Delayed cerebral ischemia (DCI) remains a significant cause of morbidity and mortality following aneurysmal subarachnoid hemorrhage (aSAH). Despite identification of numerous predictors, risk remains variable even among patients with similar hemorrhage severity suggesting presence of unrecognized modifiers. One factor receiving little attention is intracranial arterial disease (ICAD): stenosis and calcification. We aim to examine their additive impacts to known modifiers. We analyzed 526 patients with aSAH treated at a single, tertiary care center between 2015 and 2025. DCI was defined as new neurologic deficits and/or new cerebral infarction ≥ 48 h from hemorrhage not explained by other etiologies. Stenosis (≥ 25

BACKGROUND:The EMBOLISE trial (The Embolization of the Middle Meningeal Artery With Onyx Liquid Embolic System in the Treatment of Subacute and Chronic Subdural Hematoma) demonstrated that middle meningeal artery embolization as an adjunct to surgical drainage reduces recurrence of symptomatic subacute and chronic subdural hematomas. We performed a subgroup analysis of the EMBOLISE surgical cohort to determine how the timing of embolization relative to surgery impacted various outcomes. METHODS:We performed a post hoc subgroup analysis to examine the association of the timing of embolization relative to surgery with the primary end point (hematoma reoperation within 90 days), secondary end points (clinical and radiographic outcomes), and safety end points (serious adverse events, neurological death, all-cause death, and stroke). RESULTS:Middle meningeal artery embolization before surgery (embolization-first group) and middle meningeal artery embolization after surgery (surgery-first group) were performed in 107 and 78 patients, respectively. Demographics and baseline clinical characteristics of the 2 groups were similar. The core laboratory confirmed the procedure to be successful in all patients with similar rates of distal penetration of Onyx into middle meningeal artery branches at the end of the embolization procedure in both groups (49.5% and 48.7%, respectively, P>0.99). Six of 103 patients in the embolization-first group (5.8%) and none in the surgery-first group needed reoperation within 90 days (analysis with observed data, P=0.08). Hematoma volumes at 90 and 180 days were similar except for lower hematoma thickness in the surgery-first group (2.3±3.0 mm versus 4.4±5.6 mm, P=0.03) at 180 days. Clinical and safety outcomes at 30, 90, and 180 days were similar. CONCLUSIONS:Performing surgical drainage before embolization in patients with subacute and chronic subdural hematomas may help minimize treatment failures and enhance hematoma resolution. REGISTRATION:URL: https://www.clinicaltrials.gov; Unique identifier: NCT04402632.

Background Chronic subdural hematomas (cSDHs) are associated with high recurrence risks following surgical evacuation. The EMBOLISE trial demonstrated that, compared with surgery alone, adjunctive middle meningeal artery embolization (MMAE) significantly reduced reoperation rates. However, given the limitations of the clinical end points of the trial, which may be subject to interrater variability and certain biases, the quantitative imaging metrics need to be evaluated. Purpose To evaluate the prespecified imaging end points of the EMBOLISE trial and assess the long-term resolution of cSDH through quantitative imaging analyses. Materials and Methods EMBOLISE was a multicenter, randomized, interventional trial conducted across 39 U.S. sites between December 2020 and August 2023. Prespecified secondary imaging end points included changes in hematoma volume and thickness and midline shifts from 24 hours to 90 days after the procedure at CT and MRI. The post hoc analyses performed herein extended the assessment to 180 days and included absolute hematoma metrics. Mixed-effects modeling was employed to adjust for confounders. Results Four hundred patients were enrolled in the EMBOLISE study, among whom 352 were included (mean age, 72 years ± 10.4 [SD]; 256 men). The mean cSDH volume was 126 mL at screening, with no intergroup differences. At 90 and 180 days, the MMAE plus surgery group had lower cSDH volumes (20.6 mL vs 28.9 mL [P = .03] and 19.4 mL vs 31.5 mL [P = .04], respectively). Mixed-effects models revealed a 6.9 mL (95% CI: -13.5, -0.40; approximately 25%) greater volume reduction and an 8.4 mL (95% CI: -15.2, -1.6; approximately 30%) lower absolute volume at 90 days in the MMAE group There was no evidence of a difference in the prespecified secondary imaging end points between the groups. Conclusion While the prespecified secondary imaging end points did not significantly differ, the absolute 90- and 180-day hematoma volumes were significantly lower in patients who received MMAE and surgery. Confounder-adjusted mixed-effects analysis indicated a greater reduction in hematoma volume with adjunctive MMAE. ClinicalTrials.gov identifier NCT04402632 © RSNA, 2026 Supplemental material is available for this article. See also the editorial by Ramasamy and Baker in this issue.

