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

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.

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.

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.

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.

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.

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.

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.

BACKGROUND:Clinical practice guidelines recommend that cerebral venous thrombosis (CVT) be managed with long-term anticoagulant therapy using warfarin or low-molecular-weight heparin (LMWH) for 3 to 12 months. However, oral factor Xa inhibitors may offer preferable alternative treatment options for these patients.OBJECTIVE:The primary objective was to determine the effectiveness and safety of rivaroxaban or apixaban compared with warfarin or enoxaparin as long-term anticoagulation therapy for patients with a new diagnosis of CVT.METHODS:This was a single-center retrospective review of patients with newly diagnosed CVT who received acute and maintenance anticoagulation treatment. Study groups compared patients who received warfarin, enoxaparin, or an oral factor Xa inhibitor as their maintenance anticoagulant. The primary outcome was recurrent thrombotic events while on anticoagulation. Secondary outcomes included modified Rankin Scale, improved cerebral venous sinus opacification, duration of anticoagulant therapy, bleeding events during anticoagulant therapy, and adverse effects.RESULTS:A total of 119 patients were included in the analysis: warfarin (89), enoxaparin (11), and oral factor Xa inhibitor (19). The risk of recurrent thrombotic events were 11.2%, 0%, and 10.5% in the warfarin, enoxaparin, and oral factor Xa inhibitor treatment groups, respectively (P = 0.7635). There were no significant between-group differences observed regarding any of the secondary outcomes.CONCLUSIONS:Although the sample size is limited, these findings indicate that oral factor Xa inhibitors are a reasonable treatment option for patients with CVT. There was a trend toward more persistent symptoms in patients on warfarin, suggesting a potential improvement in recovery among patients that received an oral factor Xa inhibitor.

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.

Every 40 seconds, a stroke occurs in the United States. Strokes both disable patients and cause substantial cost to society, remaining among the top causes of long-term disability and costing an estimated $45.5 billion annually, of which $17.5 billion are due to indirect costs from lost productivity and mortality.(1) Large vessel occlusions account for the majority of acute ischemic strokes that result in moderate to severe disability or death.(2) For eligible patients with large vessel occlusions, endovascular treatment with mechanical thrombectomy, established as standard of care, has proven safe and efficacious up to 16-24 hours out from last known well.(3,4) Within the 6-hour window, multiple studies have found better functional outcomes and lower degrees of disability with earlier intervention.(5,6)

OBJECTIVE:The second-generation pipeline embolization device (PED), flex, has improved opening and resheathing ability compared to the first-generation classic PED device. A previously reported single-institutional study suggests that the PED flex devices are associated with lower rates of complications. However, there was limited discussion regarding the complication rate with respect to microcatheter choice for PED delivery and deployment. The present study aims to evaluate outcomes of aneurysm treatment with PED flex versus classic along with the Phenom microcatheter versus Marksman microcatheter.METHODS:A retrospective, IRB-approved database of all patients who received a PED classic or PED flex device between January 2012 and July 2018 was analyzed. Microcatheter choice, patient demographics, medical comorbidities, aneurysm characteristics, treatment information, and outcome data were analyzed using univariate analyses.RESULTS:A total of 75 PED procedures were analyzed. There was no significant difference in major complications between the PED classic and PED flex. However, those treated using the Marksman microcatheter were more likely to have a major complication (periprocedural hemorrhage or ischemic event; 16.6% vs. 0%, p = 0.0248) than those treated with the Phenom microcatheter. Within the PED flex cohort, all major complications were associated with the Marksman microcatheter (p = 0.0289).CONCLUSIONS:The present study does not replicate significantly fewer complications with PED flex but demonstrates a significant reduction in complications with the Phenom microcatheter. Ultimately, this suggests multiple factors are involved in achieving positive outcomes and low complication rates in PED treated unruptured cerebral aneurysms.

