Introduction: Medical therapy and endovascular therapy for intracranial atherosclerotic disease (ICAD) have evolved over the past two decades with improved medical therapy benchmarks, and improved techniques and patient selection for stenting. This study investigated patient co-morbidity trends to determine if these factors have led to better national patient outcomes. Methods: We performed a data search from the U.S. National Inpatient Sample (NIS) database from 2009 to 2020, evaluating patients who presented with stroke from ICAD and were treated with angioplasty and stenting and analyzed presenting co-morbidities and patient outcomes. The sample included patients who presented with stroke due to severe stenosis and underwent elective stenting, and those who presented with large vessel occlusion (LVO) with underlying ICAD who underwent rescue stenting following thrombectomy. We analyzed Elixhauser co-morbidity groups to look for trends and looked at all-cause in-hospital mortality. Results: Data from 2009 to 2020 showed no significant difference in patient mortality over the study period for patients who presented with LVO and underlying ICAD who underwent thrombectomy and rescue stenting, but there was a trend towards increased baseline co-morbidities. There was a significant decrease in mortality over the study period in patients who presented with stroke and severe stenosis who underwent elective angioplasty and stenting alone (p = 0.0103). Interestingly, there was a trend towards increased co-morbidities in patients during this period, despite the improved outcomes. There were significantly higher incidences in uncontrolled hypertension (28.2% vs 7.9%), diabetes (33.6% vs 4.6%), obesity (26.4% vs 10.2%) in the 2020 patient group compared to the 2009 patients. Hypercholesterolemia data is not captured in the Elixhauser co-morbidity analysis. Conclusions: Despite SAMMPRIS aggressive medical therapy guidelines published in 2011, over the study period there was a trend towards worse co-morbidity profiles in both the thrombectomy plus stent and stent only cohorts. While there was no change in mortality in the thrombectomy plus stent group over time, there was a significant trend towards better outcomes with lower mortality in the stenting only cohort, suggesting improved outcomes with best practice techniques and better patient selection criteria for endovascular therapy

Introduction: For a subset of patients with acute ischemic stroke (AIS) with large vessel occlusion (LVO) mechanical thrombectomy with a stent retriever and/or aspiration is insufficient to revascularize the target artery. Rescue therapy with angioplasty alone or with stenting has been utilized. This study assesses the longitudinal trends for adjunctive treatments following failed thrombectomy in the U.S. Methods: We performed a data search from the National Inpatient Sample (NIS) database using ICD9 and ICD10 procedure codes from 2009 through 2020. Data was collected for patients with stroke who underwent thrombectomy for LVO and subsequent angioplasty or angioplasty and stenting. The use of drug eluting stents, patient demographics, regional trends, length of stay, and mortality statistics were also assessed. Results: Between 2009 and 2020, the NIS data shows a significant increase in the use of stenting as adjunctive therapy to thrombectomy for LVO. In 2009, stenting with thrombectomy in LVO represented 5.6% (25/443) of patients stented with stroke from ICAD. In 2020, these cases represented 48.6% (520/1,070) of the patients stented. Over the study period, this increase in stent use during LVO treatment was significant (p<0.001). There has been a mild increase in the use of drug eluting stents in rescue therapy, but not as significant as bare metal stents. Angioplasty as an adjunct to thrombectomy for LVO has steadily increased over the study period, with 87 cases in 2009 and 265 cases in 2020, representing a 205% increase. Conclusion: There has been a progressive, significant increase in the number of rescue procedures for failed thrombectomy over the study period with stent procedures outnumbering angioplasty alone. Referencing published data these cases represent approximately 2-3% of the total number of thrombectomies performed for AIS.

The management of intracranial atherosclerotic disease (ICAD) has been evolving with advanced imaging, refinements of best medical treatment, and the development of endovascular options. There has been a significant increase in the use of endovascular therapy for symptomatic ICAD in the USA over the past 6 years. The rationale for this review is to update neurointerventionalists in these areas so that evidence-based decisions can be considered when counseling potential patients regarding their risks, benefits, and potential complications. The landmark SAMMPRIS trial demonstrated superiority of aggressive medical management (AMM) over intracranial stenting as an initial treatment. However, the risk of disabling or fatal stroke remains high in patients presenting with stroke treated with AMM. Recent studies showed a significantly lower rate of periprocedural complications from intracranial stenting. Patients who have failed medical treatment may therefore benefit from intracranial stenting, particularly in those with hemodynamic compromise and large vessel embolic stroke. Drug coated angioplasty balloons and drug eluting stents may potentially reduce the risk of in-stent re-stenosis. Large vessel occlusion (LVO) due to underlying ICAD is seen in a subset of thrombectomy-eligible patients. The use of stenting as a rescue therapy in LVO thrombectomy has also shown promising early results.

