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Background: Successful reperfusion is one of the strongest predictors of functional outcomes after mechanical thrombectomy (MT). Despite continuous advancements in MT technology and techniques, reperfusion failure still occurs in ≈15% to 30% of patients with large vessel occlusion strokes undergoing MT. We aim to evaluate the safety and efficacy of rescue intracranial stenting for large vessel occlusion stroke after failed MT. Methods: The SAINT (Stenting and Angioplasty in Neurothrombectomy) Study is a retrospective analysis of prospectively collected data from 14 comprehensive stroke centers through January 2015 to December 2020. Patients were included if they had anterior circulation large vessel occlusion stroke due to intracranial internal carotid artery and middle cerebral artery-M1/M2 segments and failed MT. The cohort was divided into 2 groups: rescue intracranial stenting and failed recanalization (modified Thrombolysis in Cerebral Ischemia score 0–1). Propensity score matching was used to balance the 2 groups. The primary outcome was the shift in the degree of disability as measured by the modified Rankin Scale at 90 days. Secondary outcomes included functional independence (90-day modified Rankin Scale score 0–2). Safety measures included symptomatic intracranial hemorrhage and 90-day mortality. Results: A total of 499 patients were included in the analysis. Compared with the failed reperfusion group, rescue intracranial stenting had a favorable shift in the overall modified Rankin Scale score distribution (acOR, 2.31 [95% CI, 1.61–3.32]; P P P =0.04) at 90 days. Rates of symptomatic intracerebral hemorrhage were comparable across both groups (7.1% versus 10.2%; aOR, 0.99 [95% CI, 0.42–2.34]; P =0.98). The matched cohort analysis demonstrated similar results. Specifically, rescue intracranial stenting (n=107) had a favorable shift in the overall modified Rankin Scale score distribution (acOR, 3.74 [95% CI, 2.16–6.57]; P P P =0.03) at 90 days with similar rates of symptomatic intracerebral hemorrhage (7.5% versus 11.2%; aOR, 0.87 [95% CI, 0.31–2.42]; P =0.79) compared with patients who failed to reperfuse (n=107). There was no heterogeneity of treatment effect across the prespecified subgroups for improvement in functional outcomes. Conclusions: Acute intracranial stenting appears to be a safe and effective rescue strategy in patients with large vessel occlusion stroke who failed MT. Randomized multicenter trials are warranted.

Importance: Clinical trials focusing on new mechanical thrombectomy (MT) technologies have been typically single-arm studies using historical comparison data to determine the safety and efficacy of the novel device. To date, there has not been a contemporaneous prospective, randomized, controlled study comparing standard to newer designed stent-retrievers. Objective: To evaluate the safety and efficacy of the pRESET (phenox Ltd) compared to the Solitaire (Medtronic Corp) thrombectomy devices in the treatment of large vessel occlusion strokes (LVOS). Methods: Multicenter, prospective, randomized, open-label, blinded endpoint, core lab adjudicated, non-inferiority trial that enrolled 340 patients from October 2019 to February 2022 across 19 US & 5 German sites. Patients aged ≥ 18 years with either anterior or posterior circulation LVOS were included up to 8 hours after symptom onset. Patients were randomly assigned in a 1:1 ratio to either pRESET or Solitaire for the first three device passes.The Primary Endpoint was the proportion of patients achieving a modified Rankin Scale score of 0-2, analyzed by intent to treat with a non-inferiority margin of 0.125 based on the lower bound 95% Confidence Interval. The Primary Safety Endpoint was the proportion of subjects with device- or procedure-related symptomatic intracerebral hemorrhage at 24 (-8/+12) hours as per the SITS-MOST criteria. Secondary Outcome Measures included the rates of (1) Successful Revascularization (defined as expanded Thrombolysis in Cerebrovascular Infarction [eTICI] ≥2b50 ≤3 passes of the assigned device; (2) eTICI ≥2c following the first pass of the assigned device; (3) 90-day mortality and (4) Distribution of 90-day mRS across the entire spectrum of disability (ordinal shift). Results: The study database was locked in August 2022. The analysis is ongoing and the final results will be presented at the 2023 International Stroke Conference. Conclusions and Relevance: PROST is the first randomized clinical trial aiming to compare a novel versus an established stent-retriever technology, establishing a new scientific benchmark for stroke device trials. (ClinicalTrials.gov: NCT03994822).

BackgroundThe aim of this article is to outline a position statement on pregnancy and parental leave for physicians practicing neurointerventional surgery.MethodsWe performed a structured literature review regarding parental leave policies in neurointerventional surgery and related fields. The recommendations resulted from discussion among the authors, and additional input from the Women in NeuroIntervention Committee, the full Society of NeuroInterventional Surgery (SNIS) Standards and Guidelines Committee, and the SNIS Board of Directors.ResultsSome aspects of workplace safety during pregnancy are regulated by the US Nuclear Regulatory Commission. Other aspects of the workplace and reasonable job accommodations are legally governed by the Family and Medical Leave Act of 1993, the Affordable Care Act of 2010 and the Fair Labor Standards Act of 1938, Americans with Disabilities Act of 1990, Title IX of the Education Amendments of 1972, Title VII of the Civil Rights Act of 1964 as well as rights and protections put forth by the Occupational Safety and Health Administration as part of the United States Department of Labor. Family friendly policies have been associated not only with improved job satisfaction but also with improved parental and infant outcomes. Secondary effects of such accommodations are to increase the number of women within the specialty.ConclusionsSNIS supports a physician’s ambition to have a family as well as start, develop, and maintain a career in neurointerventional surgery. Legal and regulatory mandates and family friendly workplace policies should be considered when institutions and individual practitioners approach the issue of childbearing in the context of a career in neurointerventional surgery.

