response times.MethodsA literature search was conducted to identify articles covering stroke during COVID-19 that included time metrics data pre- and post-pandemic. For each outcome, pooled relative change from baseline and 95% CI were calculated using random-effects models. Heterogeneity was explored through subgroup analyses comparing comprehensive stroke centers (CSCs) to non-CSCs.Results38 included studies reported on 6109 patients during COVID-19 and 14 637 patients during the pre-COVID period. Pooled increases of 20.9% (95% CI 5.8% to 36.1%) in last-known-well (LKW) to arrival times, 1.2% (−2.9% to 5.3%) in door-to-imaging (DTI), 0.8% (–2.9% to 4.5%) in door-to-needle (DTN), 2.8% (−5.0% to 10.6%) in door-to-groin (DTG), and 19.7% (11.1% to 28.2%) in door-to-reperfusion (DTR) times were observed during COVID-19. At CSCs, LKW increased by 24.0% (−0.3% to 48.2%), DTI increased by 1.6% (−3.0% to 6.1%), DTN increased by 3.6% (1.2% to 6.0%), DTG increased by 4.6% (−5.9% to 15.1%), and DTR increased by 21.2% (12.3% to 30.1%). At non-CSCs, LKW increased by 12.4% (−1.0% to 25.7%), DTI increased by 0.2% (−2.0% to 2.4%), DTN decreased by −4.6% (−11.9% to 2.7%), DTG decreased by −0.6% (−8.3% to 7.1%), and DTR increased by 0.5% (−31.0% to 32.0%). The increases during COVID-19 in LKW (p=0.01) and DTR (p=0.00) were statistically significant, as was the difference in DTN delays between CSCs and non-CSCs (p=0.04).ConclusionsFactors during COVID-19 resulted in significantly delayed LKW and DTR, and mild delays in DTI, DTN, and DTG. CSCs experience more pronounced delays than non-CSCs.

Seizures are the second most common presenting symptom of cerebral arteriovenous malformations (AVMs). Evidence supporting different treatment modalities is continuously evolving and it remains unclear which modality offers better seizure outcomes.To compare various interventional treatment modalities (i.e., microsurgery, radiosurgery, endovascular embolization, or multimodality treatment), regarding outcomes in AVM-associated epilepsy.PubMed, Embase, and Web of Science were searched on December 31, 2020 for studies that evaluated outcomes in patients with AVM-associated epilepsy after undergoing different treatment modalities. Pooled analysis was performed using a random-effects model and stratified by different modalities.Forty-nine studies including 2668 patients were included. Interventional management was associated with a 56.0% probability of seizure freedom and a 73.0% probability of seizure improvement. The probability of discontinuing antiepileptic drugs was estimated at 38.0%. The stratified analysis showed that microsurgery was associated with a higher probability of seizure freedom and seizure improvement than was radiosurgery, endovascular, or multimodality treatment. The probability of antiepileptic drug cessation was also higher after microsurgery compared with radiation therapy; however, only clinical but not statistical significance could be inferred because of the lack of comparative analyses.Interventional management of AVM-related epilepsy was associated with seizure freedom and seizure improvement in 56% and 73% of cases. Microsurgery seemed to be associated with a higher incidence of seizure freedom and seizure improvement than did other modalities. Future well-designed comparative studies are needed to draw definitive conclusions regarding each modality.

Background and ObjectivesWhile somatic mutations have been well-studied in cancer, their roles in other complex traits are much less understood. Our goal is to identify somatic variants that may contribute to the formation of saccular cerebral aneurysms.MethodsWe performed whole-exome sequencing on aneurysm tissues and paired peripheral blood. RNA sequencing and the CRISPR/Cas9 system were then used to perform functional validation of our results.ResultsSomatic variants involved in supervillin (SVIL) or its regulation were found in 17% of aneurysm tissues. In the presence of a mutation in theSVILgene, the expression level of SVIL was downregulated in the aneurysm tissue compared with normal control vessels. Downstream signaling pathways that were induced by knockdown ofSVILvia the CRISPR/Cas9 system in vascular smooth muscle cells (vSMCs) were determined by evaluating changes in gene expression and protein kinase phosphorylation. We found thatSVILregulated the phenotypic modulation of vSMCs to the synthetic phenotype via Krüppel-like factor 4 and platelet-derived growth factor and affected cell migration of vSMCs via the RhoA/ROCK pathway.DiscussionWe propose that somatic variants form a novel mechanism for the development of cerebral aneurysms. Specifically, somatic variants inSVILresult in the phenotypic modulation of vSMCs, which increases the susceptibility to aneurysm formation. This finding suggests a new avenue for the therapeutic intervention and prevention of cerebral aneurysms.

BackgroundCatheter retention and difficulty in retrieval have been observed during embolization of brain arteriovenous malformations (bAVMs) with the Onyx liquid embolic system (Onyx). The Apollo Onyx delivery microcatheter (Apollo) is a single lumen catheter designed for controlled delivery of Onyx into the neurovasculature, with a detachable distal tip to aid catheter retrieval. This study evaluates the safety of the Apollo for delivery of Onyx during embolization of bAVMs.MethodsThis was a prospective, non-randomized, single-arm, multicenter, post-market study of patients with a bAVM who underwent Onyx embolization with the Apollo between May 2015 and February 2018. The primary endpoint was any catheter-related adverse event (AE) at 30 days, such as unintentional tip detachment or malfunction with clinical sequelae, or retained catheter. Procedure-related AEs (untoward medical occurrence, disease, injury, or clinical signs) and serious AEs (life threatening illness or injury, permanent physiological impairment, hospitalization, or requiring intervention) were also recorded.ResultsA total of 112 patients were enrolled (mean age 44.1±17.6 years, 56.3% men), and 201 Apollo devices were used in 142 embolization procedures. The mean Spetzler–Martin grade was 2.38. The primary endpoint was not observed (0/112, 0%). The catheter tip detached during 83 (58.5%) procedures, of which 2 (2.4%) were unintentional and did not result in clinical sequelae. At 30 days, procedure related AEs occurred in 26 (23.2%) patients, and procedure-related serious AEs in 12 (10.7%). At 12 months, there were 3 (2.7%) mortalities, including 2 (1.8%) neurological deaths, none of which were device-related.ConclusionThis study demonstrates the safety of Apollo for Onyx embolization of bAVMs.Clinical trial registrationCNCT02378883.

Background Hemorrhagic vascular lesions in the posterior cerebral circulation such as ruptured aneurysms and dissections can be challenging to treat. Flow diversion has become an important off-label option, but few studies have analyzed the safety of these devices in this setting. Using an international, multicenter cohort, we reviewed posterior circulation subarachnoid hemorrhage (SAH) patients treated with the Pipeline Embolization Device (PED) in the acute setting and assessed the incidence of Takotsubo cardiomyopathy (TCM). Methods Eleven neurovascular centers were queried to identify cases of posterior circulation aneurysms or dissections treated with the PED in the acute setting of SAH. Among those, 5 centers had cases that matched the inclusion criteria. The following variables were evaluated: demographics, the location and morphology of the aneurysm, the clinical presentation, the specific form of treatment, complications including the development of TCM, antiplatelet medication regimen, and follow-up time. Results A total of 23 patients were treated with PED after posterior circulation SAH, and 13% of these developed TCM. The lesions were the result of hemorrhagic intracranial dissection (8 patients), ruptured pseudoaneurysm (3), ruptured saccular aneurysm (7), blister aneurysm (4), and fusiform aneurysm (1). Ninety-one percent of patients had complete or near-complete aneurysm occlusion on follow-up imaging. Five patients died in the perioperative period; 16/18 survivors had a favorable outcome. Conclusions We describe an unexpectedly high incidence of TCM after the placement of PEDs in patients with posterior circulation SAH in our large case series. Further studies will be needed to elucidate possible causes.