Introduction: Endovascular therapy is a treatment option for patients with severe symptomatic intracranial atherosclerotic disease (ICAD). The utilization of angioplasty and stenting has varied since the development of stents for this disease in 2005. This study assesses the longitudinal trends for endovascular treatment of ICAD in the U.S. Methods: We performed a data search from the National Inpatient Sample (NIS) database using ICD9 and ICD10 procedure codes from 2008 through 2019. Data was collected for patients with stroke from ICAD who underwent stenting or angioplasty alone. We also assessed the utilization of stenting or angioplasty in thrombectomy cases for large vessel occlusion (LVO), the use of drug eluting stents, patient demographics, regional trends, length of stay, and mortality statistics. Results: Between 2008 and 2019, the nadir of ICAD stenting cases in the U.S. was in 2011 (n=242). There was over a 207% increase in stenting cases in 2015 (n=730), and another increase of 47% in ICAD stenting in 2018 and 2019 (2018=965, 2019=1,175). There was a significant increase in stenting for ICAD over the entire study period (p=0.003). The data also shows a significant increase in the use of stenting as adjunctive therapy to thrombectomy for LVO. In 2011, stenting with thrombectomy in LVO represented 17.8% (43/242) of patients stented with stroke from ICAD. In 2019, these cases represented 48.1% (565/1,175) of the patients stented. Over the study period, this increase in stent use during LVO treatment was significant (p<0.001). Angioplasty alone for ICAD in non-occluded vessels has not significantly changed (p=0.289). Angioplasty as an adjunct to thrombectomy for LVO has steadily increased over the past 10 years, with 94 cases in 2008 and 210 cases in 2019, representing a 123% increase. Conclusion: There has been a progressive increase in stenting for ICAD since the nadir of this procedure in 2011 which is statistically significant. This increase was seen in patients with severe symptomatic ICAD, but also in patients undergoing thrombectomy for acute LVO with ICAD. Positive clinical stenting trials such as WEAVE and the post-hoc analysis from SAMMPRIS, and the increase in endovascular therapy for LVO appear temporally related to these changes.

BACKGROUND:The PerfusiOn imaging Selection of Ischemic sTroke patIents for endoVascular thErapy (POSITIVE) trial was designed to evaluate functional outcome in patients with emergent large vessel occlusion (ELVO) presenting within 0-12 hours with pre-specified bifurcated arms of early and late window presentation, who were selected for endovascular thrombectomy with non-vendor specific commercially available perfusion imaging software. Recent trials demonstrating the benefit of thrombectomy up to 16-24 hours following ELVO removed equipoise to randomize late window ELVO patients and therefore the trial was halted. METHODS:Up to 200 patients were to be enrolled in this FDA-cleared, prospective, randomized, multicenter international trial to compare thrombectomy and best medical management in patients with ELVO ineligible for or refractory to treatment with IV tissue plasminogen activator (IV-tPA) selected with perfusion imaging and presenting within 0-12 hours of last seen normal. The primary outcome was 90-day clinical outcome as measured by the raw modified Rankin Scale (mRS) with scores 5 and 6 collapsed (mRS shift analysis). RESULTS:The POSITIVE trial suspended enrollment with the release of results from the DAWN trial and was stopped after the release of the DEFUSE 3 trial results. Thirty-three patients were enrolled (21 for medical management and 12 for thrombectomy). Twelve of the 33 patients were enrolled in the 6-12 hour cohort. Despite the early cessation, the primary outcome demonstrated statistically significant superior clinical outcomes for patients treated with thrombectomy (P=0.0060). The overall proportion of patients achieving an mRS score of 0-2 was 75% in the thrombectomy cohort and 43% in the medical management cohort (OR 4.00, 95% CI 0.84 to 19.2). CONCLUSION:POSITIVE supports the already established practice of delayed thrombectomy for appropriately selected patients presenting within 0-12 hours selected by perfusion imaging from any vendor. The results of the POSITIVE trial are consistent with other thrombectomy trials. The statistically significant effect on functional improvement, despite the small number of patients, reinforces the robust benefits of thrombectomy. CLINICAL TRIAL REGISTRATION:NCT01852201.