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

Background and Purpose: The Tigertriever is a novel, radially adjustable, fully visible, stentriever that permits the operator to align radial expansion with target vessel diameters. This multicenter trial compared the Tigertriever’s effectiveness and safety compared with established stent retrievers. Methods: Single arm, prospective, multicenter trial comparing the Tigertriever to efficacy and safety performance goals derived from outcomes in 6 recent pivotal studies evaluating the Solitaire and Trevo stent-retriever devices with a lead-in and a main-study phase. Patients were enrolled if they had acute ischemic stroke with National Institutes of Health Stroke Scale score ≥8 due to large vessel occlusion within 8 hours of onset. The primary efficacy end point was successful reperfusion, defined as core laboratory-adjudicated modified Thrombolysis in Cerebral Ischemia score 2b-3 within 3 passes of the Tigertriever. The primary safety end point was a composite of 90-day all-cause mortality and symptomatic intracranial hemorrhage. Secondary efficacy end points included 3-month good clinical outcome (modified Rankin Scale score 0–2) and first-pass successful reperfusion. Results: Between May 2018 and March 2020, 160 patients (43 lead-in, 117 main phase) at 17 centers were enrolled and treated with the Tigertriever. The primary efficacy end point was achieved in 84.6% in the main-study phase group compared with the 63.4% performance goal and the 73.4% historical rate (noninferiority P P P =0.004; superiority P =0.57). Good clinical outcome was achieved in 58% at 90 days. Conclusions: The Tigertriever device was shown to be highly effective and safe compared with Trevo and Solitaire devices to remove thrombus in patients with large-vessel occlusive stroke eligible for mechanical thrombectomy. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03474549.

The pediatric population spans a diverse age group,1 from neonates and infants to adult-sized teenagers, each with unique physiological characteristics that must be considered when performing diagnostic cerebral angiography (DCA). Herein we refer to pediatric patients as under the age of 18 years. Neonates will not be discussed further due to the very limited role of DCA in the absence of planned neurointervention, most commonly for vein of Galen malformations and other high-flow arteriovenous fistulas leading to life-threatening heart failure. The number of pediatric neuroangiography procedures performed continues to grow2 and it is evident that the technical aspects of performing pediatric DCA are highly variable among practitioners, including our own Task Force members. This reflects the diversity of angiographers from different specialties and the varying levels of prior pediatric neuroangiography training and experience. In 2019, the Society of Neurointerventional Surgery (SNIS) surveyed its membership regarding their individual fellowship training and current practice as it relates collectively to pediatric neuroangiography, including both diagnostic and interventional procedures. Unpublished results indicate that pediatric neuroangiography training and current experience is limited across the nation (figure 1). Most respondents (94%) performed pediatric DCA during fellowship, though this experience was mostly limited and low volume. In children under 4 years of age, that experience was further reduced (40%: 0–10 cases; 45%: 11–49 cases). Despite this limited exposure, 76% of respondents reported currently treating pediatric patients, though in more than half (53%), that volume remains low: 0–10 pediatric cases per year. Practice guidelines for cervicocerebral catheter angiography have been published for adults,3 however, no similar recommendations exist for children. Given this information, Pediatric Neurointerventional Task Force Committee members of the SNIS sought to provide a framework with which safe pediatric DCA can be performed, detailing specific procedural considerations as well as peri-procedural evaluation and …

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

While the landmark 2015 stroke trials demonstrated that endovascular therapy (EVT) was superior to medical management for the treatment of acute ischemic stroke due to large vessel occlusion, the efficacy of EVT for patients presenting with a low NIHSS score remains undetermined. We conducted a review of the EVT low National Institutes of Health Stroke Scale (NIHSS) stroke literature, identifying 24 quantitative and six qualitative publications. Details of study designs and outcome were extracted and critically discussed.All identified qualitative studies were retrospective. There was significant study design heterogeneity, with 18 unique study designs between the 24 identified quantitative manuscripts. Study investigations included low NIHSS EVT feasibility (n=6), EVT versus best medical management (BMM; n=10), EVT versus intravenous therapy (IVT, n=3), and low NIHSS score versus high NIHSS score (n=3). From single-arm EVT feasibility studies, the reported ranges of modified Thrombolysis in Cerebral Infarction and symptomatic intracranial hemorrhage were 78–97% and 0–10%, respectively. The EVT versus BMM literature had heterogeneous results with 40% reporting benefit with EVT and 60% reporting neutral findings. None of the studies comparing EVT with IVT reported a difference between the two revascularization therapies. The four identified meta-analyses had incongruent inclusion criteria and conflicting results. Two randomized trials are currently investigating EVT in patients with a low NIHSS score. Selected meta-analyses do suggest a potential benefit of EVT over BMM; however, current and future randomized clinical trials will better elucidate the efficacy of EVT in this patient population.

BackgroundClinicalTrials.gov is one of the largest trials’ registries in the world.ObjectiveTo leverage the ClinicalTrials.gov database to define the portfolio of clinical trials of neurointervention.MethodsWe restricted our extraction to interventional clinical trials submitted between 2007 and 2018, and included MeSH terms that are part of the nervous system (n=19 344) or cardiovascular disease (n=19 234) categories and included a list of neurointerventional terms. The characteristics of trials, geographic distribution, dissemination, and funding sources were explored using descriptive and regression models.ResultsA total of 206 neurointerventional clinical trials across 1691 medical centers were identified. Acute stroke was the most studied conditions (68, 33%), followed by aneurysms (63, 31%), carotid stenosis (48, 24%), intracranial atherosclerotic disease (7, 3.5%), cerebral venous thrombosis (6, 3%), arteriovenous malformation (4, 2%), idiopathic intracranial hypertension (3, 1.5%), and others (6, 3%). Overall, 59 (29%) trials were completed, 79 (37%) were active trials (28% recruiting), and 22 (11%) were terminated or suspended. Academic centers and industry were the most common primary funding source (63% and 29%, respectively), with no funding source reported in 16 (7.7%) trials. Among 77 completed or terminated trials, only 9 (11.7%) trials reported findings within 12 months. Median time to publication for trials funded by academia was 1.66 years (interquartile range (IQR) 0.7–2.1) versus 2.1 years (IQR 1.2–3.25) for industry-funded studies.ConclusionsA low dissemination rate for results and a high rate of study non-completion, as well as lack of geographic dispersion of trials appear to be major challenges in the field.

