Superior cerebellar artery (SCA) aneurysms are rare, accounting for only 1%-2% of all intracranial aneurysms, and are predominantly wide-necked. Due to the typically acute angle between the SCA and the basilar artery, stent delivery to the SCA through the basilar artery in an anterograde approach is technically challenging. In contrast, accessing the SCA from the anterior circulation through the posterior communicating artery is considerably more feasible. This approach to guiding a microcatheter from the anterior to the posterior circulation is called the transcirculation technique. Notably, the stent could be deployed across the entire length of the aneurysm neck via transcirculation, ensuring effective coverage of the target aneurysm. Herein, we present a case of an SCA aneurysm successfully treated with the transcirculation technique (Video 1). This approach may represent a promising alternative for treating wide-necked SCA aneurysms in selected cases with an acute angle between the SCA and the basilar artery. The procedure was performed following informed consent.
Radial access has become more common among interventionalists for neurointerventional procedures due to lower complication rates and patient comfort.1, 2 However, rare but serious complications such as catheter fracture and retention require recognition and investigation of advanced retrieval strategies.3 We present a two-stage case involving a patient in their 70s who initially underwent successful mechanical thrombectomy for left M1 occlusion. Hours later, new onset of neurological deficits led to repeat digital subtraction angiography via right radial access. During catheter withdrawal and after initial medical management of suspected vasospasm, the RIST guide catheter became entrapped and fractured within the axillary artery. Transfemoral access was used to retrieve the distal catheter fragment using a snare technique. Post-retrieval imaging confirmed vessel integrity, though ulnar artery occlusion led to ischemia requiring vascular surgery. This case illustrates a rare complication of radial access and highlights suspected novel technical considerations for retrieval, rescue planning, and catheter system selection.
Cerebrospinal fluid-venous fistula (CSFVF) is an increasingly recognized cause of spontaneous intracranial hypotension (SIH). We present a rare case of a 41-year-old woman with SIH caused by a right S2-S3 CSFVF draining in the right internal iliac vein. Successfully transvenous endovascular embolization using Onyx was performed. This report highlights diagnostic challenges and procedural details, emphasizing the efficacy of endovascular approaches in managing CSFVF in atypical anatomical locations.
BackgroundTransradial mechanical thrombectomy offers reduced complications compared to transfemoral approach but has been limited by the inability to safely deliver large-bore aspiration catheters through a radial sheath. The Food and Drug Administration (FDA)-cleared Zebra laser-cut catheter with 7F (0.087″ inner diameter; 0.096″ outer diameter) and 6F versions (0.074″ inner diameter; 0.083″ outer diameter) addresses this limitation.MethodsWe conducted a retrospective review of 26 patients undergoing transradial mechanical thrombectomy for acute ischemic stroke using the Zebra catheter through radial sheaths at two centers (January-August 2025). Primary outcomes included radial access success, recanalization (Thrombolysis in Cerebral Infarction [TICI] 2b-3), and access-site complications.ResultsMean age was 65.04 ± 12.82, mean National Institutes of Health Stroke Scale (NIHSS) was 20.88 ± 7.87. Radial access success rate was 96.2% (25/26). One conversion to femoral occurred due to catheter herniation at acute innominate-left common carotid angulation with aberrant right subclavian anatomy; the procedure was completed successfully via femoral route using the same system. Successful recanalization (TICI 2b-3) occurred in 88.5% (23/26) of patients. Zebra accommodated aspiration catheters ranging 0.055-0.071″ inner diameter and navigated complex anatomy including tortuous carotid origins with subclavian elevation up to 15 mm. No access-site complications occurred. Mean fluoroscopy time was 23.07 ± 18.24 min with 88.5% of procedures rated "easy" by the operator. Acute aortic branch angles represented the primary anatomical limitation, while distal tortuosity and moderate subclavian elevation were manageable.ConclusionZebra enabled transradial mechanical thrombectomy with high recanalization rates without access-site complications. Zebra succeeded across complex anatomy and demonstrated compatibility with various large bore suction catheters, allowing uniform utilization for thrombectomy in radial versus femoral access.