BackgroundCerebral venous thrombosis (CVT) is a rare but important cause of stroke. The superficial venous sinuses, including the superior sagittal sinus, are the most common location of CVT. Thrombosis of the deep venous system occurs less frequently, but can be more clinically severe by causing disturbances of consciousness due to involvement of deep anatomic structures including the thalamus and basal ganglia, leading to a higher incidence of death and disability. While anticoagulation is the standard initial recommended therapy for patients with CVT, endovascular intervention is sometimes proposed to help relieve cerebral venous hypertension.MethodsWe performed a retrospective case series review of a single-center interventional database over a 13-year time period to identify cases of CVT that underwent endovascular therapy and analyzed clinical and radiographic characteristics of these patients.ResultsWe identified 43 patients who underwent endovascular treatment for CVT. Twelve of these cases involved the deep system. Of the 12 patients in our consecutive case series, all 12 experienced recanalization of the deep system following catheter-directed alteplase infusions in the superficial or straight sinuses. On follow-up, these patients clinically did well in spite of initially poor neurologic examinations.ConclusionIn this single-center retrospective case series of 12 patients with deep and superficial venous thrombosis, endovascular treatment with site-directed thrombolytic infusion of the superficial venous sinuses with or without catheterization of the straight sinus resulted in angiographic recanalization of the deep veins and improved radiologic and clinical outcomes in 100% of the patients.

There is a paucity of data available on the context preceding anterior fusion failure or the need for a posterior fusion, the timing of the second operation, or any correlation between the different instrumentation and failure rates. A retrospective chart review was performed of 131 identified patients who underwent anterolateral corpectomy and fusion for a thoracolumbar burst fracture from 2000 to 2012 in a single institution. 96 patients had clinical and radiographic follow up of greater than two months. Mean kyphosis correction from preoperative (14.1°) to postoperative kyphosis (6.3°) was 7.7° and 37

Background: Blister aneurysms are high-risk intracranial vascular lesions. Definitive treatment of these lesions has been challenging. Severe disability or mortality rates are as high as 55% when these lesions are treated with open surgery. Recent data show that flow diversion is a safe and effective alternative treatment for blister aneurysms. Rerupture of the functionally unsecured lesion remains a concern as flow diversion does not immediately exclude the aneurysm from the circulation. Methods: A retrospective review was performed of any patients with ruptured blister aneurysms treated with a pipeline embolization device between 2010 and 2020 at the University of Colorado. Results: In this paper, we present the results of the intensive care management of ruptured intracranial blister aneurysms after flow-diverting stent placement. Conclusion: Despite the need for dual antiplatelet therapy and the delayed occlusion of blister aneurysms treated with flow diversion, we did not find an increase in periprocedural complications.

BACKGROUND AND OBJECTIVES:Dual antiplatelet therapy (DAPT) is necessary to minimize the risk of periprocedural thromboembolic complications associated with aneurysm embolization using pipeline embolization device (PED). We aimed to assess the impact of platelet function testing (PFT) on reducing periprocedural thromboembolic complications associated with PED flow diversion in patients receiving aspirin and clopidogrel. METHODS:Patients with unruptured intracranial aneurysms requiring PED flow diversion were identified from 13 centers for retrospective evaluation. Clinical variables including the results of PFT before treatment, periprocedural DAPT regimen, and intracranial complications occurring within 72 h of embolization were identified. Complication rates were compared between PFT and non-PFT groups. Differences between groups were tested for statistical significance using the Wilcoxon rank sum, Fisher exact, or χ 2 tests. A P -value <.05 was statistically significant. RESULTS:580 patients underwent PED embolization with 262 patients dichotomized to the PFT group and 318 patients to the non-PFT group. 13.7% of PFT group patients were clopidogrel nonresponders requiring changes in their pre-embolization DAPT regimen. Five percentage of PFT group [2.8%, 8.5%] patients experienced thromboembolic complications vs 1.6% of patients in the non-PFT group [0.6%, 3.8%] ( P = .019). Two (15.4%) PFT group patients with thromboembolic complications experienced permanent neurological disability vs 4 (80%) non-PFT group patients. 3.7% of PFT group patients [1.5%, 8.2%] and 3.5% [1.8%, 6.3%] of non-PFT group patients experienced hemorrhagic intracranial complications ( P > .9). CONCLUSION:Preprocedural PFT before PED treatment of intracranial aneurysms in patients premedicated with an aspirin and clopidogrel DAPT regimen may not be necessary to significantly reduce the risk of procedure-related intracranial complications.