The global pandemic of coronavirus disease 2019 (COVID-19), caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), represents an unprecedented challenge to our healthcare system.1 As the number of identified COVID-19 patients exponentially increases, protocols for the safe delivery of care of both patients and providers are vital. This is especially true, given the number of healthcare providers who have contracted the disease. If we fail to protect physicians, nursing staff, and ancillary providers, we will fail to meet the needs of future patients. The successful care of future COVID-19 patients will depend on effective safety and prevention strategies for healthcare workers.2 Patients with acute ischemic stroke (AIS) are a high-risk patient cohort. Li et al performed an analysis of six studies encompassing 1527 patients with COVID-19 and showed that patients with cardio/cerebrovascular disease comprised 16.4% of the cohort, but that the incidence was approximately threefold higher among patients with severe COVID-19 requiring intensive care (ICU) admission.3 Thus, patients with a history of AIS and/or its risk factors are particularly at risk for the severe form of COVID-19. Additionally, there is early evidence that SARS-CoV-2 can cause neurologic signs, and that it has been reported in the brains of both patients and animal models.4 Of patients with SARS-CoV-2 respiratory distress, 36.4% had neurologic symptoms with 4.5% of severe patients suffering ischemic stroke.5 In this setting, neurointerventionalists should expect to be involved in the care of COVID-19-positive patients, as well as those whose status is unknown and those at risk of a severe form of the disease. While the data on COVID-19 are rapidly emerging, the Society of NeuroInterventional Surgery seeks to provide neurointerventionalists with rapid up-to-date recommendations on the management of stroke thrombectomy in this setting with an emphasis on safety measures for …

Background Although still recommended, using intravenous tissue plasminogen activator (IV-tPA) for large vessel occlusions (LVOs) has been questioned in the era of mechanical thrombectomy (MT). We sought to determine the impact of IV-tPA if used before MT. Methods We used a single-institution, prospectively maintained stroke database from July 2017 through June 2019. All patients undergoing MT with or without IV-tPA treatment for LVO with pretreatment computed tomography angiography (CTA) head and neck were included. We compared the initial CTA images of clot location and morphology to the angiographic findings visualized on the first injection before mechanical intervention. Results Eighty patients were included. About a third (33%) received IV-tPA before thrombectomy. Among patients receiving IV-tPA, significantly more, 29% versus 5.6% without IV-tPA, experienced distal clot migration or changes in morphology between first CTA acquisition and first angiographic run before thrombectomy (P = 0.006). On logistic regression IV-tPA was the only significant predictor of clot migration (P = 0.024). Of note, clot migration due to IV-tPA use was not associated with superior recanalization rates or outcomes in this analysis (P = 0.27). Original site clot resolution was noted in 8% (2/24) of patients who received IV-tPA; however, distal M4/5 embolic cutoffs were noted in both patients. Conclusions IV-tPA administration for LVO has a low rate of primary recanalization with risk of distal embolic phenomenon often still requiring MT. No significant changes in patient outcomes were noted in this study due to clot migration. Larger studies will be necessary to determine if IV-tPA plus MT truly benefits entire clot removal versus MT alone.

BackgroundPipeline embolization devices (PEDs) are increasingly used in the treatment of cerebral aneurysms. Yet, major ischemic or hemorrhagic complications after PED treatment associated with antiplatelet regimens are not well-established.ObjectiveTo investigate the risk of ischemic and hemorrhagic complications associated with common antiplatelet regimens following PED treatment, and to examine whether platelet function testing (PFT) is associated with a lower risk of these complications.MethodsWe searched Medline, Embase, and Cochrane from 2009 to 2017. Twenty-nine studies were included that had reported a uniform antiplatelet regimen protocol and had provided data on major ischemic and hemorrhagic complications following PED treatment. Random-effect meta-analysis was used to pool overall ischemic and hemorrhagic event rates across studies. The rate of these complications with respect to the antithrombotic regimen and PFT was assessed by χ2 proportional tests.ResultsOverall, 2002 patients (age 55.9 years, 76% female) were included. A low-dose acetylsalicylic acid (ASA) regimen before and after PED treatment was associated with a higher rate of late ischemic complications than with high-dose ASA therapy (2.62 (95% CI 1.46 to 4.69) and 2.56 (1.41 to 4.64), respectively). Duration of post-procedure clopidogrel therapy ConclusionHigh-dose ASA therapy and clopidogrel treatment for at least 6 months were associated with a reduced incidence of ischemic events, without affecting the risk of hemorrhagic events.

Reversible cerebral vasoconstriction syndrome (RCVS), is rare in the pediatric population and is characterized by severe headaches and other neurologic symptoms. We present a case of RCVS occurring concomitantly with posterior reversible encephalopathy syndrome in an 8-year-old African American child with sickle cell disease (HbSS). Imaging studies including computed tomography, magnetic resonance imaging and cerebral angiography of the brain showed acute hemorrhagic stroke and a beaded appearance of peripheral cerebral vessels. In this report, we focus on the typical features of RCVS and discuss the underlying risk factors that may increase the risk in patients with HbSS disease.