BackgroundMechanical thrombectomy is the standard of care for acute ischemic stroke due to large vessel occlusion. Choosing a transradial approach (TRA) for anterior circulation occlusions is a matter of debate. The use of a triaxial 7F low-profile system could help mitigate numerous issues related to transradial MT.MethodsFrom 10/2022 to 7/2025, 111 patients underwent TRA-MT for anterior circulation LVOs, both as first-line and as rescue from transfemoral access failure, with the same setup (7F sheath, 7F guide catheter, and aspiration catheters ranging from 062 in. to 043 in. in relation to occlusion site). Choice of thrombectomy technique was at the operator's discretion. Patients' demographic data, clinical presentation, treatment details, complications, rate of TFA crossover, successful reperfusion (mTICI score ≥2b), and good clinical outcome at 3 months (mRS 0-2) were reported.ResultsOf 111 patients, 66 (50%) had occlusion of the M1 MCA, 20 (18%) of the internal carotid artery termination, and 23 (20.7%) of the M2 MCA. Right-sided occlusions were 56/111 (50.5%) and left-sided 56/111 (49.6%). Median patients' age was 80 years, and median NIHSS score was 17 at admission. Successful reperfusion (mTICI ≥2b) was achieved in 103/111 patients (92.8%). Total procedural complication rate was 8/111 (7.2%). No serious access-site complications were reported. Symptomatic ICH occurred in 18/111 (16.2%) patients. Clinical follow-up was available for 104 out of 111 total patients; of them, mRS scores of 0-2 were 54/104 (51.9%)ConclusionsThe high technical effectiveness and good safety profile of this specific tricoaxial setup for TRA-MT in AIS, even for large proximal LVOs, could constitute an optimal alternative to TFA-MT in selected cases.
BackgroundFlow reversal, achieved by occluding both the common and external carotid arteries to induce retrograde flow from the internal carotid artery, is a useful method for preventing distal embolization in cases of carotid artery stenting (CAS). The "conventional method" employed by our institute for CAS involves the use of one-way valves incorporated in a flow reversal system for rapid manual blood aspiration. Subsequently, we recently transitioned from the conventional method to the "simplified flow reversal carotid artery revascularization for radial access (SF-CARR)," in which external carotid artery occlusion is omitted while a transradial approach is implemented. This study aimed to clarify the efficacy and safety of SF-CARR in patients undergoing CAS.MethodsA retrospective study was conducted in 50 patients diagnosed with internal carotid artery stenosis between 2022 and 2025. Of these, 24 were treated with SF-CARR, while the others underwent the conventional method. We investigated patient characteristics, endovascular procedures, procedural invasiveness, including procedural time, radiation exposure, or contrast agent use, and clinical outcomes.ResultsCompared to the conventional group, a reduced procedural time (p = 0.001) was observed in the SF-CARR group. The radiation exposure dose (p = 0.020), fluoroscopy time (p = 0.003), amount of contrast agent injected (p < 0.001), and number of contrast agent injections (p < 0.001) were also reduced in the SF-CARR group. In addition, the transradial approach was adopted more frequently in the SF-CARR group (p < 0.001), and no significant differences were reported in complications or patients' outcomes between the two groups.ConclusionThis novel flow reversal method, "SF-CARR," can provide minimally invasive treatment to patients with carotid artery stenosis.