Object The breadth and complexity of neurovascular pathologies treated with endovascular neurosurgery has expanded dramatically in recent years. Many aneurysms remain difficult to treat safely. Transcirculation (contralateral and/or retrograde) approaches through the circle of Willis are useful alternatives for treating challenging lesions endovascularly. Here, we present a series of patients treated with unconventional transcirculation techniques. Methods A total of six patients were treated: four patients with five aneurysms, one patient with an MCA stroke, and one patient with a meningioma requiring preoperative embolization were initially thought not to be amenable to endovascular treatment. The decision was made to treat these patients with transcirculation approaches. All patients were treated by one interventionist. One aneurysm was located in the cavernous internal carotid artery (ICA), one in the vertebral artery, two in the paraclinoid ICA, and one in a cerebellar AVM feeder vessel were treated. Results Five of six patients (83%) made a full neurologic recovery. Three aneurysms were treated to complete occlusion, one aneurysm was left with small residual neck filling, and one aneurysm was not able to be treated. One patient underwent mechanical thrombectomy of a middle cerebral artery (MCA) embolus and MCA filling was restored after treatment. One patient underwent complete embolization of the deep vascular supply of a meningioma. Conclusions Although many neurovascular pathologies remain unsuitable for endovascular treatment, transcirculation approaches can allow for safe, successful treatment of challenging lesions in select patients.

BackgroundFlow diversion is a common endovascular treatment for cerebral aneurysms, but studies comparing different types of flow diverters are scarce.ObjectiveTo perform a propensity score matched cohort study comparing the Pipeline Embolization Device (PED) and Flow Redirection Intraluminal Device (FRED) for posterior circulation aneurysms.MethodsConsecutive aneurysms of the posterior circulation treated at 25 neurovascular centers with either PED or FRED were collected. Propensity score matching was used to control for age, duration of follow-up imaging, adjunctive coiling, and aneurysm location, size, and morphology; previously ruptured aneurysms were excluded. The two devices were compared for the following outcomes: procedural complications, aneurysm occlusion, and functional outcome.ResultsA total of 375 aneurysms of the posterior circulation were treated in 369 patients. The PED was used in 285 (77.2%) and FRED in 84 (22.8%) procedures. Aneurysms treated with the PED were more commonly fusiform and larger than those treated with FRED. To account for these important differences, propensity score matching was performed resulting in 33 PED and FRED unruptured aneurysm pairs. No differences were found in occlusion status and neurologic thromboembolic or hemorrhagic complications between the two devices. The proportion of patients with favorable functional outcome was higher with FRED (100% vs 87.9%, p=0.04).ConclusionComparative analysis of PED and FRED for the treatment of unruptured posterior circulation aneurysms did not identify significant differences in aneurysm occlusion or neurologic complications. Variations in functional outcomes warrant additional investigations.

BackgroundTo analyse the clinical characteristics of COVID-19 with acute ischaemic stroke (AIS) and identify factors predicting functional outcome.MethodsMulticentre retrospective cohort study of COVID-19 patients with AIS who presented to 30 stroke centres in the USA and Canada between 14 March and 30 August 2020. The primary endpoint was poor functional outcome, defined as a modified Rankin Scale (mRS) of 5 or 6 at discharge. Secondary endpoints include favourable outcome (mRS ≤2) and mortality at discharge, ordinal mRS (shift analysis), symptomatic intracranial haemorrhage (sICH) and occurrence of in-hospital complications.ResultsA total of 216 COVID-19 patients with AIS were included. 68.1% (147/216) were older than 60 years, while 31.9% (69/216) were younger. Median [IQR] National Institutes of Health Stroke Scale (NIHSS) at presentation was 12.5 (15.8), and 44.2% (87/197) presented with large vessel occlusion (LVO). Approximately 51.3% (98/191) of the patients had poor outcomes with an observed mortality rate of 39.1% (81/207). Age >60 years (aOR: 5.11, 95% CI 2.08 to 12.56, pConclusionThere is relationship between COVID-19-associated AIS and severe disability or death. We identified several factors which predict worse outcomes, and these outcomes were more frequent compared to global averages. We found that elevated neutrophil-to-lymphocyte ratio, rather than D-Dimer, predicted both morbidity and mortality.

Machine learning (ML) has been increasingly used in medicine and neurosurgery. We sought to determine whether ML models can distinguish ruptured from unruptured aneurysms and identify features associated with rupture.We performed a retrospective review of patients with intracranial aneurysms detected on vascular imaging at our institution between 2002 and 2018. The dataset was used to train 3 ML models (random forest, linear support vector machine [SVM], and radial basis function kernel SVM). Relative contributions of individual predictors were derived from the linear SVM model.Complete data were available for 845 aneurysms in 615 patients. Ruptured aneurysms (n = 309, 37%) were larger (mean 6.51 mm vs. 5.73 mm; P = 0.02) and more likely to be in the posterior circulation (20% vs. 11%; P0.001) than unruptured aneurysms. Area under the receiver operating curve was 0.77 for the linear SVM, 0.78 for the radial basis function kernel SVM models, and 0.81 for the random forest model. Aneurysm location and size were the 2 features that contributed most significantly to the model. Posterior communicating artery, anterior communicating artery, and posterior inferior cerebellar artery locations were most highly associated with rupture, whereas paraclinoid and middle cerebral artery locations had the strongest association with unruptured status.ML models are capable of accurately distinguishing ruptured from unruptured aneurysms and identifying features associated with rupture. Consistent with prior studies, location and size show the strongest association with aneurysm rupture.

Delayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage continues to be associated with high levels of morbidity and mortality. This complication had long been thought to occur secondary to severe cerebral vasospasm, but expert opinion now favors a multi-factorial etiology, opening the possibility of new therapies. To date, no definitive treatment option for DCI has been recommended as standard of care, highlighting a need for further research into potential therapies. Milrinone has been identified as a promising therapeutic agent for DCI, possessing a mechanism of action for the reversal of cerebral vasospasm as well as potentially anti-inflammatory effects to treat the underlying etiology of DCI. Intra-arterial and intravenous administration of milrinone has been evaluated for the treatment of DCI in single center case series and cohorts and appears safe and associated with improved clinical outcomes. Recent results have also brought attention to the potential outcome benefits of early, more aggressive dosing and titration of milrinone. Limitations exist within the available data, however, and questions remain about the generalizability of results across a broader spectrum of patients suffering from DCI. The development of a standardized protocol for milrinone use in DCI, specifically addressing areas requiring further clarification, is needed. Data generated from a standardized protocol may provide the impetus for a multi-center, randomized control trial. We review the current literature on milrinone for the treatment of DCI and propose a preliminary standardized protocol for further evaluation of both safety and efficacy of milrinone.

Background Arteriovenous malformation (AVM) rupture is highly morbid. Outcomes after AVM rupture differ from other types of brain hemorrhage. There are no specific widely used grading systems designed to predict clinical outcome after AVM rupture. Objective To develop an all-comers scoring system to grade patients with AVM rupture and predict clinical outcome more accurately than grading systems currently in use. Methods We retrospectively reviewed patients who presented to our institution with a ruptured AVM. Using change in modified Rankin Score (mRS) as our response variable, we generated an ordinal logistic regression model to test for significant predictor variables. The full model was sequentially condensed until the simplest model with the highest area under the receiver operating curve (AUROC) was achieved. Results A total of 115 patients who presented with ruptured AVMs were included in the study, with a mean follow-up time of 4 yr. The Ruptured AVM Grading Scale (RAGS) consists of the Hunt and Hess (HH) score (1-5), patient age ( 70 = 2), deep venous drainage (1), and eloquence (1). The RAGS score outperformed other neurosurgical grading scales in predicting change in mRS, with an AUROC greater than 0.80 across all follow-up periods. Conclusion The RAGS score is a simple extension of the HH scale that predicts clinical outcome after AVM rupture more accurately than other grading systems.