Background In patients who have failed systemic anticoagulation therapy, various endovascular approaches may assist in emergent recanalization. Methods We searched the PubMed database from January 1999 to August 2018 for studies that reported endovascular treatment modalities and associated clinical outcomes including recanalization, functional independence, mortality, or intracranial complications. Random-effect models were used to pool estimates across studies using R software. Results Overall, 393 patients with cerebral venous thrombosis from 21 studies were included in the study. Transvenous local chemolysis treatment results were as follows: good outcome rate. 0.88 (95% confidence interval [CI], 0.80–0.93), mortality, 0.08 (95% CI, 0.04–0.16), postprocedural hemorrhagic rate, 0.11 (95% CI, 0.06–0.19), and complete recanalization rate, 0.59 (95% CI, 0.48–0.70). Transvenous mechanical thrombectomy results were as follows: good outcome rate, 0.66 (95% CI, 0.41–0.84), mortality, 0.09 (95% CI, 0.03–0.26), postprocedural hemorrhagic rate, 0.03 (95% CI, 0–0.16), and complete recanalization rate, 0.60 (95% CI, 0.35–0.80). Combined approach treatment results were as follows: good outcome rate, 0.80 (95% CI, 0.70–0.87), mortality, 0.10 (0.04–0.22), postprocedural hemorrhagic rate, 0.17 (95% CI, 0.10–0.27), and complete recanalization rate, 0.75 (95% CI, 0.64–0.84). Mixed approach to treatment results were as follows: good outcome rate, 0.61 (95% CI, 0.51–0.70), mortality, 0.23 (95% CI, 0.16–0.32), postprocedural hemorrhagic rate, 0.46 (95% CI, 0.33–0.59), and complete recanalization rate, 0.48 (95% CI, 0.37–0.58). Conclusions The combination approach treatment tended to have better outcomes, although this meta-analysis did not achieve statistical significance in all outcome parameters. Future studies are needed to establish the best treatment options with tailoring to specific clinical or angiographic scenarios.

There are several methods to achieve the therapeutic sacrifice of the vessel, coiling brings the most commonly used. Penumbra occlusion device (POD) system is a newer modality for therapeutic large vessel occlusion, and it is the Food and Drug Administration approved only for peripheral vessels. We report a case where therapeutic vertebral artery (VA) occlusion was achieved with the POD system and Ruby coils for the first time. A patient was diagnosed with a new malignant-appearing tumor of the cervical spine. A conventional angiogram showed multiple tiny arterial feeders from the VA beyond scope of coil/onyx embolization, so we performed a balloon occlusion test followed by therapeutic sacrifice of the VA. A successful VA occlusion was achieved with significant reduction in the tumor blush, followed by open resection of the tumor. The patient had favorable postoperative course and without any neurological symptoms attributed to the VA occlusion.

Introduction/purpose Neuroendovascular therapies are increasingly used in treatment of cerebral aneurysms. However, data is sparse on outcomes of various treatment strategies for anterior cerebral artery (ACA) territory. We performed a systematic review and meta-analysis to compare outcomes of treatment strategies for ruptured or unruptured ACA aneurysms from prior high quality published data. Materials and methods We searched MEDLINE, Embase, and Cochrane from January 2000 until January 2018. High quality studies were included that had reported initial morbidity indices, occlusion rates, late follow up data, and operative complications (ischemic, hemorrhagic, retreatment rate) for endovascular coiling vs pipeline flow-diversion vs neurosurgical clipping separately reported for ruptured and unruptured aneurysms of ACA territory. Random-effect or fixed-effect models were used to pool estimates across studies using R software. Results Overall, 1230 ACA aneurysms from 22 studies including 910 (775 ruptured) coiling, 105 pipeline (All unruptured) and 140 clipping (130 ruptured) treatments were identified using a systematic method. For ruptured ACA aneurysms treated with coiling, occlusion rates were 0.86 (0.84–0.89) and 0.85 (0.72–0.93) in immediate and late assessment respectively. Final occlusion rate was 0.96 (0.87–0.99) for ruptured ACA aneurysms treated with clipping. For unruptured ACA aneurysms treated with coiling, occlusion rates were 0.93 (0.85–0.97) and 0.86 (0.73–0.93) in immediate and late assessment respectively. Final occlusion rate was 0.82 (0.71–0.89) for unruptured ACA aneurysms treated with pipeline device. For ruptured ACA aneurysms treated with coiling, secondary ICH occurred in 0.08 (0.07–0.11) (n=731) and retreatment rate was 0.10 (0.05–0.18). For those treated with clipping, ICH occurred in 0.12 (0.03–0.37) and retreatment rate was 0.06 (0.02–0.13) (n=110). No study of ruptured ACA aneurysm treated with pipeline device was eligible to be included in our meta-analysis. For unruptured ACA aneurysms treated with coiling, the risk of ischemic stroke was 0.09 (0.05–0.18) (n=121), ICH occurred in 0.05 (0.02–0.12) (n=121) and retreatment rate was 0.10 (0.05–0.18) (n=100). For those treated with pipeline device, the risk of ischemic stroke was 0.03 (0.01–0.09) (n=103), ICH occurred in 0.04 (0.02–0.11) and retreatment rate was 0.02 (0.01–0.08) (n=105). Meta-analysis was not technically possible for unruptured ACA aneurysm treated with surgical clipping due to small numbers. Conclusion Endovascular and surgical treatment modalities appear safe and effective in treatment of ACA aneurysm. There is a large amount of heterogeneity in reporting baseline characteristics and final outcomes in the literature limiting number of studies for comparison of outcomes by vascular territory. Disclosures H. Saber: None. G. Rajah: None. H. Fadel: None. B. Kolb: None. A. Luqman: None. S. Narayanan: None.

