INTRODUCTION:Dural arteriovenous fistulae (dAVFs) can lead to subarachnoid hemorrhage and other devastating complications. A rare subtype of dAVFs is those located in the anterior condylar confluence adjacent to the hypoglossal canal. These dAVFs can be difficult to treat, with some electing to utilize endovascular approaches for these lesions. There is a need to further assess the safety and efficacy of this approach. CASE DESCRIPTION:All patients that underwent endovascular treatment of dAVFs affecting the anterior condylar confluence at our center were included. Pre-treatment factors including anatomy and presentation were recorded, as were follow-up data including angiographic cure and clinical or technical complications. Three patients were included in this study. Presenting symptoms included ocular hyperemia, proptosis, auditory symptoms (whooshing, tinnitus), and Cranial Nerve 6 palsy. Both transarterial and transvenous embolization were employed in select cases, with Onyx HD-500 and coils both used as embolic materials. No clinical or technical complications were reported in these patients, and patients were asymptomatic at final follow-up without recurrence or regrowth of their dAVF. CONCLUSIONS:Treatment of dAVFs located in the anterior condylar confluence can be achieved endovascularly using both transarterial and transvenous approaches.

Software programs leveraging artificial intelligence to detect vessel occlusions are now widely available to aid in stroke triage. Given their proprietary use, there is a surprising lack of information regarding how the software works, who is using the software, and their performance in an unbiased real-world setting. In this educational review of automated vessel occlusion software, we discuss emerging evidence of their utility, underlying algorithms, real-world diagnostic performance, and limitations. The intended audience includes specialists in stroke care in neurology, emergency medicine, radiology, and neurosurgery. Practical tips for onboarding and utilization of this technology are provided based on the multidisciplinary experience of the authorship team.

BACKGROUND:Intracranial atherosclerotic disease (ICAD) remains a major source of stroke world-wide, with high recurrence risk. Prior evaluation of posterior circulation ICAD patients enrolled in the prospective VERiTAS and MYRIAD studies revealed regional hypoperfusion assessed by large vessel flow measurements using quantitative MRA (QMRA) predicts subsequent stroke risk. We examined whether a similar approach to regional flow assessment predicted stroke risk in anterior circulation ICAD patients in MYRIAD. METHODS:MYRIAD enrolled patients with symptomatic 50-99 % stenosis of proximal intracranial artery. The primary outcome was recurrent ischemic stroke in the stenotic artery territory within one year. Flow was measured in the major intracranial arteries at baseline using QMRA. We designated patients as low or normal flow based on an algorithm assessing distal flow and collateral capacity using age-normalized middle cerebral artery (MCA) and hemispheric flows. Thresholds for flow status categorization were tested to determine the optimal algorithm for stroke risk prediction. RESULTS:Of 73 enrolled subjects with symptomatic anterior circulation ICAD, 7 (9.6 %) had recurrent stroke. Z-score thresholds for age-normalized flow were examined, from which we identified an optimal threshold of -1 for the MCA and -0.75 for hemispheric flow. Based on these thresholds, 24 (33 %) patients were categorized as low flow; recurrent stroke occurred in 21 % of low flow vs 4 % of normal flow patients (age adjusted OR 7.2, 95 % CI 1.2-43.2). In the full cohort of 99 subjects with anterior and posterior circulation ICAD, 11 (11.1 %) had recurrent stroke, with a higher recurrent stroke risk in low flow patients (21.4 % vs 7 %, age adjusted OR 3.8, 95 % CI 1.02-14.2). CONCLUSIONS:Distal flow status assessed through QMRA regional flow measurement appears to be similarly predictive for recurrent clinical stroke in both the anterior and posterior ciruclation. Identification of high-risk patients has implications for future investigation of therapeutic interventions.