BACKGROUND:Stent-assisted coiling of wide-necked intracranial aneurysms (IAs) using the Neuroform Atlas Stent System (Atlas) has shown promising results.OBJECTIVE:To present the primary efficacy and safety results of the ATLAS Investigational Device Exemption (IDE) trial in a cohort of patients with posterior circulation IAs.METHODS:The ATLAS trial is a prospective, multicenter, single-arm, open-label study of unruptured, wide-necked, IAs treated with the Atlas stent and adjunctive coiling. This study reports the results of patients with posterior circulation IAs. The primary efficacy endpoint was complete aneurysm occlusion (Raymond-Roy (RR) class I) on 12-month angiography, in the absence of re-treatment or parent artery stenosis >50%. The primary safety endpoint was any major ipsilateral stroke or neurological death within 12 months. Adjudication of the primary endpoints was performed by an imaging core laboratory and a Clinical Events Committee.RESULTS:The ATLAS trial enrolled and treated 116 patients at 25 medical centers with unruptured, wide-necked, posterior circulation IAs (mean age 60.2±10.5 years, 81.0% (94/116) female). Stents were placed in all patients with 100% technical success rate. A total of 95/116 (81.9%) patients had complete angiographic follow-up at 12 months, of whom 81 (85.3%) had complete aneurysm occlusion (RR class I). The primary effectiveness outcome was achieved in 76.7% (95% CI 67.0% to 86.5%) of patients. Overall, major ipsilateral stroke and secondary persistent neurological deficit occurred in 4.3% (5/116) and 1.7% (2/116) of patients, respectively.CONCLUSIONS:In the ATLAS IDE posterior circulation cohort, the Neuroform Atlas Stent System with adjunctive coiling demonstrated high rates of technical and safety performance. Trial registration number https://clinicaltrials.gov/ct2/show/NCT02340585.

Background Prior studies evaluating the Wingspan stent for treatment of symptomatic intracranial atherosclerotic disease have included patients with a spectrum of both on-label and off-label indications for the stent. The WEAVE trial assessed 152 patients stented with the Wingspan stent strictly by its current on-label indication and found a 2.6% periprocedural stroke and death rate. Objective This WOVEN study assesses the 1-year follow-up from this cohort. Methods Twelve of the original 24 sites enrolling patients in the WEAVE trial performed follow-up chart review and imaging analysis up to 1 year after stenting. Assessment of delayed stroke and death was made in 129 patients, as well as vascular imaging follow-up to assess for in-stent re-stenosis. Results In the 1-year follow-up period, seven patients had a stroke (six minor, one major). Subsequent to the periprocedural period, no deaths were recorded in the cohort. Including the four patients who had periprocedural events in the WEAVE study, there were 11 strokes or deaths of the 129 patients (8.5%) at the 1-year follow-up. Conclusions The WOVEN study provides the 1-year follow-up on a cohort of 129 patients who were stented according to the current on-label use. It provides a more homogeneous patient group for analysis than prior studies, and demonstrates a relatively low 8.5% 1-year stroke and death rate in stented patients.