Introduction/purpose Data on the predictive value of thrombus characteristics on initial CT imaging and radiologic outcomes is conflicting in stroke patients treated with endovascular thrombectomy (EVT). We aimed to evaluate the association between thrombus CT characteristics and successful recanalization in patients with acute large vessel occlusive stroke treated with EVT. Materials and methods We performed a retrospective study using a prospectively maintained database of individuals with acute ischemic stroke admitted to the neurointensive care unit at Detroit Medical Center between 2014–2017. Patients with confirmed large vessel occlusion (LVO) treated with EVT were included. Primary outcome successful recanalization defined as TICI2b/3. Data was recorded for baseline risk factors, initial NIHSS, time-to-treatment, tPA administration, as well as initial CT findings including hyperdense artery sign (HAS), thrombus length (millimeter) and thrombus density (absolute Hounsfield unit values). Independent two-sample T-test and Fisher’s exact test were used to investigate the association between thrombus CT characteristics and successful recanalization. Results Overall 74 patients with LVO strokes (age 67.75+13.38, 44% female) treated with EVT were included. Successful recanalization was achieved in 72.6% of patients. HAS was present in 54% and intravenous tPA was administered in 37% of patients as adjunctive therapy. Baseline clinical characteristics including hypertension, diabetes, atrial fibrillation, initial NIHSS as well as tPA administration (p=0.5) or presence of HAS (p=0.7) were not predictive of successful recanalization. Thrombus density values were comparable in those with and without successful recanalization (61.6±1.7 vs 61.0±3.2, p=0.8, respectively). Greater thrombus length was a significant predictor for non-recanalization following EVT (34.3±12.4 vs 17.5±01.9, p=0.03 for thrombus length in TICI 0–2a vs TICI 2b/3 groups, respectively). Conclusions We observed that thrombus length but not thrombus density or tPA administration are predictive of successful recanalization in LVO treated with EVT. Disclosures H. Saber: None. J. Kinariwala: None. G. Rajah: None. S. Narayanan: None. A. Luqman: None. M. Ibrahim: None. K. Suchdev: None.

Remote intracerebral hemorrhage in stroke patients treated with intravenous recombinant tissue-type plasminogen (IV-tPA) is a poorly understood entity with uncertain etiology. A 65 year old woman was treated with IV-tPA after presenting to our institution with a one hour history of right sided weakness and speech difficulty. Cerebral angiography showed occlusion of the left superior M2 division of middle cerebral artery (MCA). Mechanical thrombectomy of the left MCA clot was performed with confirmation of subsequent TICI-3a flow. Intraoperative left vertebral artery injection was performed to look for collateral flow, which revealed contrast extravasation from the left thalamoperforator arteries in real time. With no CT evidence of prior infarct in this region and a demonstrated lack of perfusion defect via angiography, this novel observation supports the hypothesis that remote intracerebral hemorrhage following IV-tPA is due to pre-existing small vessel disease, with or without microbleeds. As we enter the era of endovascular stroke treatment, our observation that pre-existing small vessel disease with or without microbleeds plays a role in the etiology of remote intracerebral hemorrhage indicates that risk factors for small vessel disease should be incorporated into future risk models for thrombolytic stroke therapy. Disclosures P. Chamiraju: None. B. Kolb: None. H. Saber: None. P. Maddali: None. S. Narayanan: None.

Background: Idiopathic intracranial hypertension (IIH) is characterized by an elevated intracranial pressure without any identifiable causative factor such as an intracranial mass. Dural venous sinus stenosis (DVSS) has been suggested to be associated with IIH. Objective: We performed an updated systematic review and meta-analysis to determine clinical outcomes as well as stent survival and stent-adjacent stenosis rates in patients undergoing DVSS for the management of medically refractory IIH. Methods: We searched PubMed, Embase, and Cochrane databases to identify prospective or retrospective cohorts or case series of patients with IIH treated with DVSS between 2000 and 2017. Results: A total of 473 patients were included from 24 studies. Headache was present in 429 (91.8%) patients and resolved or improved in 319/413 (77.2%) after the procedure. Headache, papilledema, visual acuity, and tinnitus improved in 256/330 (77.6%), 247/288 (85.8%), 121/172 (70.3%), and 93/110 (84.5%) patients following DVSS at the final follow-up (mean of 18.3 months). In a meta-analysis of 395 patients with available follow-up data on stenting outcome (mean of 18.9 months), the stent survival and stent-adjacent stenosis rates were 84% (95% confidence interval [CI] 79–87%) and 14% (95% CI 11–18%), respectively. The rate of major neurological complications was less than 2%. Conclusion: Stent-adjacent stenosis is an important complication following venous stenting in patients with DVSS and IIH. Further studies are needed to identify determinants of stent-adjacent stenosis and stent nonsurvival.

BackgroundEndovascular thrombectomy has demonstrated benefit for patients with acute ischemic stroke from proximal large vessel occlusion. However, limited evidence is available from recent randomized trials on the role of thrombectomy for M2 segment occlusions of the middle cerebral artery (MCA).MethodsWe conducted a systematic review and meta-analysis to investigate clinical and radiographic outcomes, rates of hemorrhagic complications, and mortality after M2 occlusion thrombectomy using modern devices, and compared these outcomes against patients with M1 occlusions. Recanalization was defined as Thrombolysis in Cerebral Infarction (TICI) 2b/3 or modified TICI 2b/3.ResultsA total of 12 studies with 1080 patients with M2 thrombectomy were included in our analysis. Functional independence (modified Rankin Scale 0–2) rate was 59% (95% CI 54% to 64%). Mortality and symptomatic intracranial hemorrhage rates were 16% (95% CI 11% to 23%) and 10% (95% CI 6% to 16%), respectively. Recanalization rates were 81% (95% CI 79% to 84%), and were equally comparable for stent-retriever versus aspiration (OR 1.05; 95% CI 0.91 to 1.21). Successful M2 recanalization was associated with greater rates of favorable outcome (OR 4.22; 95% CI 1.96 to 9.1) compared with poor M2 recanalization (TICI 0–2a). There was no significant difference in recanalization rates for M2 versus M1 thrombectomy (OR 1.05; 95% CI 0.77 to 1.42).ConclusionsThis meta-analysis suggests that mechanical thrombectomy for M2 occlusions that can be safely accessed is associated with high functional independence and recanalization rates, but may be associated with an increased risk of hemorrhage.