The development of methods to detect and treat intracranial large-vessel occlusions (LVOs) has revolutionized the management of acute ischemic stroke. CT angiography (CTA) of the head and neck is effective in depicting LVOs and widely used in the evaluation of patients who have had a stroke. Ongoing efforts are now focused on the potential to detect and treat intracranial medium-vessel occlusions (MeVOs), which by definition are smaller than LVOs and thus more difficult to detect with CTA. The authors review common and variant anatomies of medium-sized cerebral arteries and the appearance of a variety of MeVOs on CT angiograms. Possible pitfalls in MeVO detection include rare anatomic variants, calcified thrombi, and stump occlusions. Current recommendations for performing CTA and ancillary methods that might aid in MeVO detection are discussed. Understanding the relevant anatomy and the variety of appearances of MeVOs aids radiologists in identifying these occlusions, particularly in the setting of urgent stroke. ©RSNA, 2024 See the invited commentary by Ospel and Nguyen in this issue.

HomeStrokeAhead of PrintExploring the Limits of Endovascular Therapy for Large Core Patients: Where Do We Need More Data? No AccessArticle CommentaryRequest AccessAboutView PDFSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toNo AccessArticle CommentaryRequest AccessExploring the Limits of Endovascular Therapy for Large Core Patients: Where Do We Need More Data? Gregory W. Albers, Jeremy J. Heit, Maarten G. Lansberg, Manabu Inoue, Xiaochuan Huo, Vivek S. Yedavalli, Pierre Seners, Margy McCullough-Hicks, Carlo W. Cereda, Jenny P. Tsai, Eva A. Mistry, Arindam R. Chatterjee, Colin P. Derdeyn, Pooja Khatri, J.M. Olivot, Michael D. Hill, Jeffrey L. Saver and Marc Fisher Gregory W. AlbersGregory W. Albers Correspondence to: Gregory W. Albers, MD, Department of Neurology, Stanford University, 453 Quarry Rd, Palo Alto, CA 94304. Email E-mail Address: [email protected] https://orcid.org/0000-0003-0263-4632 Department of Neurology, Stanford University, CA. (G.W.A., M.G.L.) , Jeremy J. HeitJeremy J. Heit Department of Radiology, Stanford University, CA. (J.J.H.) , Maarten G. LansbergMaarten G. Lansberg Department of Neurology, Stanford University, CA. (G.W.A., M.G.L.) , Manabu InoueManabu Inoue https://orcid.org/0000-0001-5228-6643 Division of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan (M.I.). , Xiaochuan HuoXiaochuan Huo https://orcid.org/0000-0003-1264-5132 Cerebral Vascular Disease Department, Beijing Anzhen Hospital, Capital Medical University, China (X.H.). , Vivek S. YedavalliVivek S. Yedavalli https://orcid.org/0000-0002-2450-4014 Department of Neurology, Johns Hopkins University, Baltimore, MD (V.S.Y.). , Pierre SenersPierre Seners https://orcid.org/0000-0002-2134-0691 Neurology Department, Hôpital Fondation A. de Rothschild, Paris, France (P.S.). , Margy McCullough-HicksMargy McCullough-Hicks https://orcid.org/0000-0003-3770-8689 Department of Neurology, University of Minnesota, Minneapolis (M.M.C.-H.). , Carlo W. CeredaCarlo W. Cereda https://orcid.org/0000-0002-6479-1476 Neurocenter of Southern Switzerland, EOC, Lugano, Switzerland (C.W.C.). , Jenny P. TsaiJenny P. Tsai https://orcid.org/0000-0003-4866-567X Cerebrovascular Center and Department of Neurology, Cleveland Clinic, OH (J.P.T.). , Eva A. MistryEva A. Mistry https://orcid.org/0000-0002-7426-3650 Department of Neurology, University of Cincinnati, OH (E.A.M., P.K.). , Arindam R. ChatterjeeArindam R. Chatterjee https://orcid.org/0000-0002-6172-2010 Department of Radiology, Washington University School of Medicine, Saint Louis, MO (A.R.C.). , Colin P. DerdeynColin P. Derdeyn https://orcid.org/0000-0002-5932-2683 Department of Radiology and Medical Imaging, University of Virginia School of Medicine, Charlottesville (C.P.D.). , Pooja KhatriPooja Khatri https://orcid.org/0000-0002-7344-8266 Department of Neurology, University of Cincinnati, OH (E.A.M., P.K.). , J.M. OlivotJ.M. Olivot Neurology Department, CHU Toulouse, France (J.M.O.). , Michael D. HillMichael D. Hill Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Canada (M.D.H.). , Jeffrey L. SaverJeffrey L. Saver https://orcid.org/0000-0001-9141-2251 Department of Neurology, University of California Los Angeles (J.L.S.). and Marc FisherMarc Fisher https://orcid.org/0000-0002-6116-475X Department of Neurology, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, MA (M.F.). Originally published5 Jun 2024https://doi.org/10.1161/STROKEAHA.124.047228Stroke. 2024;0FootnotesFor Sources of Funding and Disclosures, see page XXX.This manuscript was sent to Harold P. Adams, Jr, Guest Editor, for review by expert referees, editorial decision, and final disposition.The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Correspondence to: Gregory W. Albers, MD, Department of Neurology, Stanford University, 453 Quarry Rd, Palo Alto, CA 94304. Email albers@stanford.edu eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate.Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.Sign In to Submit a Response to This Article Previous Back to top Next FiguresReferencesRelatedDetails Advertisement Article InformationMetrics © 2024 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.124.047228PMID: 38836345 Originally publishedJune 5, 2024 Keywordsendovascular procedurespatient selectionperfusionstroketomographyPDF download Advertisement SubjectsComputerized Tomography (CT)Magnetic Resonance Imaging (MRI)