OBJECTIVEParaclinoid aneurysms represent approximately 5% of intracranial aneurysms (Drake et al. [1968]). Visual impairment, which occurs in 16%–40% of patients, is among the most common presentations of these aneurysms (Day [1990], Lai and Morgan [2013], Sahlein et al. [2015], and Silva et al. [2017]). Flow-diverting stents, such as the Pipeline Embolization Device (PED), are increasingly used to treat these aneurysms, in part because of their theoretical reduction of mass effect (Fiorella et al. [2009]). Limited data on paraclinoid aneurysms treated with a PED exist, and few studies have compared outcomes of patients after PED placement with those of patients after clipping or coiling.METHODSThe authors performed a retrospective analysis of 115 patients with an aneurysm of the cavernous to ophthalmic segments of the internal carotid artery treated with clipping, coiling, or PED deployment between January 2011 and March 2017. Postoperative complications were defined as new neurological deficit, aneurysm rupture, recanalization, or other any operative complication that required reintervention.RESULTSA total of 125 paraclinoid aneurysms in 115 patients were treated, including 70 with PED placement, 23 with coiling, and 32 with clipping. Eighteen (14%) aneurysms were ruptured. The mean aneurysm size was 8.2 mm, and the mean follow-up duration was 18.4 months. Most aneurysms were discovered incidentally, but visual impairment, which occurred in 21 (18%) patients, was the most common presenting symptom. Among these patients, 15 (71%) experienced improvement in their visual symptoms after treatment, including 14 (93%) of these 15 patients who were treated with PED deployment. Complete angiographic occlusion was achieved in 89% of the patients. Complications were seen in 17 (15%) patients, including 10 (16%) after PED placement, 2 (9%) after coiling, and 5 (17%) after clipping. Patients with incomplete aneurysm occlusion had a higher rate of procedural complications than those with complete occlusion (p = 0.02). The rate of postoperative visual improvement was significantly higher among patients treated with PED deployment than in those treated with coiling (p = 0.01). The significant predictors of procedural complications were incomplete occlusion (p = 0.03), hypertension, (p = 0.04), and diabetes (p = 0.03).CONCLUSIONSIn a large series in which patient outcomes after treatment of paraclinoid aneurysms were compared, the authors found a high rate of aneurysm occlusion and a comparable rate of procedural complications among patients treated with PED placement compared with the rates among those who underwent clipping or coiling. For patients who presented with visual symptoms, those treated with PED placement had the highest rate of visual improvement. The results of this study suggest that the PED is an effective and safe modality for treating paraclinoid aneurysms, especially for patients who present with visual symptoms.

Background and Purpose— Mechanical thrombectomy has been shown to improve clinical outcomes in patients with acute ischemic stroke. However, the impact of balloon guide catheter (BGC) use is not well established. Methods— STRATIS (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke) was a prospective, multicenter study of patients with large vessel occlusion treated with the Solitaire stent retriever as first-line therapy. In this study, an independent core laboratory, blinded to the clinical outcomes, reviewed all procedures and angiographic data to classify procedural technique, target clot location, recanalization after each pass, and determine the number of stent retriever passes. The primary clinical end point was functional independence (modified Rankin Scale, 0–2) at 3 months as determined on-site, and the angiographic end point was first-pass effect (FPE) success rate from a single device attempt (modified Thrombolysis in Cerebral Infarction, ≥2c) as determined by a core laboratory. Achieving modified FPE (modified Thrombolysis in Cerebral Infarction, ≥2b) was also assessed. Comparisons of clinical outcomes were made between groups and adjusted for baseline and procedural characteristics. All participating centers received institutional review board approval from their respective institutions. Results— Adjunctive technique groups included BGC (n=445), distal access catheter (n=238), and conventional guide catheter (n=62). The BGC group had a higher rate of FPE following first pass (212/443 [48%]) versus conventional guide catheter (16/62 [26%]; P =0.001) and distal access catheter (83/235 [35%]; P =0.002). Similarly, the BGC group had a higher rate of modified FPE (294/443 [66%]) versus conventional guide catheter (26/62 [42%]; P P =0.003). The BGC group achieved the highest rate of functional independence (253/415 [61%]) versus conventional guide catheter (23/55 [42%]; P =0.007) and distal access catheter (113/218 [52%]; P =0.027). Final revascularization and mortality rates did not differ across the groups. Conclusions— BGC use was an independent predictor of FPE, modified FPE, and functional independence, suggesting that its routine use may improve the rates of early revascularization success and good clinical outcomes. Clinical Trial Registration— URL: https://www.clinicaltrials.gov . Unique identifier: NCT02239640.

Background and Purpose— Digital subtraction angiography has been used as the gold standard to confirm successful aneurysmal obliteration after aneurysm clipping procedures using titanium or cobalt alloy clips. Computed tomographic angiography is a newer, less invasive imaging technique also used to confirm successful aneurysmal obliteration; however, its use compared with digital subtraction angiography remains controversial. Methods— A comprehensive literature search was conducted on Pubmed, EMBASE, and Cochrane databases through November 6, 2017, for studies that evaluated postclipping aneurysm obliteration with both computed tomographic angiography and digital subtraction angiography. Pooled sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR−) were calculated using the bivariate random-effects model. Results— Out of 6916 studies, 13 studies met inclusion criteria for this meta-analysis. A total of 510 patients with 613 aneurysms were included. Compared with digital subtraction angiography, which detected 87 residual aneurysms, computed tomographic angiography detected 58 resulting in a pooled sensitivity of 69% (95% CI, 54%–81%) and a pooled specificity of 99% (95% CI, 97%–99%). This corresponded to LR+ of 55.5 (95% CI, 23.6–130.9) and LR− of 0.31 (95% CI, 0.20–0.48). Univariate meta-regression revealed that the pooled sensitivity was worse in prospective designs ( P interaction P interaction Conclusions— This meta-analysis revealed that computed tomographic angiography had a favorable LR+ but not a favorable LR−. Thus, this imaging modality may be applicable to rule in, but not rule out, residual aneurysms after clipping.

Significance: Intracranial pressure (ICP), variability in perfusion, and resulting ischemia are leading causes of secondary brain injury in patients treated in the neurointensive care unit. Continuous, accurate monitoring of cerebral blood flow (CBF) and ICP guide intervention and ultimately reduce morbidity and mortality. Currently, only invasive tools are used to monitor patients at high risk for intracranial hypertension. Aim: Diffuse correlation spectroscopy (DCS), a noninvasive near-infrared optical technique, is emerging as a possible method for continuous monitoring of CBF and critical closing pressure (CrCP or zero-flow pressure), a parameter directly related to ICP. Approach: We optimized DCS hardware and algorithms for the quantification of CrCP. Toward its clinical translation, we validated the DCS estimates of cerebral blood flow index (CBFi) and CrCP in ischemic stroke patients with respect to simultaneously acquired transcranial Doppler ultrasound (TCD) cerebral blood flow velocity (CBFV) and CrCP. Results: We found CrCP derived from DCS and TCD were highly linearly correlated (ipsilateral R2 = 0.77, p = 9 × 10 − 7; contralateral R2 = 0.83, p = 7 × 10 − 8). We found weaker correlations between CBFi and CBFV (ipsilateral R2 = 0.25, p = 0.03; contralateral R2 = 0.48, p = 1 × 10 − 3) probably due to the different vasculature measured. Conclusion: Our results suggest DCS is a valid alternative to TCD for continuous monitoring of CrCP.

Infectious intracranial aneurysms (IIAs), or mycotic aneurysms, are infectious inflammatory lesions that can cause devastating neurological damage or death. Recent systemic reviews have suggested endovascular treatment to be efficacious for IIA management.To compare the safety profile of different endovascular methods for treating ruptured and unruptured IIAs and factors associated with good clinical and radiographic outcomes.We conducted a retrospective single study of endovascularly treated ruptured and unruptured IIAs between 2003 and 2019. Univariate and multivariate analyses were used to study patient presentation, endovascular treatments used, and clinical and radiographic outcomes.Thirty-eight patients with ruptured (n = 20) and unruptured (n = 18) IIAs treated with endovascular methods were included. One patient required retreatment after aneurysm recanalization, and 2 patients demonstrated new infarcts after embolization. There was no postprocedural radiographic hemorrhage or infarct and no difference in clinical and radiographic outcomes comparing treatment modality. Hypertension was associated with ruptured IIA status and worse clinical outcome at 6 mo (odds ratio: 0.03 [95% confidence interval: 0.002-0.52]).In this study, the largest single-center series to date, we showed that endovascular intervention is a safe and effective strategy for both ruptured and unruptured IIAs. Hypertension was associated with ruptured status and worse clinical outcome. Procedures are generally well-tolerated and safe, with good outcomes for patients.