Introduction/Purpose Pipeline embolization devices (PEDs) are increasingly used in treatment of cerebral aneurysms. Yet, risk factors associated with major ischemic or hemorrhagic complications after PED treatment are not well-established. We performed a meta-analysis to investigate risk factors associated with major intracranial complications following PED treatment. We also aimed to examine whether platelet function testing is associated with lower risk of these complications. Materials and methods We searched PubMed database to identify reports on the treatment of cerebral aneurysms using PEDs between 2009 and 2017, with data available on major ischemic/hemorrhagic complications, or platelet function testing before intervention. Random-effect models were used to pool data on determinants of ischemic or hemorrhagic complications across studies. Results A total of 14 studies were included in this analysis, including 2388 patients with available data on platelet function testing. The mean follow-up interval was 6.4 months. Variables associated with higher odds of ischemic or hemorrhagic complications included male sex (odds ratio [OR], 1.79; 95% confidence interval [CI], 1.01–3.17), hypertension (2.54, 1.44–4.49) and concurrent aneurysm treatment (4.08, 1.63–10.18). Anterior location and size Conclusion In this pooled analysis, we reported the main factors associated with major intracranial complications in patients undergoing PED placement. Platelet function testing was not associated with decreased major complications in these patients. Future prospective studies are required to identify subgroups with highest risk of major complications after treatment with PEDs. Disclosures H. Saber: None. P. Chamiraju: None. S. Narayanan: None.

Introduction/Purpose Idiopathic intracranial hypertension (IIH) is characterized by an elevated intracranial pressure without any identifiable causative factor such as an intracranial mass. Venous sinus stenosis has been increasingly known as a treatable cause of elevated intracranial pressure in patients with medically refractory IIH. We aimed to perform a systematic review and analysis of outcomes and complications in all patients undergoing dural venous sinus stenting (DVSS) for the management of medically refractory IIH. Materials and methods We searched PubMed and Google Scholar databases to identify prospective or retrospective cohorts or case-series of patients with IIH treated with DVSS between 2000 and 2017. Results A total of 418 patients were included in our analysis from 30 studies. Headache was present in 386 (92%) of patients and resolved or improved in 293 (76%) after DVSS. Tinnitus resolved in 95% (129/136) of patients after venous stenting. Papilledema and visual changes improved in 87% (284/327) and 85% (211/247) of patients following DVSS. Overall, 46 (12.2%) of patients required re-treatment with re-stenting or other surgical procedures. The rate of major neurological complications was less than 0.1%. Conclusions Our results add to the growing body of literature that proposes DVSS as a safe treatment option with high clinical success rate and low complications in patients with medically refractory IIH and evidence of venous stenosis. Disclosures H. Saber: None. P. Chamiraju: None. S. Narayanan: None.

Here we present a 46-yr-old man with recurrent syncopal episodes thought to be of cardiac origin. He was eventually found to harbor a giant, partially thrombosed, saccular aneurysm arising from the A1/A2 segment of the right anterior cerebral artery with foramen of Monro obstruction and a trapped left-sided ventricular system. An azygous left A2 artery segment supplied both callosomarginal arteries. We performed an in situ side-to-side anastomosis between the distal left azygous anterior cerebral artery and the right pericallosal artery, which was previously supplied by the right A1. The right A1 was clip ligated, and the aneurysm evacuated with an ultrasonic aspirator. Postoperatively, the patient did well with no recurrence of the aneurysm and resolution of his preoperative obstructive hydrocephalus. He continues to be independent >7 yr post surgery. His 6-mo follow-up angiogram revealed a patent bypass.

Every year almost 800 000 people in the USA suffer a new or recurrent stroke, and stroke is the third leading cause of death with over 140 000 deaths in the USA in 1995.1 Additionally, stroke is a leading cause of long-term disability with an estimated cost of $68.9 billion in 2009. The relationship between carotid artery disease and stroke was first described by Fisher in 1951,2 and it is estimated that about one-third of ischemic strokes are due to carotid artery thromboembolic disease.3 ,4 Several trials have established carotid endarterectomy (CEA) as an excellent surgical technique for revascularization and prevention of future stroke, with a reasonable safety profile. Over the last 10–15 years, carotid artery stenting has been studied as an alternative and potentially less invasive revascularization method. Early trials of carotid artery stenting struggled with high complication rates but, as experience has grown and techniques improved, more recent trials have shown complication rates comparable to CEA. The goals of this document are to suggest standards of practice for patients treated with carotid artery angioplasty and stenting (CAS) and to provide a reporting framework for series of patients treated with CAS. Our evidence-based treatment recommendations were assessed according to criteria published by the American Heart Association/American Stroke Association (AHA/ASA) and the University of Oxford's Center for Evidence Based Medicine (CEBM). The development of treatment guidelines for CAS is facilitated by several large clinical trials that have already investigated surgical treatment for extracranial carotid stenosis as well as trials that have compared CAS with the established surgical treatment (CEA). In addition to this standards document, we would also recommend previously published guidelines for the use of CAS.5 Note that this document is not addressing the use of angioplasty with or without stenting in the setting of acute ischemic …