BackgroundMechanical thrombectomy (MT) is an important treatment for middle cerebral artery (MCA) M2 occlusions. However, it carries a risk of intracranial hemorrhage (ICH), especially with a stent retriever. We investigated the correlation between MCA M1 tortuosity and ICH after MT using a stent retriever for M2 occlusions, along with other clinical outcomes.MethodsThis single-center, retrospective study included patients with isolated MCA M2 occlusions treated using a stent retriever. M1 tortuosity was assessed using pre-MT imaging, with patients classified into tortuous (≥ 2 angulations) and non-tortuous (≤ 1 angulation) groups. The primary outcome was any ICH. Secondary outcomes included symptomatic ICH (sICH), procedural outcomes, and functional outcomes.ResultsAmong 153 patients (median age: 78 years, 48% female), 55 (36%) had tortuous M1 segments. The tortuous group showed higher NIHSS scores (median score 19 vs. 14, p = 0.045) and a higher prevalence of chronic renal failure at baseline (15% vs. 4%, p = 0.029). Any ICH occurred in 69 patients (45%) and was more frequent in the tortuous group (64% vs. 35%, p = 0.003; adjusted odds ratio [aOR], 3.09; 95% confidence interval [CI], 1.48-6.42). Among the ICH subtypes, subarachnoid hemorrhage (SAH) was more common in the tortuous group (49% vs. 27%, p = 0.01; aOR, 2.61; 95% CI, 1.26-5.41). However, the incidence of sICH (5.5% vs. 4.1%, p = 0.70) and good neurological outcome at 90 days after MT (45% vs. 50%, p = 0.62) were comparable.ConclusionMCA M1 tortuosity was associated with a higher incidence of any ICH, particularly SAH, after MT using a stent retriever for M2 occlusions.
Background and purposeEndovascular treatment of wide-neck bifurcation aneurysms has historically proved difficult with variable outcomes of efficacy and safety. We assessed the short- and long-term clinical and radiologic outcomes in the real-world use of Contour neurovascular system.Materials and methodsThis study was a retrospective analysis of unruptured intracranial aneurysms treated with the Contour. The primary radiologic outcomes were quantified on DSA, CTA, or MRA using the modified Raymond-Roy criteria. The outcomes were defined as complete occlusion (RROC 1) and adequate occlusion (RROC 1 and RROC 2) at 6 months and 2-years. The primary safety outcome was the rate of device-related adverse events. Secondary safety outcomes included time to discharge and change in the modified Rankin scale (mRS) score at 6-month follow-up.Results54 patients were treated with Contour from February 2017 to July 2022. 50 aneurysms underwent 6-month follow-up. 28 of 50 aneurysms treated (56%) remained completely occluded at 6-month follow-up (RROC 1), whilst 44 of 50 aneurysms treated (88%) were adequately occluded. 46 aneurysms underwent 2-year follow-up. 28 of 46 aneurysms treated (60.9%) remained completely occluded at 2-year follow-up (RROC 1), whilst 38 of 46 aneurysms (82.6%) were adequately occluded (RROC 1 and RROC2). Immediate postoperative complications occurred in 5 patients; only 1 patient (1.8%) had residual neurologic deficits at 6 months (mRS 1).ConclusionsManagement of wide-neck aneurysms remains difficult, with high rates of recurrence and complications. The use of the Contour demonstrated a promising and safe addition to the intravascular stock for the treatment of complex wide-neck aneurysms.
IntroductionThe ARUBA trial has influenced a shift towards more conservative management of small, unruptured cerebral arteriovenous malformations (AVMs), leading to less aggressive treatment approaches among neurointerventionalists. However, with evolving endovascular techniques, it is important to assess whether national practice changes have impacted rupture rates and outcomes.MethodsData from the Nationwide Inpatient Sample (NIS) for 2016-2022 regarding clinical characteristics, cost, morbidity, and mortality endovascularly treated AVMs was analyzed. Trends were evaluated using multivariable regression modeling, controlling for patient and hospital characteristics.ResultsA total of 8,935 patients underwent endovascular treatment for cerebral AVMs (6,500 unruptured and 2,435 ruptured). Endovascular treatment for unruptured AVMs declined significantly from 1195 cases in 2016 to 780 in 2022 (-34.7%, p = 0.020). Over the same period, the proportion of AVMs presenting ruptured increased from 15.7% to 25.7%, a 63.7% relative increase (p = 0.015). Multivariable analysis confirmed rising odds of rupture over time among endovascularly treated patients (OR = 1.12, 95% CI 1.00-1.25, p = 0.042). Among 11,205 ruptured AVM patients, the in-hospital mortality rate of thosewho did not undergo surgery rose 67.2% over time (6.7% in 2016 to 11.2% in 2022, p = 0.006).ConclusionThe study reveals an increase in the probability of patients presenting with ruptured AVMs and being observed with a consequent increase in in-hospital mortality. This may be an unintended consequence of less aggressive strategies following the ARUBA trial, prompting a need to reevaluate current management techniques amidst rising costs, morbidity, and mortality.