Purpose:The aim of this publication is to present a case of idiopathic spinal cord herniation (ISCH) associated with a transdural disk herniation, demonstrate an operative technique used to treat this condition and provide an updated review the literature.Background Context:ISCH is an infrequent condition that can cause progressive myelopathy leading to severe neurological dysfunction. This condition is characterized by ventral displacement of the spinal cord across a defect in the dura, either congenital or acquired, resulting in vascular compromise and adhesion that subsequently causes injury to the spinal cord. We present the management of such a patient, in addition to a review of the literature regarding management of ISCH.Methods:This patient underwent surgery using the dural graft sling technique for repair of the dural defect and restoration of normal spinal cord position within the thecal sac. A review of the literature revealed a total of 171 patients supplemented by our 1 patient, which were then analyzed.Results:The majority of patients, treated with a variety of surgical techniques, experienced improvements in symptomatology. Our patient experienced significant improvement in symptomatology.Conclusions:Although ISCH is a rare clinical condition that causes myelopathy, patients managed with surgery generally, though not universally, have a favorable neurological outcome. The associated surgical technique video demonstrates the dural sling technique for the treatment of this rare disorder.

Purpose: The aim of this publication is to present a case of idiopathic spinal cord herniation (ISCH) associated with a transdural disk herniation, demonstrate an operative technique used to treat this condition and provide an updated review the literature. Background Context: ISCH is an infrequent condition that can cause progressive myelopathy leading to severe neurological dysfunction. This condition is characterized by ventral displacement of the spinal cord across a defect in the dura, either congenital or acquired, resulting in vascular compromise and adhesion that subsequently causes injury to the spinal cord. We present the management of such a patient, in addition to a review of the literature regarding management of ISCH. Methods: This patient underwent surgery using the dural graft sling technique for repair of the dural defect and restoration of normal spinal cord position within the thecal sac. A review of the literature revealed a total of 171 patients supplemented by our 1 patient, which were then analyzed. Results: The majority of patients, treated with a variety of surgical techniques, experienced improvements in symptomatology. Our patient experienced significant improvement in symptomatology. Conclusions: Although ISCH is a rare clinical condition that causes myelopathy, patients managed with surgery generally, though not universally, have a favorable neurological outcome. The associated surgical technique video demonstrates the dural sling technique for the treatment of this rare disorder.

Neuroangiography (NA) is a minimally invasive procedure used to diagnose patients with neurovascular diseases. Noninvasive imaging has improved dramatically in recent years and is utilized more frequently; however, further evaluation with NA is still required in certain cases. NA indications include intracranial (cerebral aneurysms, arteriovenous malformations, dural arteriovenous fistula, cerebral vasculitis, cerebral vasospasm, ischemic stroke, nontraumatic subarachnoid hemorrhage, intracerebral hemorrhage, Moyamoya, vein of Galen malformation, intracranial tumors, and pseudotumor cerebri) and extracranial (internal and common carotid artery stenosis, vertebral artery stenosis, carotid artery blowout, vertebral artery blowout, epistaxis, oropharyngeal bleeding, and carotid body tumor) pathologies which can help with diagnosis and potential subsequent endovascular treatment. A thorough understanding of normal and variant cervical/cranial vascular anatomy is required. In addition, periprocedural management, catheter technique, equipment needed, and underlying disease pathology are paramount to successful and safe outcomes. This article will review basic neurovascular anatomy, periprocedural management, NA technique, and tips for safe and successful outcomes.

Idiopathic intracranial hypertension (IIH) is a disease process of abnormally increased intracranial pressure in the absence of a mass lesion. Medical management, optic nerve fenestration, and surgical shunting procedures have failed to produce consistently successful results. In an unknown percentage of cases, IIH is caused by dural venous sinus obstruction which can be cured by endovascular treatment with dural venous sinus stent placement. This helps prevent progressive vision loss and worsening papilledema caused by underlying increased intracranial pressure from venous outflow obstruction. Patients are required to have an established diagnosis of IIH, preferably made by a neuroophthalmologist, with clearly documented papilledema or at minimum visual disturbance along with lumbar puncture opening pressure greater than 25 cm H2O. Transverse to sigmoid sinus focal narrowing (intraluminal filling defect or extrinsic compression) must be seen during the venous phase of neuroangiography (NA) along with a pressure gradient of 10 mm Hg or greater across the focal narrowing during dural venous sinus pressure monitoring. A successful reduction is defined as a pressure gradient of less than 10 mm Hg after stent placement. Neuroophthalmologic follow-up occurs within 1 to 2 months to assess for changes in papilledema. If papilledema is unchanged or worsened, NA and hemodynamic evaluation is repeated for consideration of restenting. Appropriate patient selection criteria are required for IIH venous sinus stenting. The utilization of refined endovascular techniques along with postprocedure follow-up protocols can ultimately cure IIH for a select group of patients.