Vertebroplasty and kyphoplasty are minimally invasive image-guided procedures that involve the injection of cement (typically polymethylmethacrylate (PMMA)) into a vertebral body. Kyphoplasty involves inflation of a balloon tamp to create a cavity within the vertebral body into which cement is subsequently injected. The majority of these vertebral augmentation procedures are performed to relieve back pain from osteoporotic or cancer-related vertebral compression fractures and to reinforce the vertebral body with neoplasm or vascular tumor. The primary goal of vertebroplasty and kyphoplasty is to reduce back pain and to improve patient's functional status, and the secondary goal is stabilization of a vertebra weakened by fracture or neoplasia. ### Osteoporotic vertebral fractures Osteoporosis is a common disease that causes significant morbidity and incurs a significant healthcare cost to the community. The major osteoporotic fractures involve the hip, vertebra, proximal humerus and distal forearm; the lifetime osteoporotic fracture risk at age 50 is approximately one in two women and one in five men.1 The lifetime incidence of symptomatic osteoporotic vertebral fractures in women at age 50 is estimated at 10–15%1; once a vertebral fracture occurs, there is a 20% risk of another vertebral fracture within 12 months.2 Most osteoporotic vertebral compression fractures are asymptomatic or result in minimal pain; only a third of vertebral fractures result in medical attention.3 Conservative medical therapy is therefore appropriate for the vast majority of vertebral compression fractures since most acute back pain symptoms are mild and subside over a period of 6–8 weeks as the fracture heals. The goals of conservative therapy are pain reduction (with analgesics and/or bed rest), improvement in functional status (with orthotic devices and physical therapy) and prevention of future fractures (with vitamin D, calcium supplementation and antiresorptive agents). However, conservative treatment for those with severe pain or limitation of function is not benign. It …

Introduction: Intracranial atherosclerotic stenosis (ICAS) is a disease state that has been implicated as a leading cause of recurrent ischemic stroke. While popular media has promoted the use of omega-3 fatty acid (OFA) supplementation for its purported health benefits, few studies have looked at the molecular mechanisms at play within the cerebral vasculature. We adapted a rat model for atherosclerosis and applied it to the brain, for the first time to our knowledge, to study intracranial atherosclerosis (ICA). In this study we investigated the hypothesis that dietary supplementation of OFA attenuated the progression of ICA. Methods: Twelve week old male Sprague-Dawly rats were placed on a 1% cholesterol diet. During the first two weeks, NG-nitro-L-arginine methyl ester (L-NAME, 3 mg/mL) was added to their drinking water to induce intimal changes making the rats susceptible to atherosclerosis. One group of rats had their diet supplemented with OFA (5mg/kg/day). Animals were sacrificed at three, six of supplementation. Histological sections of the brains were made to study middle cerebral artery (MCA) morphometry and intimal thickening was quantified by measuring lumen and vessel wall areas. Additionally at each time point blood lipids and glucose were measured before animal sacrifice. Results: The rats subjected to the high cholesterol diet and L-NAME administration displayed blood markers of atherosclerosis which became more severe in time. The levels of LDL, glucose, cholesterol, and triglycerides were significantly elevated compared to control. In the OFA treatment group, these biomarkers were dramatically attenuated. Furthermore, while the atherogenic treatment led to stenosis of the lumen and intimal thickening in the MCA, dietary OFA prevented these characteristic morphological changes, in which the infiltration of the vessel walls by macrophages was observed, supporting the antiatherogenic nature of this treatment. Conclusions: Long term dietary supplementation with OFA thwarts the development of ICA. It prevents the infiltration of the vessel walls by macrophages thus reducing inflammation and intimal thickening. Omega-3 fatty acids are an inexpensive and widely available dietary supplement which shows promise in preventing ICAS.

Background Symptomatic intracranial atherosclerotic disease (ICAD) worldwide represents one of the most prevalent causes of stroke. When severe, studies show that it has a very high risk for recurrent stroke, highlighting the need for effective preventative strategies. The mainstay of treatment has been medical therapy and is of critical importance in all patients with this disease. Endovascular therapy is also a possible therapeutic option but much remains to be defined in terms of best techniques and patient selection. This guideline will serve as recommendations for diagnosis

Background Management of vascular tumors of the head, neck, and brain is often complex and requires a multidisciplinary approach. Peri-operative embolization of vascular tumors may help to reduce intra-operative bleeding and operative times and have thus become an integral part of the management of these tumors. Advances in catheter and non-catheter based techniques in conjunction with the growing field of neurointerventional surgery is likely to expand the number of peri-operative embolizations performed. The goal of this article is to provide consensus reporting standards and guidelines for embolization treatment of vascular head, neck, and brain tumors. Summary This article was produced by a writing group comprised of members of the Society of Neurointerventional Surgery. A computerized literature search using the National Library of Medicine database (Pubmed) was conducted for relevant articles published between 1 January 1990 and 31 December 2010. The article summarizes the effectiveness and safety of peri-operative vascular tumor embolization. In addition, this document provides consensus definitions and reporting standards as well as guidelines not intended to represent the standard of care, but rather to provide uniformity in subsequent trials and studies involving embolization of vascular head and neck as well as brain tumors. Conclusions Peri-operative embolization of vascular head, neck, and brain tumors is an effective and safe adjuvant to surgical resection. Major complications reported in the literature are rare when these procedures are performed by operators with appropriate training and knowledge of the relevant vascular and surgical anatomy. These standards may help to standardize reporting and publication in future studies.

Current clinical practice standards are addressed for the invasive interventional management of post-hemorrhagic cerebral vasospasm (PHCV) in patients with aneurysmal subarachnoid hemorrhage. The conclusions, based on an assessment by the Standards Committee of the Society of Neurointerventional Surgery, included a critical review of the literature using guidelines for evidence based medicine proposed by the Stroke Council of the American Heart Association and the University of Oxford, Centre for Evidence Based Medicine. Specifically examined were the safety and efficacy of established invasive interventional therapies, including transluminal balloon angioplasty (TBA) and intra-arterial vasodilator infusion therapy (IAVT). The assessment shows that these invasive interventional therapies may be beneficial and may be considered for PHCV-that is, symptomatic with cerebral ischemia and refractory to maximal medical management. As outlined in this document, IAVT may be beneficial for the management of PHCV involving the proximal and/or distal intradural cerebral circulation. TBA may be beneficial for the management of PHCV that involves the proximal intradural cerebral circulation. The assessment shows that for the indications described above, TBA and IAVT are classified as Class IIb, Level B interventions according to the American Heart Association guidelines, and Level 4, Grade C interventions according to the University of Oxford Centre for Evidence Based Medicine guidelines.