Objectives: To investigate the safety and efficacy of using the pEGASUS HPC stent pusher instead of a microwire for catheterization of nonruptured cerebral aneurysms during stent-assisted coiling. Methods: In this multicenter retrospective study (July 2021–June 2024), 107 patients with 118 incidental nonruptured cerebral aneurysms underwent stent-assisted coiling using pEGASUS HPC stents. Based on the catheterization technique, cases were assigned to either the microwire-assisted catheterization (MAC, n = 58) or the stent pusher-assisted catheterization (PAC, n = 60) group. Clinical and procedural data were analyzed to compare safety and efficacy, focusing on success rates, required catheterization time, complications, and adverse events. Results: The cohort (mean age 59 ± 13.2 years; 52.3% female). In the MAC group, aneurysm catheterization was successful in all cases (100%), with one procedure-related perforation caused by the microwire (1.7%). In contrast, the PAC group achieved a slightly lower success rate of 95% (57/60), but no perforations were observed. The mean catheterization time was significantly shorter in the PAC group (0.67 ± 0.24 minutes) compared to the MAC group (4.43 ± 0.59 minutes), demonstrating that PAC is approximately seven times faster. No other relevant complications were reported. Conclusion: PAC with the pEGASUS HPC stent pusher appears safe and effective for catheterizing nonruptured cerebral aneurysms, with high success, no perforations, and significantly shorter catheterization time. Larger prospective studies are needed to confirm these results.
BackgroundThe usefulness of CASPER, a second-generation carotid stent, for carotid artery stenosis is becoming increasingly clear. However, few studies have directly compared treatment outcomes with those of the first-generation Carotid WALLSTENT. This study aimed to compare the outcomes of carotid artery stenting using CASPER and Carotid WALLSTENT for carotid artery stenosis performed at a single institution.MethodsThis retrospective study included 117 consecutive cases (Carotid WALLSTENT, 58 cases; CASPER, 59 cases) where carotid stent placement was performed for internal carotid artery stenosis between 2020 and 2021. Patient background, the presence or absence of ischemic complications as postoperative treatment outcomes, and the presence or absence of restenosis were extracted from the electronic medical records, and the results were compared between the Carotid WALLSTENT and the CASPER treatment groups.ResultsWhen comparing ischemic complications between the two groups, the treatment outcomes in the CASPER group were significantly better (Carotid WALLSTENT vs. CASPER: 6 (10.3%) vs. 2 (3.4%), respectively, p = 0.039). However, no significant difference in postoperative restenosis was observed between the two groups. Multivariate analysis revealed that using CASPER significantly reduced ischemic complications (odds ratio: 0.101, 95% confidence interval: 0.0117-0.878).ConclusionsCarotid artery stenting using CASPER for internal carotid artery stenosis was associated with fewer ischemic complications than that with the Carotid WALLSTENT. No differences in treatment outcomes were observed with CASPER and Carotid WALLSTENT in terms of postoperative restenosis.
Neurointervention via transradial access (TRA) is challenging when the radial artery is narrow. We performed aneurysm embolization via TRA using a novel 3-Fr guiding sheath (GS) (Axcelguide; Medikit, Tokyo, Japan) with an outer diameter of only 1.76 mm for patients with a radial artery of inner diameter less than 2 mm, and described the whole procedure and pitfalls as a technical note. Here, we present two patients with radial arteries less than 2 mm. One patient had a narrow neck intracranial aneurysm at the bifurcation of the left vertebral artery and posterior inferior cerebellar artery, which was embolized with the primary coiling technique. The other was a patient with a wide-necked extracranial aneurysm in the cavernous portion of the right internal carotid artery, which was embolized with the transcell technique with stent. We utilized a 3-Fr GS, distal access catheter, and a 0.0165-inch microcatheter for coil embolization. All aneurysms were completely occluded, without neurological or puncture site-related complications including subcutaneous hematoma, radial artery occlusion, and vasospasm. This report provides the first description of neurointervention using a 3-Fr GS. The 3-Fr GS contributed to successful completion of TRA aneurysm embolization without neurological or puncture site-related complications in patients with radial arteries narrower than 2 mm. The 3-Fr GS may be useful to accomplish aneurysmal embolization via TRA even in patients with a small radial artery.