BACKGROUNDPure arterial malformations (PAMs) are rare vascular anomalies that are commonly mistaken for other vascular malformations. Because of their purported benign natural history, PAMs are often conservatively managed. The authors report the case of a ruptured PAM leading to subarachnoid hemorrhage (SAH) with intraventricular extension that was treated endovascularly.OBSERVATIONSA 38-year-old man presented with a 1-day history of headaches and nausea. A computed tomography scan demonstrated diffuse SAH with intraventricular extension, and angiography revealed a right posterior inferior cerebellar artery–associated PAM. The PAM was treated with endovascular Onyx embolization.LESSONSTo the authors’ knowledge, only 2 other cases of SAH associated with PAM have been reported. In those 2 cases, surgical clipping was pursued for definitive treatment. Here, the authors report the first case of a ruptured PAM treated using an endovascular approach, showing its feasibility as a treatment option particularly in patients in whom open surgery is too high a risk.

Some skull base tumors can be extremely hypervascular, incorporating multiple vascular territories and demonstrating arteriovenous shunting. Devascularization is a critical step undertaken early in meningioma surgery, necessary before the debulking that is required in skull base tumors. While devascularization can often be achieved with appropriate approach selection, bony drilling, and microsurgical cautery, preoperative embolization of meningiomas has an invaluable role in selected cases.1,2 Embolization, however, does have added risk, magnified in large tumors by the potential infarction with subsequent edema that can potentially lead to acute deterioration and neurosurgical emergency. Hence, to achieve devascularization of an extremely vascular tumor, embolization and surgical resection should be performed concomitantly, as one operation, in which embolization might be the first stage, or might be performed after the craniotomy flap is raised, if necessary.3 Naturally, this requires the multifaceted neurosurgical expertise of embolization and microsurgical resection, and the facility to perform such. We present a case of a giant, hypervascular, radiation-induced, skull base meningioma with internal and external carotid artery supply in a young patient with deteriorating vision in his only eye. Selective embolization of the internal maxillary, middle meningeal, and middle cerebral artery blood supplies was performed. Microsurgical interruption of the ethmoidal artery blood supply was then performed. This hybrid approach safely and effectively devascularized the tumor and allowed for a complete resection of this high-risk tumor4 while minimizing risk to the ophthalmic artery and optic nerve. The patient was consented for surgery.

Background: Subarachnoid hemorrhage (SAH) associated with vessel injury during endovascular therapy for acute ischemic stroke is a known complication. Arterial anatomy may predispose to increased risk of SAH and technical safety, yet factors such as clot location, arterial size and tortuosity have not been explored. We examined these anatomical factors with respect to SAH during thrombectomy. Methods: Arterial anatomy at the site of occlusion and mechanical thrombectomy during device deployment was detailed by the STRATIS core lab. Luminal diameters, arterial branching and segmental tortuosity were measured. Arterial tortuosity was quantified using the distance factor metric (DFM). Statistical analyses included descriptives of arterial anatomy, with univariate and multivariate modeling to predict SAH. Results: Arterial tortuosity in each segment from the proximal cerebral arteries to the site of occlusion was quantified in 790 subjects treated with mechanical thrombectomy in STRATIS. Cumulative arterial tortuosity to the site of vessel occlusion was greater in distal lesions (Table 1). SAH was clearly linked with more distal thrombectomy (p=0.017), with 19.0% of distal M2, 16.7% of M3, 7.3% of distal M1, 5.8% of proximal M2, 2.4% of distal ICA and 2.1% of proximal M1. Multivariate prediction of SAH revealed that arterial diameter was unrelated to SAH (p=0.30) when accounting for tortuosity, whereas the presence of tortuosity tripled the risk of SAH (OR 3, p Conclusions: This novel systematic analysis of arterial tortuosity and angiographic anatomy during mechanical thrombectomy establishes tortuosity as a determinant of SAH, providing insight for future techniques and innovative device designs.

Background: Mechanical thrombectomy is established for large vessel occlusions in acute ischemic stroke, but the potential role in distal vessel occlusions of medium arteries is largely unknown. Such distal arterial segments have not been measured with respect to thrombectomy devices used during endovascular therapy. We conducted a systematic analysis of arterial size, segmental anatomy and stent retriever device performance during thrombectomy. Methods: The STRATIS angiography core lab adjudicated the exact location of the occlusion, proximal and distal device deployment, relationship to arterial bifurcations and anatomical nomenclature. Arterial diameters were measured at all of these sites. Statistical analyses examined the relationship between these variables, arterial recanalization and eTICI reperfusion. Results: Thrombectomy was performed with various device sizes, including Solitaire 4x40 in 36.3% (306/844), Solitaire 6x30 in 31.4% (265/844), Solitaire 4x20 in 26.4% (223/844), unspecified in 3.8% (32/844), Solitaire 6x20 in 1.3% (11/844) and Solitaire 4x15 in 0.8% (7/844). Arterial diameter at the occlusion site was median 2.17mm (1.40-3.59) in the distal M1, 1.67mm (0.81-2.98) in the proximal M2, 1.50mm (0.92-1.99) in the distal M2, 1.24mm (0.67-2.00) in the M3 and 1.88mm (1.49-1.94) in the P1. Considerable overlap was noted between arterial sizes at occlusion sites carrying different segmental arterial nomenclature or vessel names. During device deployment in STRATIS, median arterial diameter at the occlusion site was 2.4mm (IQR 1.9, 3.4), 2.9mm (IQR 2.2, 3.6) at the proximal stent marker and 1.4mm (IQR 1.2, 1.7) at the distal stent marker. Substantial eTICI reperfusion (2b-3) was achieved in all distal vessel occlusions (Table 1). Conclusions: Substantial reperfusion may be achieved with currently available mechanical thrombectomy devices for distal vessel occlusions in medium arteries.

Background: The role of tight glycemic control in the management of acute ischemic stroke remains uncertain. Objective: Our goal is to evaluate the effects of tight glucose control with insulin therapy after acute ischemic stroke. Methods: We searched PubMed, CENTRAL, and EMBASE for randomized controlled trials (RCTs) that evaluated the effects of tight glycemic control (70 - 135 mg/dL) in acute ischemic stroke. Analysis was performed using fixed- and random-effects models. Outcomes were death, independence and modified Rankin Scale (mRS) score at ≥90 days follow-up, and symptomatic or severe hypoglycemia during treatment. Results: Twelve RCTs including 2,734 patients were included. When compared to conventional therapy or placebo, tight glycemic control was associated with similar rates of mortality at ≥90 days follow-up (pooled odds ratio [pOR], 0.99 [95% CI, 0.79 - 1.22], I 2 0%), independence at ≥90 days follow-up (pOR, 0.95 [0.79 - 1.14], I 2 0%) and mRS scores at ≥90 days follow-up (standardized mean difference, 0.014 [-0.15 - 0.17], I 2 0%). In contrast, tight glycemic control was associated with increased rates of symptomatic or severe hypoglycemia during treatment (pOR 5.2 [1.87 - 14.42], I 2 20%). Conclusion: Tight glucose control after acute ischemic stroke is not associated with improvements in mortality, independence or mRS score and leads to higher rates of symptomatic or severe hypoglycemia.