Vascular anomalies are classified broadly into vascular tumors and vascular malformations.1 Vascular malformations are further subdivided based on the histology of the lesion and whether the lesion is ‘high flow’ or ‘low flow’.1–3 The ‘low flow’ vascular anomalies are the focus of this article, and this category is broadly comprised of venous malformations (VM) and lymphatic malformations (LM). VM and LM are congenital anomalies thought to occur secondary to developmental errors in venous or lymphatic patterning, respectively.3–6 These lesions most commonly affect the head and neck, and have a prevalence of approximately 1%.3 ,5 ,7 Lesions involving the aerodigestive tract may result in airway obstruction, impaired food intake, and prevent normal speech. Similarly, lesions that involve the orbit may compromise visual acuity or ocular mobility. Vascular malformations may become quite large and demonstrate contiguous extension from the neck into the chest, pleura, cervical spine, or thoracic spine with associated pleural effusions and osteolysis. The vast majority of VM and LM are sporadic, although an increased prevalence of these anomalies has been described in multiple syndromes and with inherited gene mutations.8–13 It is important to recognize the categorization of LM into macrocystic or microcystic subtypes when contemplating treatment of these lesions. Macrocystic LM are comprised of larger cysts (≥2 cm in diameter) and respond well to percutaneous sclerotherapy and surgery with good to excellent outcomes in 76–95% of patients.3 ,8 ,14–17 By contrast, microcystic LM are comprised of innumerable small cysts (

This is the first in a set of documents intended to standardize techniques, procedures, and practices in the field of endovascular surgical neuroradiology. Standards are meant to define core practices for peer review, comparison, and improvement. Standards and guidelines also form the basic dialogue, reporting, and recommendations for ongoing practices and future development.

Objective There are limited data about the rate of recanalization following complete coil occlusion. Long term clinical and angiographic outcome of completely occluded intracranial aneurysms (IAs) by the endovascular approach are presented. Methods Over the course of 4 years, patients with IAs which were completely occluded by coiling at our institution were reviewed. Clinical and angiographic data were analyzed. The patients were clinically assessed using the Glasgow Outcome Scale (GOS). Follow-up angiographic findings were categorized as: stable aneurysm with no recanalization, recanalization with a neck remnant and recanalization with a body remnant. Results 83 aneurysms were identified in 74 patients (15 men and 59 women, average age 52.4 years) with complete occlusion post intervention. Treatment by coiling only was used in 73 aneurysms while stent assisted coiling was used in 10 cases. At the last angiographic follow-up (mean 16.3 months), 20 of the 83 aneurysms demonstrated various degrees of recanalization of which five had neck remnants and 15 had body remnants. The recanalization rate was significantly higher in large aneurysms (57%) compared with small aneurysms (14%). Clinically, 65 of the 74 patients showed good recovery (GOS score 5), eight had moderate disability (GOS score 4) and one was severely disabled (GOS score 3). Conclusion Complete endovascular occlusion of IA is certainly effective in preventing aneurysmal bleeding. However, recanalization rate, despite being lower when compared with subtotal occlusion, remains an issue. Longer follow-up is required.

PURPOSE To describe the technique of percutaneous, infraocular embolization of indirect carotid-cavernous fistulas (CCFs) and analyze the results in a small clinical series. METHODS A retrospective case series of 4 patients treated at Emory University Hospital. RESULTS Four patients with indirect CCFs and limited transvenous access were successfully treated with transcutaneous, infraocular embolization of the recipient cavernous sinus via the ipsilateral superior orbital fissure. Main outcome measures were clinical examination findings and cerebral angiography. All patients had either preservation or improvement in final visual outcome. One patient required early retreatment because of clot lysis and reopening of a secondary, iatrogenic direct CCF. Two patients suffered early postprocedural orbital hemorrhage requiring treatment with lateral canthotomy and inferior cantholysis. CONCLUSIONS Based these findings, percutaneous, infraocular, trans-superior orbital fissure embolization of CCFs is a viable alternative in patients with refractory fistulas failing management with more conventional techniques. Orbital hemorrhage is a significant risk, and availability of an ophthalmologist skilled in the management of this complication is imperative.

Advances in skull base surgery have resulted in the ability to perform large scale en bloc resections of neoplasms of the clivus, sphenoid wings, sella, and other deep structures. Such tumors frequently involve the internal carotid artery (ICA), and complete resection may require dissection or sacrifice of the ICA. ICA occlusion without graft placement is performed to treat certain aneurysms— for example, fusiform cavernous ICA aneurysms with mass effect or partially thrombosed pseudoaneurysms with embolic potential. These and other less common indications for ICA sacrifice necessitate our ability to predict the results of ICA occlusion. There is some variability in the performance and reporting of balloon test occlusion (BTO). This paper represents a consensus statement of the Standards and Guidelines Committee of the Society of NeuroInterventional Surgery, with the goal of providing standardized recommendations for indication, performance, documentation, and complication reporting of BTO procedures. Without any type of temporary test occlusion, the incidence of stroke after permanent carotid artery occlusion ranges from 17% to 30%.1–5 In 1911, Matas6 described temporary arterial occlusion by manual compression of the common carotid artery to determine tolerance for permanent arterial occlusion. Serbinenko7 introduced the concept of endovascular arterial occlusion using small endovascular balloons in the early 1970s. His novel method of endovascular arterial occlusion has since been widely adopted and remains the current foundation for temporary arterial test occlusion. When carotid artery BTO is clinically tolerated, the morbidity and mortality associated with permanent arterial occlusion are reduced but, unfortunately, not eliminated. Since the report of endovascular temporary arterial occlusion presented by Serbinenko7 was published, a variety of adjunctive methods have been tested to improve the sensitivity and specificity of clinical neurologic evaluation alone for the detection of insufficient cerebral …