Background Subacute and chronic subdural hematomas are common and frequently recur after surgical evacuation. The effect of adjunctive middle meningeal artery embolization on the risk of reoperation remains unclear. Methods In a prospective, multicenter, interventional, adaptive-design trial, we randomly assigned patients with symptomatic subacute or chronic subdural hematoma with an indication for surgical evacuation to undergo middle meningeal artery embolization plus surgery (treatment group) or surgery alone (control group). The primary end point was hematoma recurrence or progression that led to repeat surgery within 90 days after the index treatment. The clinical secondary end point was deterioration of neurologic function at 90 days, which was assessed with the modified Rankin scale in a noninferiority analysis (margin for risk difference, 15 percentage points). Results A total of 197 patients were randomly assigned to the treatment group and 203 to the control group. Surgery occurred before randomization in 136 of 400 patients (34.0%). Hematoma recurrence or progression leading to repeat surgery occurred in 8 patients (4.1%) in the treatment group, as compared with 23 patients (11.3%) in the control group (relative risk, 0.36; 95% confidence interval [CI], 0.11 to 0.80; P=0.008). Functional deterioration occurred in 11.9% of the patients in the treatment group and in 9.8% of those in the control group (risk difference, 2.1 percentage points; 95% CI, -4.8 to 8.9). Mortality at 90 days was 5.1% in the treatment group and 3.0% in the control group. By 30 days, serious adverse events related to the embolization procedure had occurred in 4 patients (2.0%) in the treatment group, including disabling stroke in 2 patients; no additional events had occurred by 180 days. Conclusions Among patients with symptomatic subacute or chronic subdural hematoma with an indication for surgical evacuation, middle meningeal artery embolization plus surgery was associated with a lower risk of hematoma recurrence or progression leading to reoperation than surgery alone. Further study is needed to evaluate the safety of middle meningeal artery embolization in the management of subdural hematoma. (Funded by Medtronic; EMBOLISE ClinicalTrials.gov number, NCT04402632.) Adjunctive Embolization for Subdural Hematoma In patients with subdural hematoma and an indication for surgical evacuation, middle meningeal artery embolization plus surgery led to a lower risk of reoperation for recurrence or progression within 90 days than surgery alone.

A single center had a collaborative, multidisciplinary review to determine how to best implement new acute ischemic stroke trials involving large vessel occlusions. A flow diagram process map was created for clinical decision support. Patients were divided into four groups based upon size of infarct and timing of presentation. The process map, available in the electronic health record (EHR) for clinicians to reference, guides the selection of patients for endovascular therapy with neuroimaging. In addition, the process map offers guidance for discussions with families and patients experiencing large vessel occlusions with both small and large core infarcts. This manuscript describes the process of creating the process map through a multidisciplinary review and discussion, with points of controversy and how these were addressed.