Introduction: Early endovascular treatment (EVT) in patients with large vessel occlusions (LVO) is associated with better outcomes. Identifying and categorizing delays to EVT may reveal areas for improvement. Methods: We prospectively identified all patients who underwent EVT at our hospital between May 2022 - 2023. We determined eight steps in acute care: arrival, imaging, IR activation, ED release, arrival to IR, groin puncture, first pass, and recanalization. We classified patients as delayed if any interval exceeded their rolling six-month median. We created 12 categories and 36 subcategories of delays. We used t-test and odds ratios to compare intervals and outcomes between delayed and non-delayed patients. We analyzed subgroups based on causes of delay and location of presentation. Results: Out of 183 LVO patients who underwent EVT, 111 (61%) were delayed. There were no significant differences in age, gender, last known normal to arrival, NIHSS, thrombolytic use, or TICI scale. The delayed group had higher door to groin (99 min), door to device (126 min), and door to recanalization (159 min) compared to the non-delayed group (40, 65, 81 min; p < 0.001). The most common causes of delay were: general case complexity (20%), which was associated with higher door to imaging (59 min, p < 0.001) and imaging to IR activation (37 min, p = 0.03); after hours presentation (19%), which was associated with higher door to imaging (53 min, p = 0.02) and imaging to IR activation (36 min, p = 0.01); and procedural complexity (18%) which was associated with higher groin to device (34 min, p < 0.001) and device to recanalization (53 min, p < 0.001) when compared to other causes of delay. Between the delayed and non-delayed group, there was no significant difference in the length of stay, change in NIHSS at discharge, in-hospital mortality, disposition, or 90-day mRS. Subgroup analysis showed a trend towards higher mortality in delayed patients who presented after hours (OR 3.60 (CI) 0.92-14.10) or in-hospital (OR 2.41 (CI) 0.57-10.19). Conclusions: We determined seven intervals where delays can occur between arrival and recanalization of LVO patients. We created a system for categorizing delays that showed areas for improvement including after hours and in-hospital stroke evaluation.