BACKGROUND: The Pipeline Embolization Device (PED; Medtronic) has been used off-label for the treatment of challenging posterior circulation aneurysms. Data on this modality are primarily limited to small retrospective single-center series. OBJECTIVE: To assess safety and efficacy of this treatment by establishing an international, multicenter collaboration. METHODS: Consecutive posterior circulation aneurysms treated with the PED from 2012 to 2019 across 11 neurovascular centers were retrospectively reviewed. Baseline demographics, aneurysm and treatment characteristics, complications, occlusion status, and functional outcome were assessed. RESULTS: There were 149 posterior circulation aneurysms treated with PED in 146 patients. A total of 24 (16.4) patients presented with subarachnoid hemorrhage. Most aneurysms were dissecting/blister (36.2) in morphology, followed by saccular (35.6) and fusiform (28.2). The most common locations were the vertebral (51.7) and basilar arteries (22.8). Complete or near-complete occlusion (>90) was achieved in 90.9 of aneurysms at a median follow-up of 12 mo. Dissecting/blister aneurysms were most likely to occlude (P =.06). Symptomatic neurologic complications occurred in 9.4 of aneurysms, associated with larger size, ruptured presentation, presentations with brain stem compression, cranial nerve palsy, or stroke. Favorable functional outcome (modified Rankin Score 0-2) was achieved in 86.2 of patients. There were 6 fatalities of which 4 occurred in aneurysmal subarachnoid hemorrhage patients. CONCLUSION: This multicenter study shows that PED for the treatment of posterior circulation is preferentially used for the treatment of fusiform and dissecting/blister aneurysm morphologies. Despite the challenges presented by these less-common morphologies, flow diversion may be performed with a neurologic complication rate of about 10 and favorable long-term aneurysm occlusion rates. © 2020 by the Congress of Neurological Surgeons

A 53-year-old Salvadoran woman with hyperlipidemia and no previous neurologic complaints presented to the emergency department with sudden-onset right-sided weakness and dysarthria while speaking with a friend. Two days prior to presentation, she endorsed a mild bifrontal headache but denied any constitutional symptoms.

Objectives Aneurysms associated with hemorrhagic moyamoya disease (MMD) are reported to stabilize or recede following revascularization. Case report/results A 29 year-old male with no past medical history presented obtunded with diffuse intraventricular hemorrhage and vascular imaging demonstrating bilateral MMD without any associated aneurysms. He underwent a delayed right-sided STA-MCA bypass and pial synangiosis, and was subsequently discharged on hospital day 24 with a modified Rankin Scale score (mRS) of 2. He returned eleven days later from a rehabilitation facility with recurrent IVH. A saccular 5 mm right P4 segment posterior cerebral artery aneurysm was seen on a diagnostic angiogram and embolized with Onyx glue. Conclusions Distal posterior circulation artery aneurysmal rupture is a rare cause of hemorrhagic MMD. This case demonstrates the capacity of these aneurysms to re-rupture following revascularization and underscores the importance of treating the aneurysms directly.

Supplemental Digital Content is available in the text., Background: Endovascular treatment with mechanical thrombectomy (MT) is beneficial for patients with acute stroke suffering a large-vessel occlusion, although treatment efficacy is highly time-dependent. We hypothesized that interhospital transfer to endovascular-capable centers would result in treatment delays and worse clinical outcomes compared with direct presentation. Methods: STRATIS (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke) was a prospective, multicenter, observational, single-arm study of real-world MT for acute stroke because of anterior-circulation large-vessel occlusion performed at 55 sites over 2 years, including 1000 patients with severe stroke and treated within 8 hours. Patients underwent MT with or without intravenous tissue plasminogen activator and were admitted to endovascular-capable centers via either interhospital transfer or direct presentation. The primary clinical outcome was functional independence (modified Rankin Score 0–2) at 90 days. We assessed (1) real-world time metrics of stroke care delivery, (2) outcome differences between direct and transfer patients undergoing MT, and (3) the potential impact of local hospital bypass. Results: A total of 984 patients were analyzed. Median onset-to-revascularization time was 202.0 minutes for direct versus 311.5 minutes for transfer patients (P

Background and Purpose— Mechanical thrombectomy with stent retrievers has become standard of care for treatment of acute ischemic stroke patients because of large vessel occlusion. The STRATIS registry (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke) aimed to assess whether similar process timelines, technical, and functional outcomes could be achieved in a large real world cohort as in the randomized trials. Methods— STRATIS was designed to prospectively enroll patients treated in the United States with a Solitaire Revascularization Device and Mindframe Capture Low Profile Revascularization Device within 8 hours from symptom onset. The STRATIS cohort was compared with the interventional cohort of a previously published SEER patient-level meta-analysis. Results— A total of 984 patients treated at 55 sites were analyzed. The mean National Institutes of Health Stroke Scale score was 17.3. Intravenous tissue-type plasminogen activator was administered in 64.0%. The median time from onset to arrival in the enrolling hospital, door to puncture, and puncture to reperfusion were 138, 72, and 36 minutes, respectively. The Core lab–adjudicated modified Thrombolysis in Cerebral Infarction ≥2b was achieved in 87.9% of patients. At 90 days, 56.5% achieved a modified Rankin Scale score of 0 to 2, all-cause mortality was 14.4%, and 1.4% suffered a symptomatic intracranial hemorrhage. The median time from emergency medical services scene arrival to puncture was 152 minutes, and each hour delay in this interval was associated with a 5.5% absolute decline in the likelihood of achieving modified Rankin Scale score 0 to 2. Conclusions— This largest-to-date Solitaire registry documents that the results of the randomized trials can be reproduced in the community. The decrease of clinical benefit over time warrants optimization of the system of care. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT02239640.

BACKGROUND AND IMPORTANCE Aneurysms affecting double origin (DO) posterior inferior cerebellar artery (PICA) variants are rare. Most reports describe endovascular occlusion of the affected branch to treat the aneurysm, but we describe a patient in which open surgical sacrifice of 1 branch resulted in insufficient perfusion. CLINICAL PRESENTATION We report the only case of open surgical treatment of an aneurysm affecting a leg of a DOPICA. A 42-year-old woman presenting with the worst headache of her life was found to have a DOPICA aneurysm and initially treated by trapping the aneurysm. Intraoperative indocyanine green imaging revealed insufficient perfusion through the caudal branch, which was remediated by end-to-end anastomosis to preserve flow through both origins. The patient made a full recovery. CONCLUSION Treating a DOPICA aneurysm by sacrificing 1 of the origins is not possible for all patients. This first report of open surgical treatment of a DOPICA leg aneurysm suggests that 1 or both branches may be required for sufficient perfusion, and the unique embryology of DOPICA development suggests a possible mechanism.

Background Described variations of tentorial venous anatomy impact surgical sectioning of the tentorium in skull base approaches; however, described configurations do not consistently explain postoperative complications. To understand the outcomes of 2 clinical cases we studied the tentorial venous anatomy of 2 cadavers. Methods The venous anatomy of the tentorium isolated in 2 uninjected fresh cadaver head specimens with preserved bridging veins was observed by transillumination before and after methylene blue injection of the dural sinuses and tentorial veins. Our findings in cadavers were applied to explain the clinical and radiologic (magnetic resonance imaging and computed tomographic venography) findings in the 2 cases presented. Results A consistent transtentorial venous system, arising from transverse and straight sinuses, communicating with supra- and infratentorial bridging veins was seen in the cadaver and patient radiography (magnetic resonance imaging and computed tomographic venography). Our first patient had a cerebellar venous infarct from compromise of the venous drainage from the adjacent brain after ligation of a temporal lobe bridging vein to the tentorium. Our second patient suffered no clinical effects from bilateral transverse sinus occlusion due to drainage through the accessory venous system within the tentorium. Conclusions Herein, we elaborate on transtentorial venous anatomy. These veins, previously reported to obliterate in completed development of the tentorium, remain patent with consistent observed configuration. The same transtentorial venous system was observed in both cases and provided insight to their outcomes. These findings emphasize the importance of the transtentorial venous system physiologically and in surgical approaches.

Introduction: Interhospital transfer for endovascular treatment of large vessel occlusion (LVO) stroke results in significant delays and worse outcomes. We hypothesized that interhospital patient transfer using air transport would result in shorter transit times compared to ground ambulance. Methods: Subjects from the STRATIS registry that underwent interhospital transfer for endovascular treatment were separated by air transport vs. ground ambulance transport and analyzed by transfer distance. The primary endpoint was transfer-time, calculated as the time from imaging at the initial hospital to arrival at the treating hospital. Also assessed was travel-time, calculated as time of departure from the initial hospital to arrival at the treating hospital. Results: There were 232 subjects from 41 sites. Mean transfer-time for all air subjects (n=118) was 147.1 min, and for all ground subjects (n=114) was 130.0 min (p=0.019). Mean travel-time was 45.0 min for air transport and 40.2 min for ground transport (p=0.239); though the average travel distance was longer for air (65.5 miles) vs. ground (27.6 miles; p Conclusions: In this large, real-world study, interhospital transfer via air transport did not result in faster transfer times compared to ground ambulance. In fact, there was an advantage to ground transportation for distances of less than 20 miles. These results suggest that ground ambulance should routinely be used for interhospital transfer of stroke patients for travel less than 20 miles.