BACKGROUND:"Telescoping" multiple overlapping Pipeline Embolization Devices (PEDs; Medtronic) has increased their utility by allowing for more impermeable coverage and providing the ability to off-set landing zone sites and extend treatment constructs.OBJECTIVE:To consider the technical nuances and challenges of telescoping PEDs for the treatment of intracranial aneurysms.METHODS:Databases from 3 U.S. academic neurovascular centers were retrospectively queried to identify patients with intracranial aneurysms treated with multiple PED constructs. Data on patient and aneurysm characteristics, as well as outcomes including Raymond-Roy occlusion classification, modified Rankin Scale score, and complications, were gathered.RESULTS:Forty-six patients had 48 intracranial aneurysms treated, including 16 (33%) in whom placement of telescoping PEDs was planned. Fourteen (30%) patients presented with a ruptured aneurysm. Twenty-one aneurysms (44%) were treated with proximal extension, 13 (27%) with distal extension, and 14 (29%) with PED placement inside one another. Thirty (70%) patients had complete aneurysm occlusion at follow-up. Two (4%) patients had to be retreated. Three patients with unruptured and 1 with ruptured aneurysm had a permanent intraprocedural complication. We present descriptive cases illustrating PEDs that were placed inside one another, proximally, distally, and to improve wall apposition because of vessel tortuosity.CONCLUSION:Our data indicate a higher than expected complication rate that is likely because of the technical complexity of these cases. The case illustrations presented demonstrate the indications and challenging aspects of telescoping PEDs.

ABSTRACTOBJECTIVESManual record review is a crucial step for electronic health record (EHR)-based research, but it has poor workflows and is error prone. We sought to build a tool that provides a unified environment for data review and chart abstraction data entry.MATERIALS AND METHODSReviewR is an open-source R Shiny application that can be deployed on a single machine or made available to multiple users. It supports multiple data models and database systems, and integrates with the REDCap API for storing abstraction results.RESULTSWe describe two real-world uses and extensions of ReviewR. Since its release in April 2021 as a package on CRAN it has been downloaded 2,204 times.DISCUSSION AND CONCLUSIONReviewR provides an easily accessible review interface for clinical data warehouses. Its modular, extensible, and open source nature afford future expansion by other researchers.LAY SUMMARYWhen doing research using data from electronic health records (EHRs), data may need to be extracted by hand, either to perform the study or to ensure its accuracy. However many researchers can’t access the EHR for this purpose. Even when researchers have access, they must flip between their review list, the EHR, and the location they are recording the results of their review, which is difficult and can cause errors. We developed a software application, ReviewR, to make this process easier and less error prone and have used it in two real-world projects.

PURPOSE:Flow diverting stents have revolutionized the treatment of intracranial aneurysms through endoluminal reconstruction of the parent vessel. Despite this, certain aneurysms require retreatment. The purpose of this study was to identify clinical and radiologic determinants of aneurysm retreatment following flow diversion. METHODS:A multicenter flow diversion database was evaluated to identify patients presenting with an unruptured, previously untreated aneurysm with a minimum of 12 months' clinical and angiographic follow-up. Univariate and multivariate logistic regression modeling was performed to identify determinants of retreatment. RESULTS:We identified 189 aneurysms treated in 189 patients with a single flow-diverting stent. Mean age was 54 years, and 89% were female. Complete occlusion was achieved in 70.3% and 83.6% of patients at six and 12 months, respectively. Aneurysm retreatment with additional flow-diverting stents occurred in 5.8% of cases. Univariate analysis revealed that dome diameter ≥10 mm (p = 0.012), pre-clinoid internal carotid artery location (p = 0.012), distal > proximal parent vessel diameter (p = 0.042), and later dual antiplatelet therapy (DAPT) discontinuation (p < 0.001) were predictive of retreatment. Multivariate analysis identified discontinuation of DAPT >12 months (p = 0.003) as a strong determinant of retreatment with dome diameter ≥10 mm trending toward statistical significance (p = 0.064). Large aneurysm neck diameter, presence of aneurysm branch vessels, patient age, smoking history, and hypertension were not determinant of retreatment on multivariate analysis. CONCLUSIONS:Prolonged DAPT is the most important determinant of aneurysm retreatment following single-device flow diversion. Abbreviating DAPT duration to only six months should be a consideration in this population, especially for patients with a large aneurysm dome diameter.

The diagnosis and treatment of cerebral cavernous malformations (CCMs), or cavernomas, continues to evolve as more data and treatment modalities become available. Intervention is necessary when a lesion causes symptomatic neurologic deficits, seizures, or has high risk of continued hemorrhage. Future medical treatment directions may specifically target the pathogenesis of these lesions. This review highlights the importance of individualized treatment plans based on specific CCM characteristics.