Background and importance Neurointervention is a very competitive specialty in the United States due to the limited number of training spots and the larger pool of applicants. The training standards are continuously updated to ensure solid training experiences. Factors affecting candidate(s) selection have not been fully established yet. Our study aims to investigate the factors influencing the selection process.Methods A 52-question survey was distributed to 93 program directors (PDs). The survey consisted of six categories: (a) Program characteristics, (b) Candidate demographics, (c) Educational credentials, (d) Personal traits, (e) Research and extracurricular activities, and (f) Overall final set of characteristics. The response rate was 59.1%. As per the programs' characteristics, neurosurgery was the most involved specialty in running the training programs (69%). Regarding demographics, the need for visa sponsorship held the greatest prominence with a mean score of 5.9 [standard deviation (SD) 2.9]. For the educational credentials, being a graduate from a neurosurgical residency and the institution where the candidate's residency training is/was scored the highest [5.4 (SD = 2.9), 5.4 (SD = 2.5), respectively]. Regarding the personal traits, assessment by faculty members achieved the highest score [8.9 (SD = 1)]. In terms of research/extracurricular activities, fluency in English had the highest score [7.2 (SD = 1.9)] followed by peer-reviewed/PubMed-indexed publications [6.4 (SD = 2.2)].Conclusion Our survey investigated the factors influencing the final decision when choosing the future neurointerventional trainee, including demographic, educational, research, and extracurricular activities, which might serve as valuable guidance for both applicants and programs to refine the selection process.

HomeRadioGraphicsVol. 44, No. 4 PreviousNext NeuroradiologyInvited Commentary: A New Era in the Treatment of Chronic Subdural HematomasArindam Rano Chatterjee Arindam Rano Chatterjee Author AffiliationsFrom the Mallinckrodt Institute of Radiology and Departments of Neurosurgery and Neurology, Washington University School of Medicine, 510 S Kingshighway Blvd, Campus Box 8131, St Louis, MO 63110.Address correspondence to the author (email: [email protected]).Arindam Rano Chatterjee Published Online:Mar 7 2024https://doi.org/10.1148/rg.240038See also the article by Schmolling et al in this issue.MoreSectionsFull textPDF ToolsAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookXLinked In References1. Embolization of the Middle Meningeal Artery With ONYX™ Liquid Embolic System In the Treatment of Subacute and Chronic Subdural Hematoma (EMBOLISE). Clinicaltrials.gov identifier: NCT04402632 https://www.clinicaltrials.gov/study/NCT04402632. Updated February 7, 2024. Accessed February 19,2024. Google Scholar2. Managing Non-acute Subdural Hematoma Using Liquid Materials: A Chinese Randomized Trial of MMA Treatment (MAGIC-MT). Clinicaltrials.gov identifier: NCT04700345 https://www.clinicaltrials.gov/study/NCT04700345. Updated August 22, 2023. Accessed February 19, 2024. Google Scholar3. The SQUID Trial for the Embolization of the Middle Meningeal Artery for Treatment of Chronic Subdural Hematoma. Clinicaltrials.gov identifier: NCT04410146. https://www.clinicaltrials.gov/study/NCT04410146. Updated August 16, 2023. Accessed February 19, 2024. Google Scholar4. Preventing Recurrences of Chronic Subdural Hematoma in Adult Patients by Middle Meningeal Artery Embolization (MEMBRANE). Clinicaltrials.gov identifier: NCT05327933 https://www.clinicaltrials.gov/study/NCT05327933. Updated November 29, 2023. Accessed February 19, 2024. Google Scholar5. Schmolling AH, Pérez-García C, Trejo C, et al. Middle Meningeal Artery Embolization for Management of Chronic Subdural Hemorrhage. RadioGraphics 2024;44(4):e230158. Google ScholarArticle HistoryReceived: Feb 19 2024Accepted: Feb 20 2024Published online: Mar 07 2024 FiguresReferencesRelatedDetailsAccompanying This ArticleMiddle Meningeal Artery Embolization for Management of Chronic Subdural HematomaMar 7 2024RadioGraphicsRecommended Articles Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: Predictors of Clinical and Radiographic Failure from 636 EmbolizationsRadiology2023Volume: 307Issue: 4Middle Meningeal Artery Embolization for Management of Chronic Subdural HematomaRadioGraphics2024Volume: 44Issue: 4Middle Meningeal Artery Embolization for Chronic Subdural HematomaRadiology2017Volume: 286Issue: 3pp. 992-999Insights into Middle Meningeal Artery Embolization in Chronic Subdural Hematoma: What Does Not WorkRadiology2023Volume: 307Issue: 4Interventional Oncology: 2043 and BeyondRadiology2023Volume: 308Issue: 1See More RSNA Education Exhibits Middle Meningeal Artery Embolization for the Management of Chronic Subdural HematomaDigital Posters2022To Glue or Not to Glue, That Was the Question - Misadventures with Glue Embolization in Peripheral ApplicationsDigital Posters2022ASPECT Score in Acute Stroke and Automated Software Tools: Pearls and PitfallsDigital Posters2020 RSNA Case Collection Sinking skin flap syndromeRSNA Case Collection2020Arachnoid CystRSNA Case Collection2021Intracranial hypotension syndromeRSNA Case Collection2021 Vol. 44, No. 4 Abbreviations Abbreviations: cSDH chronic subdural hemorrhage MMA middle meningeal artery Metrics Altmetric Score PDF download