Background and Purpose- Digital subtraction angiography has been used as the gold standard to confirm successful aneurysmal obliteration after aneurysm clipping procedures using titanium or cobalt alloy clips. Computed tomographic angiography is a newer, less invasive imaging technique also used to confirm successful aneurysmal obliteration; however, its use compared with digital subtraction angiography remains controversial. Methods- A comprehensive literature search was conducted on Pubmed, EMBASE, and Cochrane databases through November 6, 2017, for studies that evaluated postclipping aneurysm obliteration with both computed tomographic angiography and digital subtraction angiography. Pooled sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-) were calculated using the bivariate random-effects model. Results- Out of 6916 studies, 13 studies met inclusion criteria for this meta-analysis. A total of 510 patients with 613 aneurysms were included. Compared with digital subtraction angiography, which detected 87 residual aneurysms, computed tomographic angiography detected 58 resulting in a pooled sensitivity of 69% (95% CI, 54%-81%) and a pooled specificity of 99% (95% CI, 97%-99%). This corresponded to LR+ of 55.5 (95% CI, 23.6-130.9) and LR- of 0.31 (95% CI, 0.20-0.48). Univariate meta-regression revealed that the pooled sensitivity was worse in prospective designs ( P interaction0.05), and the pooled specificity was better in higher-quality studies and for postoperative aneurysm diameters of2 mm ( P interaction0.001 for both). Conclusions- This meta-analysis revealed that computed tomographic angiography had a favorable LR+ but not a favorable LR-. Thus, this imaging modality may be applicable to rule in, but not rule out, residual aneurysms after clipping.

Critical Closing Pressure (CrCP) is a non-invasive approach to estimate intracranial pressure. In 15 stroke patients, we found a strong correlation (R2 = 0.7) between CrCP derived from Diffuse Correlation Spectroscopy and from Transcranial Doppler Ultrasound

Objective In early-generation hybrid biplane endovascular operating rooms, switching from surgical to angiographic position is cumbersome. In this report, we highlight the unique design of a new hybrid neuroendovascular operating suite that allows surgical access to the head while keeping the biplane system over the lower body of the patient. Current and future hybrid neuroendovascular operating suite applications are discussed. Methods We collaborated with engineers to implement the following modifications to the design of the angiographic system: translation of the bed toward the feet to allow biplane cerebral imaging in the head-side position and the biplane left-side position; translation of the base of the A-plane C-arm away from the feet to allow increased operator space at the head of the bed and to allow cerebral imaging in both the head-side and left-side positions; use of a specialized boom mount for the display panel to increase mobility; and use of a radiolucent tabletop with attachments for the headrest or radiolucent head clamp system. Results The modified hybrid neuroendovascular operating suite allows for seamless transition between surgical and angiographic positions within seconds, improving workflow efficiency and decreasing procedure time as compared with early-generation hybrid rooms. Conclusions Combined endovascular and surgical applications are facilitated by co-locating their respective technologies and refining the ergonomics of the system to ease transition between both sets of technologies. In so doing, hybrid neuroendovascular operating suites can be anticipated to improve patient outcomes, generate novel treatment paradigms, and improve time and cost efficiency.

Background: Collateral circulation to the ischemic territory is a pivotal factor in outcomes after acute ischemic stroke. Extent of angiographic collaterals prior to endovascular therapy has been linked with reperfusion in previous trials, yet the mechanism remains unclear. We analyzed whether downstream collateral grade influences the pace and degree of ultimate reperfusion. Methods: The angiography dataset collated by the STRATIS Core Lab was analyzed to relate the grade of collateral circulation (ASITN) with adjudicated procedural time metrics to exact time of first TICI ≥ 2A and with the final eTICI score, delineating reperfusion into 7 distinct categories. Results: Collateral grade on routine angiography injections was available in 574/984 (58%) of STRATIS subjects (age 67.5 ± 15.1, 47% women, baseline NIHSS 16.8 ± 5.5). Collaterals included 203/574 (35.4%) with ASITN 3-4, 291/574 (50.7%) ASITN 2 and 80/574 (13.9%) ASITN 0-1. TICI ≥ 2A was achieved at 32.4 ± 23.5 minutes from angiography start and 26.4 ± 18.6 minutes from visualization of the arterial occlusion. The eTICI included 78 TICI 3 (13.6%), 140 TICI 2C (24.4%), 226 TICI o2B (39.3%), 68 TICI m2B (11.8%), 44 TICI 2A (7.7%), 4 TICI 1 (0.7%) and 14 TICI 0 (2.4%). More robust collateral grade was strongly associated with lower NIHSS (15.9 ± 5.4 (ASITN 3-4); 16.7 ± 5.5 (ASITN 2); 19.6 ± 5.1 (ASITN 0-1); p Collaterals and reperfusion were linked at all occlusion sites (ICA, M1, M2, BA). Conclusions: Collaterals on routinely available angiography prior to thrombectomy in STRATIS were strikingly tied to both the speed and degree of final reperfusion, across every site of arterial occlusion.

This study uses diffuse correlation spectroscopy (DCS) to monitor blood flow during mechanical thrombectomy, a novel catheter-based treatment in acute ischemic stroke patients, to assist the surgeons observing the flow changes in realtime, towards a personalized therapy.

High flow extracranial–intracranial (EC-IC) bypass with a saphenous vein graft (SVG) has been used for more than 40 years in patients with giant aneurysms of the posterior circulation refractory to medical management, and has demonstrated high long term patency rates. We report the case of a patient treated with external carotid artery (ECA)–posterior cerebral artery SVG bypass in 1989 who presented 27 years later with paresthesias and confusion, and was found to have partial occlusion of her SVG bypass graft and a basilar occlusion. She was treated with mechanical thrombectomy of the basilar occlusion via the partially thrombosed graft, the first report of such a procedure through a high flow posterior circulation EC-IC SVG, resulting in improvement of the patient’s neurologic examination. At 27 years, this is the longest reported delay in thrombosis of a high flow SVG bypass graft, highlighting the long term patency of these grafts and the feasibility of thrombectomy through occluded bypass grafts.

Purpose: Cardiac myxomas are common tumors of the heart with disproportionate impact on young patients, occasionally with dramatic systemic dissemination of tumor emboli with catastrophic multiorgan system ischemia. The coincident comorbidities can increase the risk of traditional treatments for tumor embolus in each region. Case report: A young patient with previously unknown cardiac myxoma presented with seizure and was found to have stress cardiomyopathy, multiple cerebral large vessel occlusions with acute ischemic stroke, bilateral lower extremity tumor emboli and rhabdomyolysis, and renal tumor embolus with acute tubular necrosis. We describe a multidisciplinary approach applying cerebrovascular stent retriever devices in tumor embolectomy of the renal artery of a young patient with systemic morbidity, preventing safe laparotomy for open surgical tumor embolectomy. Conclusion: We describe 2-month renal function outcomes and the considerations in applying a neuroendovascular mechanical thrombectomy device within the renal artery. This was a radiographically successful technique and her renal function appears to be improving at the 2-month follow-up, although this is complicated by other renal insults and support.