Background The purpose of this study is to evaluate the impact multiple overlapping flow‐diverting stents have on aneurysm occlusion rates and iatrogenic complications relative to single flow‐diverting stents. Methods A retrospective review of a multicenter aneurysm database from 2012 to 2020 was performed to identify saccular aneurysms treated initially with single and multiple flow‐diverting stents with ≥12‐month angiographic and clinical follow‐up. Aneurysm occlusion rates as a function of stent number served as a primary outcome measure with iatrogenic complications serving as a secondary outcome measure. Results A total of 250 patients were initially treated with a single Pipeline embolization device (PED), and 48 patients were initially treated with multiple PEDs. There was no significant difference in aneurysm size, morphology, or dual‐antiplatelet therapy regimen used between groups. There was no significant difference in the aneurysm occlusion (single, 83.6%, versus multiple, 83.4%; P=0.65) or retreatment rates (single, 8.0%, versus multiple, 10.4%; P=0.58) between groups. There was no significant difference in the number of procedure‐related complications between groups (single, 8.0%, versus multiple, 4.2%; P=0.42), with 0.8% of patients treated with a single PED and 2.1% of patients treated with multiple PEDs experiencing a procedure‐related ischemic stroke. Conclusions There is no significant difference in overall aneurysm occlusion rates between aneurysms treated initially with single versus multiple overlapping PEDs nor are there significant differences in procedure‐related complications. Single PED flow diversion may be preferred whenever possible, with multiple PED constructs reserved for extenuating clinical circumstances as may be encountered with giant aneurysms.

Brain arteriovenous malformations (AVMs) often present treatment challenges. Patients with unruptured AVMs must consider not only whether they want to be treated, but what treatment modality they would prefer. Vascular neurosurgeons, neurointerventional surgeons, and stereotactic radiosurgeons must in turn guide their patients through the most appropriate treatment course considering the risk of AVM rupture, an individual AVM's characteristics, and patient preferences. In this review we will look at how the clinical trial "A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA)" has influenced the approach to unruptured brain AVMs and the treatment modalities available to clinicians to deal with these formidable lesions.

Mechanical thrombectomy (MT) for large vessel occlusion in acute ischemic stroke (AIS) is standard of care in select adult patients; however, minimal pediatric literature supports its use. Nonetheless, MT is still successfully performed in appropriately selected children with support by the American Heart Association guidelines ( 1 Ferriero D.M. Fullerton H.J. Bernard T.J. et al. Management of stroke in neonates and children: a scientific statement from the American Heart Association/American Stroke Association. Stroke. 2019; 50: e51-e96 Crossref PubMed Scopus (124) Google Scholar ). Anatomical variants in adults can render standard transfemoral or transradial endovascular access impossible, necessitating alternative access like direct carotid puncture (DCP). As a difficult vascular anatomy is not exclusive to adults, DCP can and should also be used for MT in children.

A 34-year-old man with a history of intravenous drug use presented with aphasia and right hemiparesis and was found to have a left middle cerebral artery (MCA) occlusion in a proximal M2 segment. Mechanical thrombectomy was attempted but aborted after unsuccessful recanalization attempts. The patient’s family subsequently reported that he injected methamphetamine directly into his neck. Further review of his initial imaging disclosed the presence of 8 needle fragments in the soft tissues and arterial circulation (Figure 1A), including a needle fragment at the left carotid bifurcation (Figure 1B). A repeat CT angiogram following the attempted thrombectomy 1 Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA 2 Department of Radiology, University of Colorado School of Medicine, Aurora, CO, USA 3 Department of Neurology, Intermountain Medical Center, Salt Lake City, UT, USA 4 Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, USA