Introduction: Physiological imaging studies in patients with severe steno-occlusive carotid disease (SSCD) reveal hemodynamic compromise as a mechanism underlying watershed infarcts (WI). However, it is unclear if the watershed region (WR) is intrinsically vulnerable in healthy individuals. We measured cerebral blood flow (CBF) and oxygen extraction fraction (OEF) in healthy individuals to determine if the WR was under metabolic stress, and therefore an intrinsically vulnerable region. Methods: To define a common WR, we created an “average WI density map” using MRIs from patients with diffusion restriction ipsilateral to SSCD from a single academic center (7/10 to 8/20). WI density maps were created using 5%, 10% and 15% incidence thresholds. Maps were overlaid onto coregistered CBF and OEF maps generated from pseudo-continuous arterial spin labeling (pCASL) and asymmetric spin echo sequences, respectively, performed on healthy controls aged <55 with no vascular risk factors. OEF was normalized to whole brain values. White matter OEF and CBF was compared within vs. outside the WR using the Kruskal Wallis test. Results: 47 MRIs (mean age 62 years, 55 % females) were used to create average WI density maps using 3 thresholds (Fig A). Average CBF and OEF maps were created from 29 healthy volunteers (mean age 39 years, 59 % females). WI maps were superimposed on the CBF and OEF maps from healthy controls. OEF was higher (p<0.001), and CBF lower (p<0.001) within compared to outside the watershed regions, regardless of incidence threshold used (10% threshold shown in Fig. B-C). Conclusion: Increased OEF and decreased CBF suggest oxygen metabolic stress in the WR, suggesting that the deep white matter may be intrinsically vulnerable even in healthy individuals. Indeed, several brain pathologies (WI, white matter hyperintensities of presumed vascular origin, and multiple sclerosis lesions) are known to fall within this region.

Transient cortical blindness is a known complication of iodinated contrast administration and is believed to reflect osmotic injury or autoregulatory dysfunction of the posterior circulation. Here, we report 2 cases of postangiography transient cortical weakness, a rare clinical analog to transient cortical blindness that affects the anterior circulation. The symptoms, timeline, and imaging findings of transient cortical weakness are distinct from more common post-procedural complications such as acute ischemic stroke or transient ischemic attack.