Venous sinus stenting for dural venous sinus outflow obstruction due to an intrinsic filling obstruction or extrinsic stenosis is an increasingly popular treatment strategy for idiopathic intracranial hypertension (IIH) and isolated pulsatile tinnitus (PT). The most common site of stenosis is the lateral venous sinus at the transverse-sigmoid junction. Approximately 10% of the population has a persistent occipital venous sinus (OVS), a variant that may be the dominant venous drainage pathway in the setting of a hypoplastic or aplastic transverse sinus. OVS stenosis has been rarely associated with IIH and isolated PT with only a handful published cases. We herein report a retrospective series of OVS stenting in five patients, four of whom presented with non-IIH PT and one with IIH.
The spontaneous occlusion of brain arteriovenous malformations (bAVMs) is a rare event, particularly for unruptured ones. Associated factors include single-venous drainage and small nidus size. Most of the previously reported cases were ruptured bAVMs. We report the case of a middle-aged male patient with an unruptured, rolandic, left-sided bAVM associated with a 30-year history of refractory epilepsy. We documented the spontaneous thrombosis of the venous drainage of the AVM without any sign of bleeding. Finally, we underline the difference between ruptured-induced occlusion and truly spontaneous thrombosis of the bAVMs.
Middle meningeal artery embolization has become an important option in the management of subdural hemorrhages with multiple prospective studies demonstrating efficacy and randomized controlled trial data on the way. Access to the middle meningeal artery is usually achieved via the external carotid artery to the internal maxillary artery, then the middle meningeal artery. We report a case where a patient with symptomatic left-sided chronic subdural hemorrhage also had an external carotid artery occlusion. Direct puncture of the superficial temporal artery allowed retrograde access to the internal maxillary artery and thus the middle meningeal artery. Successful embolization of the vessel with 1:9 nBCA was performed with near total resorption of the subdural collection by 1 month postprocedure.
OBJECTIVE The low-profile Acandis Acclino flex plus (AFP) is a fourth-generation laser-cut microstent with a flexible structure designed for the treatment of a wide variety of aneurysms. We report our single-center experience with this device in the treatment of complex aneurysms. METHODS Twenty-eight patients were treated with the Acclino flex plus for 28 aneurysms. Aneurysm characteristics, technical success, complications, clinical outcome, and angiographic results were retrospectively analyzed. RESULTS The cohort included 8 unruptured untreated aneurysms, 9 unruptured recurrent aneurysms, and 12 ruptured aneurysms with aneurysm diameters ranging from 3 to 23 mm. The anterior communicating artery was the most common location (52%). Stent deployment was successful in 28 cases (97%) with an average of 1.3 stents per aneurysm. The overall procedural complication rate was 17%, including 2 (6.8%) major clinical events (one ischaemic stroke and one aneurysm perforation) and one (3.4%) minor clinical event (one seizure). Angiographic results of 23 aneurysms at a mean of 6 months were complete occlusion in 74%, neck remnants in 13% and aneurysm remnants in 13%. Three patients were retreated. CONCLUSIONS Given the complexity of the aneurysms, the use of the Acclino flex plus was feasible and associated with a favourable safety and efficacy profile. Further studies are needed to evaluate Acclino flex plus in other aneurysm subsets and to define its role in endovascular aneurysm treatment.