AimTo explore the predictors of infarct core expansion despite full reperfusion after intra-arterial therapy (IAT).MethodsWe retrospectively reviewed 604 consecutive patients who underwent IAT for anterior circulation large vessel occlusion acute ischemic stroke in two tertiary centers (2008–2013/2010–2013). Sixty patients selected by MRI or CT perfusion presenting within 11.6 mL.ResultsMean age was 67.0±13.7 years, 56% were men. Mean National Institute of Health Stroke Scale (NIHSS) score was 16.2±6.1, time from onset to puncture was 6.8±3.1 h, and procedure length was 1.3±0.6 h. MRI was used for baseline core analysis in 43% of patients. Mean baseline infarct volume was 17.1±19.1 mL, absolute infarct growth was 30.6±74.5 mL, and final infarct volume was 47.7±77.7 mL. Overall, 35% of patients had SIG. Three of 21 patients (14%) treated with stent-retrievers had SIG compared with 14 of 39 (36%) with first-generation devices. Eight of 21 patients (38%) with intravenous tissue plasminogen activator (IV t-PA) had infarct growth compared with 25/39 (64%) without. 23% of patients with SIG had a modified Rankin Scale score ≤2 at 3 months compared with 48% of those without SIG. Multivariate logistic regression indicated that race affected infarct growth. Use of IV t-PA (p=0.03) and stent-retrievers (p=0.03) were independently and inversely correlated with SIG.ConclusionsDespite full reperfusion, infarct growth is relatively frequent and may explain poor clinical outcomes in this setting. Ethnicity was found to influence SIG. Use of IV t-PA and stent-retrievers were associated with less infarct core expansion.

OBJECTIVEPatients with paraclinoid aneurysms commonly present with visual impairment. They have traditionally been treated with clipping or coiling, but flow diversion (FD) has recently been introduced as an alternative treatment modality. Although there is still initial aneurysm thrombosis, FD is hypothesized to reduce mass effect, which may decompress the optic nerve when treating patients with visually symptomatic paraclinoid aneurysms. The authors performed a meta-analysis to compare vision outcomes following clipping, coiling, or FD of paraclinoid aneurysms in patients who presented with visual impairment.METHODSA systematic literature review was performed using the PubMed and Web of Science databases. Studies published in English between 1980 and 2016 were included if they reported preoperative and postoperative visual function in at least 5 patients with visually symptomatic paraclinoid aneurysms (cavernous segment through ophthalmic segment) treated with clipping, coiling, or FD. Neuroophthalmological assessment was used when reported, but subjective patient reports or objective visual examination findings were also acceptable.RESULTSThirty-nine studies that included a total of 2458 patients (520 of whom presented with visual symptoms) met the inclusion criteria, including 307 visually symptomatic cases treated with clipping (mean follow-up 26 months), 149 treated with coiling (mean follow-up 17 months), and 64 treated with FD (mean follow-up 11 months). Postoperative vision in these patients was classified as improved, unchanged, or worsened compared with preoperative vision. A pooled analysis showed preoperative visual symptoms in 38% (95% CI 28%–50%) of patients with paraclinoid aneurysms. The authors found that vision improved in 58% (95% CI 48%–68%) of patients after clipping, 49% (95% CI 38%–59%) after coiling, and 71% (95% CI 55%–84%) after FD. Vision worsened in 11% (95% CI 7%–17%) of patients after clipping, 9% (95% CI 2%–18%) after coiling, and 5% (95% CI 0%–20%) after FD. New visual deficits were found in patients with intact baseline vision at a rate of 1% (95% CI 0%–3%) for clipping, 0% (95% CI 0%–2%) for coiling, and 0% (95% CI 0%–2%) for FD.CONCLUSIONSTo the authors’ knowledge, this is the first meta-analysis to assess vision outcomes after treatment for paraclinoid aneurysms. The authors found that 38% of patients with these aneurysms presented with visual impairment. These data also demonstrated a high rate of visual improvement after FD without a significant difference in the rate of worsened vision or iatrogenic visual impairment compared with clipping and coiling. These findings suggest that FD is an effective option for treatment of visually symptomatic paraclinoid aneurysms.

Background: ASPECTS is routinely used to estimate ischemic lesion burden in acute stroke, yet the topography and influence of collaterals has been unexplored. Imaging selection for endovascular therapy in various time epochs may also be simplified with ASPECTS. We leveraged the large-scale registry data of STRATIS to discern the role of collaterals, time and other factors in ASPECTS topography at baseline. Methods: The STRATIS Imaging Core Lab, blind to all clinical data, independently determined ASPECTS scores and regional involvement in anterior circulation occlusions. Collateral status on baseline angiography was scored by ASITN grade. Statistical analyses described ASPECTS regional involvement or topography based on arterial occlusion site and other variables available prior to intervention, determining the influence of collaterals and time duration from onset to imaging. Results: Baseline ASPECTS (n=573) was median 8.0 (2, 10). ASPECTS regions involved were lenticular nuclei 62.3% (357/573), insula 42.2% (242/573), caudate 23.4% (134/573), M2 13.6% (78/573), M4 9.4% (54/573), M5 9.2% (53/573), M1 4.0% (23/573), M3 2.1% (12/573), M6 1.9% (11/573) and internal capsule 0.2% (1/573). Distinct patterns or topography differentiated ICA, M1 and M2 arterial occlusion sites at angiography. Overall, higher ASPECTS (7-10 vs. ≤ 6) was linked with more robust collaterals (p Conclusions: ASPECTS topography and the extent of ischemic changes are a product of arterial occlusion site, collateral status and time duration. ASPECTS may infer collateral status, a pivotal determinant of outcome in endovascular therapy, irrespective of time from symptom onset.

Introduction: Paraclinoid aneurysms commonly present with visual impairment. They were traditionally treated with clipping or coiling, but flow diversion has recently been introduced as an alternative treatment modality. Although there is still initial aneurysm thrombosis, flow diversion is hypothesized to reduce mass effect, which may decompress the optic nerve when treating visually symptomatic paraclinoid aneurysms. We performed a meta-analysis to compare vision outcomes following clipping, coiling, or flow diversion of paraclinoid aneurysms in patients presenting with visual impairment. Methods: A systematic literature review was performed using the PubMed and Web of Science databases. Studies written in English between 1980-2016 were included if they reported preoperative and postoperative visual function in at least 5 patients with visually symptomatic paraclinoid aneurysms (cavernous segment through ophthalmic segment) treated with clipping, coiling, or flow diversion. Neuro-ophthalmologic assessment was used when reported. Results: Thirty-nine studies totaling 2458 patients (20%, 510 of whom presented with visual symptoms) met our inclusion criteria, including 309 visually symptomatic cases treated with clipping (mean follow-up, 25.9 mo), 138 treated with coiling (17.1 mo), and 63 treated with flow diversion (11 mo). Postoperative vision in these patients was classified as improved, unchanged, or declined compared to preoperative vision. We found that vision improved in 57% (95% CI 47-67) of patients after clipping, 45% (34-57) after coiling, and 73% (56-88) after flow diversion. Vision worsened in 11% (7-17) of patients after clipping, 8% (2-17) after coiling, and 7% (0-27) after flow diversion. New visual deficits were found in patients with intact baseline vision at a rate of 0.69% (0-2) for clipping, 0.53% (0-3) for coiling, and 0.80% (0-3) for flow diversion. Conclusion: Our data demonstrates a high rate of visual improvement and a low rate of iatrogenic vision impairment for patients with paraclinoid aneurysms treated with flow diversion. Further analysis is needed to compare flow diversion to clipping and coiling and inform clinical management of visually symptomatic paraclinoid aneurysms.