Adaptive plasticity of Breast Cancer stem cells (BCSCs) is strongly correlated with cancer progression and resistance, leading to a poor prognosis. In this study, we report the expression profile of several pioneer transcription factors of the Oct3/4 network associated with tumor initiation and metastasis. In the triple negative breast cancer cell line (MDA-MB-231) stably transfected with human Oct3/4-GFP, differentially expressed genes (DEGs) were identified using qPCR and microarray, and the resistance to paclitaxel was assessed using an MTS assay. The tumor-seeding potential in immunocompromised (NOD-SCID) mice and DEGs in the tumors were also assessed along with the intra-tumor (CD44+/CD24-) expression using flow cytometry. Unlike 2-D cultures, the Oct3/4-GFP expression was homogenous and stable in 3-D mammospheres developed from BCSCs. A total of 25 DEGs including Gata6, FoxA2, Sall4, Zic2, H2afJ, Stc1 and Bmi1 were identified in Oct3/4 activated cells coupled with a significantly increased resistance to paclitaxel. In mice, the higher Oct3/4 expression in tumors correlated with enhanced tumorigenic potential and aggressive growth, with metastatic lesions showing a >5-fold upregulation of DEGs compared to orthotopic tumors and variability in different tissues with the highest modulation in the brain. Serially re-implanting tumors in mice as a model of recurrence and metastasis highlighted the sustained upregulation of Sall4, c-Myc, Mmp1, Mmp9 and Dkk1 genes in metastatic lesions with a 2-fold higher expression of stem cell markers (CD44+/CD24-). Thus, Oct3/4 transcriptome may drive the differentiation and maintenance of BCSCs, promoting their tumorigenic potential, metastasis and resistance to drugs such as paclitaxel with tissue-specific heterogeneity.

Mounting evidence has suggested a relationship between Chiari I malformation and idiopathic intracranial hypertension, with some studies implicating anomalies of the cerebral venous system in the development of these conditions. However, precise mechanisms explaining these associations are not well described. There is a clear need to clarify the interplay between these conditions to guide further study in this area. In tandem with these efforts, it is necessary to review proper diagnosis and management to improve outcomes in patients suffering from these diseases.

BACKGROUND:Intracranial fusiform aneurysms are circumferential dilations of cerebral arteries that can lead to complications including ischemic stroke due to vessel occlusion, subarachnoid hemorrhage, or intracerebral hemorrhage. Treatment options for fusiform aneurysms have expanded significantly in recent years. Microsurgical treatment options include proximal and distal surgical occlusion and microsurgical trapping of the aneurysm, usually in association with high-flow bypass procedures. Endovascular treatment options include the placement of coils and/or flow diverters.OBSERVATIONS:Here the authors report a case of aggressive surveillance and treatment of a man with multiple progressive, recurrent, and de novo fusiform aneurysms of the left anterior cerebral circulation over 16 years. Because the long-term course of his treatment coincided with the recent expansion of endovascular treatment options, he underwent every type of treatment listed above.LESSONS:This case demonstrates the wide range of therapeutic options for fusiform aneurysms and how the treatment model for these lesions has evolved.

Traumatic cerebrovascular injury (CVI) involving the cervical carotid and vertebral arteries is rare but can lead to stroke, hemodynamic compromise, and mortality in the absence of early diagnosis and treatment. The diagnosis of both blunt CVI (BCVI) and penetrating CVI is based on cerebrovascular imaging. The most commonly used screening criteria for BCVI include the expanded Denver criteria and the Memphis criteria, each providing varying thresholds for subsequent imaging. Neck CTA has supplanted catheter-based digital subtraction angiography as the preferred screening modality for CVI in patients with trauma. This AJR Expert Panel Narrative Review describes the current state of CTA-based cervical imaging in trauma. We review the most common screening criteria for BCVI, discuss BCVI grading scales that are based on neck CTA, describe the diagnostic performance of CTA in the context of other imaging modalities and evolving treatment strategies, and provide a practical guide for neck CTA implementation.