Background: Chronic subdural hematoma (cSDH) is a challenging and common neurosurgical condition. Our goal is to demonstrate that middle meningeal artery (MMA) embolization combined with surgical evacuation can be a promising adjuvant option for treatment of cSDHs and prevent recurrence in symptomatic patients who require surgical treatment.Method: We retrospectively collected data from patients who underwent MMA embolization using polyvinyl alcohol particles and surgical evacuation with burr hole or craniotomy in a single center for the treatment of new and recurrent cSDHs. The primary outcome was recurrence of cSDH requiring surgical rescue during follow up, and secondary outcomes were defined as >50% decrease in the maximum width of cSDHs on the longest follow-up computed tomography (CT) scan, complications following procedure, and improvement in modified Rankin scale (mRS) score.Results: A total of 51 patients successfully underwent 72 MMA embolization procedures (96% of the total 75 cases in the cohort) combined with surgical evacuation. Seventy cases (93.3%) achieved at least 50% reduction in the size of the cSDHs on the last CT imaging. A surgical evacuation was required in five cases (6.7%) due to cSDH recurrence during the follow-up period. There were three complications (6.0%) related to embolization procedure. Forty patients (78.4%) showed improvement in mRS score. There was one mortality (2%) regardless of the embolization and evacuation.Conclusions: Our study demonstrates the safety and efficacy of adjunct MMA embolization in significantly reducing size and recurrence of cSDHs.
Objectives: The use of flow diversion for the treatment of intracranial aneurysms has gained broad acceptance. Three flow diverting stents are approved by the Food and Drug Administration for use in the United States. We sought to compare the outcomes and safety profiles between the three devices at our institution.Methods: A retrospective review of aneurysms treated with pipeline embolization device (PED), flow re-direction endoluminal device (FRED), and SURPASS was performed for aneurysms treated between 2018 and 2022 at our institution.Results: The study cohort consisted of 142 patients. Precisely, 86 aneurysms were treated with a pipeline, 33 aneurysms were treated with FRED, and 23 aneurysms were treated with SURPASS. The 1-year complete occlusion rates were 59.4%, 60%, and 65%, respectively (0.91). Linear regression models found that only adjunctive coiling predicted aneurysm occlusion at 6 months (p= 0.02), but this effect was lost at 1 year and beyond. There was no significant difference in acute thrombotic or acute hemorrhagic complications between the three cohorts. There was a higher rate of delayed hemorrhagic complications in the SURPASS cohort (10%) compared to the PED (1.3%) and FRED (0%) cohorts (p= 0.04). There was also a higher rate of in-stent stenosis in the SURPASS cohort (20%) compared to the PED (5%) and FRED (3.1%) cohorts (p < 0.01).Conclusions: Treatment with PED, FRED, and SURPASS all resulted in similar complete occlusion rates at 6 months and 1 year. SURPASS was associated with higher in-stent stenosis as well as delayed hemorrhagic complications. Additional future studies evaluating the newest generation of flow-diverting stents with long-term follow-up will be necessary to make any definitive conclusions.
BACKGROUND Transradial approach for neuroangiography is becoming increasingly popular because of the advantages demonstrated by interventional cardiology. Many advantages of radial access could be applied to intraoperative angiography. OBJECTIVE To report our institutional experience with transradial and transulnar intraoperative angiography, and evaluate its safety and feasibility. METHODS Intraoperative angiography through upper extremity vessels was attempted in 70 consecutive patients between April 2019 and December 2022. Data on patient characteristics and surgical indications, procedural variables, and complications were collected. RESULTS Of the 70 patients who underwent intraoperative angiography, 58.6% were female, and the mean age was 52.9 ± 14.0 years. The reason for surgery was aneurysm clipping in 42 (60.0%) cases. In total, 55 patients (78.6%) were positioned supine, 13 (18.6%) prone, and two (2.9%) were positioned three-quarters prone. Access was attempted via the radial artery in 60 (85.7%) patients and the ulnar artery in 10 (14.3%) patients. The procedure was successful in 69 of 70 cases (98.6%), as one required conversion to transfemoral approach due to significant spasm in the proximal right radial artery. The median fluoroscopy time was 8 min. No procedure was aborted, and no patient experienced access-site or angiography-related complications. Intraoperative angiography altered the surgical management in 3 (4.3%) cases. Re-access for follow-up angiography was unsuccessful in three (13.6%) of 22 due to radial artery occlusion. CONCLUSIONS Our institutional experience supports that transradial and transulnar intraoperative angiography is safe and feasible during neurovascular procedures for various indications and positions.