Introduction/Purpose Traumatic intracranial aneurysms (TICAs) comprise a rare and particularly dangerous subset of cerebral aneurysms that can be difficult to both diagnose and manage, owing to their locations, morphologies, and presence of concomitant traumatic brain injury (TBI). Materials and Methods We retrospectively reviewed internal databases comprised of intracranial aneurysms treated at two U.S. academic medical centers from 2010 to 2019. Patients with aneurysms of the intracranial circulation as a result of blunt force trauma treated with endovascular methods were included. All patients underwent initial non-contrast head CT, non-invasive vascular imaging, and diagnostic cerebral angiography. Clinical and radiographic data were recorded. Results Between January 2010 and December 2019, a total of 8 patients with traumatic intracranial aneurysms treated with endovascular methods were included. Patients were aged 9-62 years (mean 35.5) and most were male (n=5). Five of 8 patients (62%) experienced acute intracranial hemorrhage due to aneurysm rupture. All patients but one were found to have an associated fracture on initial CT, including the ipsilateral petrous bone (n=4), anterior clinoid process (n=1), posterior clinoid (n=2), sphenoid body (n=6), clivus (n=2), and carotid canal (n=3), while 6 of 8 patients were noted to have sphenoid hemosinus on initial imaging. The most frequently involved vessel was the internal carotid artery (ICA; n=6), including 2 cavernous segments, 2 supraclinoid segments, 1 ophthalmic segment, and 1 communicating segment. The other vessels involved include the anterior cerebral artery (pericallosal; n=1) and the posterior inferior cerebellar artery (tonsillomedullary segment; n=1). Aneurysm sizes ranged from 2-8 mm (mean, 4.4 mm). Three of 8 aneurysms were treated with flow diversion (FD), one of which had adjuvant coil embolization, while 3 aneurysms were treated with balloon-assisted coiling (BAC). The 2 non-ICA aneurysms were treated with parent vessel sacrifice (PVS), one with liquid embolics and coil embolization, the other with coil embolization alone. Complete angiographic cure was achieved in 5 of 8 patients. Three aneurysm recurrences were found on follow-up imaging, one of which presented as re-rupture, and all of which were re-treated. Re-treatment modalities included FD alone, FD with adjuvant coil embolization, and direct coil embolization alone. Two of 3 treated recurrences were completely cured on angiographic follow-up, while one expired before sufficient time to judge treatment efficacy had passed. Despite technical success in the overwhelming majority of cases, half of the patients were discharged with a poor functional outcome (mRS 3-6). Conclusion TICAs may form acutely or in a delayed manner following blunt force trauma and occur most frequently on the ICA owing to its proximity to the rigid bony and dural structures of the skull base. The presence of cranial fractures and sphenoid hemosinus warrants prompt intracranial vascular imaging, particularly in a TBI patient with acute neurological decline or new neurologic deficit. Endovascular management is effective, particularly FD, which has emerged as an attractive alternative to PVS in carefully selected patients. Outcomes tend to be poor despite technically successful endovascular treatment, and further investigations are needed to show which patients might benefit the most. Disclosures A. White: None. C. Roark: None. D. Case: 2; C; Medtronic. Z. Folzenlogen: None. D. Kumpe: None. D. Ding: None. J. Seinfeld: 2; C; Medtronic.

Abstract Background The 10th revision of International Classification of Disease, Clinical Modification (ICD10‐CM) increased the number of codes to identify non‐traumatic subarachnoid hemorrhage from 1 to 22. ICD10‐CM codes are able to specify the location of aneurysms causing subarachnoid hemorrhage (aSAH); however, it is not clear how frequently or accurately these codes are being used in practice. Objective To systematically evaluate the usage and accuracy of location‐specific ICD10‐CM codes for aSAH. Methods We extracted all uses of ICD10‐CM codes for non‐traumatic subarachnoid hemorrhage (I60.x) during the first 3 years following the implementation of ICD10‐CM from the billing module of the electronic health record (EHR) for UCHealth. For those codes that specified aSAH location (I60.0‐I60.6), EHR documentation was reviewed to determine whether there was an active aSAH, any patient history of aSAH, or unruptured intracranial aneurysm/s and the locations of those outcomes. Results Between 1 October 2015 and 30 September 2018, there were 3119 instances of non‐traumatic subarachnoid hemorrhage ICD10‐CM codes (I60.00‐I60.9), of which 297 (9.5%) code instances identified aSAH location (I60.0‐I60.6). The usage of location‐specific codes increased from 5.7% in 2015 to 11.2% in 2018. These codes accurately identified current aSAH (64%), any patient history of aSAH (84%), and any patient history of intracranial aneurysm (87%). The accuracy of identified outcome location was 53% in current aSAH, 72% for any history of aSAH, and 76% for any history of an intracranial aneurysm. Conclusions Researchers should use ICD10‐CM codes with caution when attempting to detect active aSAH and/or aneurysm location.