Large vessel occlusion stroke due to underlying intracranial atherosclerotic disease (ICAD-LVO) is prevalent in 10 to 30% of LVOs depending on patient factors such as vascular risk factors, race and ethnicity, and age. Patients with ICAD-LVO derive similar functional outcome benefit from endovascular thrombectomy as other mechanisms of LVO, but up to half of ICAD-LVO patients reocclude after revascularization. Therefore, early identification and treatment planning for ICAD-LVO are important given the unique considerations before, during, and after endovascular thrombectomy. In this review of ICAD-LVO, we propose a multistep approach to ICAD-LVO identification, pretreatment and endovascular thrombectomy considerations, adjunctive medications, and medical management. There have been no large-scale randomized controlled trials dedicated to studying ICAD-LVO, therefore this review focuses on observational studies.

BACKGROUND AND PURPOSE:Stent-assisted coiling of wide neck bifurcation aneurysms in the anterior communicating segment and basilar tip region can be performed with varying stent configurations, including single stenting or Y-stenting. Y-stenting requires two stents and thus incurs greater cost and procedural complexity than single-stent constructs. The influence of first stent type on the need for Y-stenting remains unknown.MATERIALS AND METHODS:Clinical and angiographic data were retrospectively obtained for patients that underwent stent-assisted coiling for basilar tip or anterior communicating aneurysms at a high-volume center. Patients were included in this study if stent-assisted coiling was performed using Neuroform Atlas or LVIS Jr stents. A multivariate binary logistic regression was performed to measure the influence of first stent type on the need for Y-stenting.RESULTS:Stent-assisted coiling was used to treat 82 aneurysms in 81 patients during the study period, and Y-stenting was performed in 18.3% (15/82) of cases. In multivariate logistic regression analysis, use of LVIS Jr. as the first stent did not significantly influence the need for subsequent Y-stenting after controlling for aneurysm morphology (OR 0.65, 95% CI 0.18-2.43).CONCLUSION:Controlling for aneurysm morphology and location, the use of Y-stenting for stent-assisted coiling was not independently influenced by the choice of LVIS Jr or Neuroform Atlas as the first stent. A larger cohort may reveal differences between these two stents, particularly for aneurysms with large neck sizes.

OBJECTIVE:Despite the adoption of same-day outpatient surgical procedures in some specialties, it remains common practice to admit patients for monitoring after elective endovascular treatment of brain aneurysms to monitor for complications. The necessity of such monitoring has not been fully characterized. Here, the authors reviewed the utilization of imaging during posttreatment hospitalization, a surrogate measure for workup of suspected complications requiring hospital resources, to infer the value of inpatient monitoring after endovascular aneurysm treatment. METHODS:Clinical and angiographic data from eligible patients were retrospectively assessed for demographic characteristics, imaging indications, timing of imaging, and imaging findings. Patients were included if they underwent elective endovascular brain aneurysm treatment, and patients were excluded if significant intraprocedural complications occurred. The recorded imaging modalities included CT, MRI, catheter-based imaging, and ultrasound; plain radiographs were excluded. Multivariable logistic regression analysis was performed to identify predictors of the need for posttreatment imaging. RESULTS:In total, 1229 elective endovascular procedures for brain aneurysm treatment were included. Patients underwent imaging before discharge in 13.4% (165/1229) of cases, with significant findings in 5.0% (61/1229) of cases. The median (interquartile range) time to first posttreatment imaging was 13.2 (4.2-22.8) hours. The need for imaging during posttreatment hospitalization was positively associated with larger aneurysm size (p < 0.05) and negatively associated with underlying cardiovascular disease (p < 0.05). CONCLUSIONS:More than 1 in 8 patients who underwent elective endovascular brain aneurysm treatment required imaging during posttreatment hospitalization, most within the first 24 hours, and 1 in 20 had significant findings. These results suggest the importance of short-term hospitalization after elective endovascular aneurysm treatment.

Tools and techniques utilized in endovascular brain aneurysm treatment have undergone rapid evolution in recent decades. These technique and device-level innovations have allowed for treatment of highly complex intracranial aneurysms and improved patient outcomes. We review the major innovations within neurointervention that have led to the current state of brain aneurysm treatment.