Background: Serial ASPECTS of ischemic stroke lesion evolution from baseline to 24-hours has been established as an effective surrogate endpoint in endovascular therapy. The use of this imaging shift has not been implemented beyond thrombectomy trials to estimate impact of endovascular therapy in large-scale registry data. Methods: The STRATIS Imaging Core Lab, blind to all clinical data, independently determined ASPECTS scores on baseline and 24-hour studies. ASPECTS regional involvement and resulting total scores were analyzed in anterior circulation occlusions in STRATIS. Statistical analyses calculated the proportion of subjects with 0 ASPECTS score shift and separately, those with shifts >4, 5, 6 points. Clinical predictors of ASPECTS shift and regional involvement were determined. Results: Baseline ASPECTS (n=517) was 8.2 ± 1.59 (median 8.0 (2, 10)) and 24-hour ASPECTS (n=547) was 6.0 ± 2.92 (median 7.0 (0, 10)). Serial ASPECTS (n=487) revealed change of -2.1 ± 2.41 (median-1.0 (-10, 3)). Absolutely no change in ASPECTS, or 0 shift from baseline to 24 hours, occurred in 157/487 (32%). Substantial ASPECTS decline of ≥4 occurred in 117/487 (24%), with ≥5 in 76/487 (16%) and ≥6 in 51/487 (10%). ASPECTS decline was linked with baseline collaterals (ASITN 4 (n=19; -0.9 ± 1.05); 3 (n=117; -0.8 ± 1.21); 2 (n=140; -2.6 ± 2.27); 1 (n=29; -3.6 ± 2.34); 0 (n=10; -4.2 ± 3.08)) and the degree of subsequent reperfusion (oTICI 3 (n=63; -1.1 ± 1.94); 2B (n=282; -1.9 ± 2.32); 2A (n=103; -3.4 ± 2.38); 1 (n=2; -3.0 ± 1.41); 0 (n=10; -4.0 ± 2.75)). Baseline predictors of ≥6 ASPECTS decline included previous TIA (OR 3.10 (95%CI 1.32, 7.31), diabetes (OR 2.23 (95%CI 1.22, 4.07)) and baseline NIHSS (OR 1.10 (95%CI 1.03, 1.16). Conclusions: Frozen ASPECTS or 0 shift from baseline to 24 hours occurs in about 1/3 of all cases treated with endovascular therapy in a large-scale registry. Poor collaterals, prior TIA, diabetes and elevated baseline NIHSS may be important predictors of those likely to experience infarct evolution despite reperfusion, identifying optimal candidates for neuroprotection with endovascular therapy.

Developmental venous anomalies (DVAs, also known as venous angiomas) are rare, asymptomatic congenital remnants of fetal venous vasculature. As persistent fetal veins, they provide critical venous drainage for the brain parenchyma, and resection or embolization is associated with significant morbidity from venous infarction. They are often incidentally discovered in association with cavernomas, which are more frequently symptomatic. They do not independently progress and therefore do not require follow-up when discovered incidentally. However, in rare circumstances, they can present with arteriovenous shunting from adjacent arteriovenous malformations, which then alters the venous drainage pattern and evolution of symptoms. Core principles in defining the risk and management plan of a DVA are attribution of presenting symptoms to DVA or another source, identifying mechanism of DVA symptomatology for indirect treatment of these symptoms as an alternative to the DVA, and defining the DVA flow pattern.

Despite rapid advances in modern medicine, stroke remains the second largest cause of death in the world. Intracerebral hemorrhage (ICH) is the deadliest form of stroke, with the highest rates of morbidity and mortality. Treatment strategies vary greatly from ischemic stroke, making the ability to recognize, diagnose, and initiate treatment of this medical emergency a requirement of all clinicians. In this chapter we review the pathology, presentation, radiographic findings, and decision making behind the most common forms of ICH. We also discuss the reasoning behind some of the advanced studies that specialist teams may request. Although surgical intervention has the ability to be acutely lifesaving in a handful of specific pathologies (e.g., hydrocephalus and large posterior fossa hemorrhage), the criteria for operating on patients with ICH are still being defined. Morbidity and mortality remain high for this disease, and a basic understanding of ICH is required to act quickly and decisively to improve outcomes.

We aimed to evaluate if vertebrobasilar anatomic variations impact reperfusion and outcome in intra-arterial therapy (IAT) for basilar artery occlusion (BAO).Consecutive BAO patients with symptom onset24 h treated with IAT were included. Vertebral artery (VA) V3 and posterior communicating artery (PCoA) diameters were measured (CT angiography or MR angiography). The presence of PCoA atresia, VA hypoplasia, VAs that end in the posterior inferior cerebellar artery (PICA), and extracranial VA occlusion was recorded.38 BAO patients were included. Mean age was 63±15 years; 52% were men. Baseline National Institutes of Health Stroke Scale score was 21±9, and mean/median time from symptom onset to IAT were 10/7 h. First generation thrombectomy devices were mostly used. Overall Treatment in Cerebral Ischemia 2b-3 reperfusion was 68.4%. Good outcome (modified Rankin Scale score ≤2) was observed in 17.8% and mortality in 64.3% of cases at 90 days. 55% of patients had an atretic PCoA while 47% had a hypoplastic VA. The mean sum of the bilateral PCoA and VA diameters were 2.3±1.2 and 5.2±5.2 mm, respectively. VAs that end in the PICA was noted in 23% of patients, and extracranial VA occlusion in 42%. BAO was proximal/mid/distal in 36%/29%/34%. Multivariate linear regression analysis indicated hypertensive disease (β=2.97; 95% CI 1.15 to 4.79; p0.01) and reperfusion rate (β=-0.40; 95% CI -0.74 to -0.70; p=0.02) independently associated with outcome. Multivariate analysis for predictors of reperfusion failed to identify other associations. A trend for better reperfusion with stent retrievers was noted (β=1.82; 95% CI -0.24 to 3.88; p=0.08).Reperfusion emerged as a predictor of good outcome in patients that underwent IAT for BAO. Angioarchitectural variations of the posterior circulation were not found to impact reperfusion or clinical outcome.

The degree of coronary artery calcification has been shown to predict outcomes in coronary artery disease. The impact of intracranial carotid artery calcification on the prognosis of acute ischemic stroke (AIS) is unknown. The authors sought to examine if the degree of intracranial carotid artery calcification influences reperfusion or outcomes in AIS intervention.All anterior circulation large vessel occlusion AIS cases that underwent intra-arterial therapy from January 2009 to July 2012 were reviewed. Clinical and radiographic data were collected. Non-contrast brain CT scans were assigned a Calcium Extent Score (degree of calcification of the carotid wall circumference), Calcium Thickness Score (thickness of the calcified plaque), and total Carotid Siphon Calcium (CSC) Score (8-point scale).One-hundred seventeen patients met inclusion criteria. The mean age was 65.4±15.6 years and 36% were male. Calcification was present in the intracranial carotid artery of 84 patients (71%). Inter-rater agreement for total CSC score was strong (Spearman's rho=0.883, p0.001). The mean Calcium Extent Score was 1.5±1.3, Calcium Thickness Score 1.3±1.0 and total CSC Score 2.8±2.2. Reperfusion and mRS were not associated with CSC. Multivariate linear regression analysis revealed that older age, history of coronary disease and cervical internal carotid occlusion/near-occlusion were independently associated with higher total CSC scores.Extensive calcification on the intracranial carotid artery does not have impact on reperfusion or clinical outcomes in AIS patients undergoing endovascular therapy. Higher CSC scores are associated with coronary artery disease, increasing age and cervical internal carotid artery occlusion/near-occlusion.

Object The resection of glomus jugulare tumors can be challenging because of their inherent vascularity. Preoperative embolization has been advocated as a means of reducing operative times, blood loss, and surgical complications. However, the incidence of cranial neuropathy associated with the embolization of these tumors has not been established. The authors of this study describe their experience with cranial neuropathy following transarterial embolization of glomus jugulare tumors using ethylene vinyl alcohol (Onyx, eV3 Inc.). Methods The authors retrospectively reviewed all cases of glomus jugulare tumors that had been treated with preoperative embolization using Onyx at their institution in the period from 2006 to 2012. Patient demographics, clinical presentation, grade and amount of Onyx used, degree of angiographic devascularization, and procedural complications were recorded. Results Over a 6-year period, 11 patients with glomus jugulare tumors underwent preoperative embolization with Onyx. All embolization procedures were completed in one session. The overall mean percent of tumor devascularization was 90.7%. No evidence of nontarget embolization was seen on postembolization angiograms. There were 2 cases (18%) of permanent cranial neuropathy attributed to the embolization procedures (facial nerve paralysis and lower cranial nerve dysfunction). Conclusions Embolizing glomus jugulare tumors with Onyx can produce a dramatic reduction in tumor vascularity. However, the intimate anatomical relationship and overlapping blood supply between these tumors and cranial nerves may contribute to a high incidence of cranial neuropathy following Onyx embolization.