Background: Intracranial atherosclerotic disease (ICAD) is one of the most challenging stroke etiologies, with frequent recurrences despite optimized medical management. Encephaloduroarteriosynangiosis (EDAS) is an indirect revascularization method that produces collaterals from the extracranial circulation into cerebral hypoperfused areas. We present the results of a phase-II trial of EDAS in patients with ICAD failing medical management. Methods: ERSIAS was a prospective objective performance criterion (OPC) trial of EDAS plus intensive medical management (IMM) in patients with symptomatic ICAD despite optimized medical management, and poor angiographic collaterals. The primary endpoint was any stroke or death within 30 days postsurgery or stroke in the territory of the qualifying artery beyond 30 days. The primary analysis compared event rates through one year with the OPC of 10·1%, based on a 10% reduction from the 20·1% rate in the IMM arm of SAMMPRIS trial. The event rates through two years were compared with propensity-score-matched (PSM) medically treated patients from the SAMPPRIS and COSS trials. Secondary endpoints included functional neurological outcome and angiographic neovascularization. Findings: Fifty-two patients underwent EDAS-plus-IMM. The median age was 52 years (IQR=38·3-65·8), and 32 were females (61·5%). The primary endpoint rate at one year was 9·6%, lower than the OPC of 10·1% (p=0·07), meeting the p<0·10 threshold for nonfutility and advancement to phase-III. In the sensitivity analysis, the primary endpoint event rate at two years was lower than in PSM control patients, 9·6 % vs. 21·2% (p<0·07). Overall, 86% of EDAS-plus-IMM patients were functionally independent at last follow-up, and 89% demonstrated neovascularization. There were two (3·8%) surgical complications (wound dehiscence) and no intracranial hemorrhages. Interpretation: ERSIAS phase-II provides evidence of safety and strong signals of the efficacy of EDAS-plus-IMM, supporting testing of the technique in a randomized controlled clinical trial. Trial Registration: NCT01819597.Funding Statement: Research reported in this publication was supported by the National Institute of Neurological Disorders and Stroke of the National Institutes of Health (NIH), under award no. K23NS079477. Declaration of Interests: None.Ethics Approval Statement: Protocol ID:IRB#12-000439 UCLA IRB Initial Approval Date: 7/19/2012 Committee: Medical IRB 3

Background and Purpose: Stent-assisted coil embolization using the new generation Neuroform Atlas Stent System has shown promising safety and efficacy. The primary study results of the anterior circulation aneurysm cohort of the treatment of wide-neck, saccular, intracranial, aneurysms with the Neuroform Atlas Stent System (ATLAS trial [Safety and Effectiveness of the Treatment of Wide Neck, Saccular Intracranial Aneurysms With the Neuroform Atlas Stent System]) are presented. Methods: ATLAS IDE trial (Investigational Device Exemption) is a prospective, multicenter, single-arm, open-label study of wide-neck (neck ≥4 mm or dome-to-neck ratio <2) intracranial aneurysms in the anterior circulation treated with the Neuroform Atlas Stent and approved coils. The primary efficacy end point was complete aneurysm occlusion (Raymond-Roy class 1) on 12-month angiography, in the absence of retreatment or parent artery stenosis (>50%) at the target location. The primary safety end point was any major stroke or ipsilateral stroke or neurological death within 12 months. Adjudication of the primary end points was performed by an independent Imaging Core Laboratory and the Clinical Events Committee. Results: A total of 182 patients with wide-neck anterior circulation aneurysms at 25 US centers were enrolled. The mean age was 60.3±11.4 years, 73.1% (133/182) women, and 80.8% (147/182) white. Mean aneurysm size was 6.1±2.2 mm, mean neck width was 4.1±1.2 mm, and mean dome-to-neck ratio was 1.2±0.3. The most frequent aneurysm locations were the anterior communicating artery (64/182, 35.2%), internal carotid artery ophthalmic artery segment (29/182, 15.9%), and middle cerebral artery bifurcation (27/182, 14.8%). Stents were placed in the anticipated anatomic location in all patients. The study met both primary safety and efficacy end points. The composite primary efficacy end point of complete aneurysm occlusion (Raymond-Roy 1) without parent artery stenosis or aneurysm retreatment was achieved in 84.7% (95% CI, 78.6%–90.9%) of patients. Overall, 4.4% (8/182, 95% CI, 1.9%–8.5%) of patients experienced a primary safety end point of major ipsilateral stroke or neurological death. Conclusions: In the ATLAS IDE anterior circulation aneurysm cohort premarket approval study, the Neuroform Atlas stent with adjunctive coiling met the primary end points and demonstrated high rates of long-term complete aneurysm occlusion at 12 months, with 100% technical success and <5% morbidity. Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT02340585.

Background and Purpose— The WEAVE trial (Wingspan Stent System Post Market Surveillance) is a postmarket surveillance trial mandated by the Food and Drug Administration to assess the periprocedural safety of the Wingspan Stent system in the treatment of symptomatic intracranial atherosclerotic disease. Methods— A total of 152 consecutive patients who met the Food and Drug Administration on-label usage criteria were enrolled at 24 hospitals and underwent angioplasty and stenting with the Wingspan stent. On-label criteria included age 22 to 80 years, symptomatic intracranial atherosclerotic stenosis of 70% to 99%, baseline modified Rankin Scale score ≤3, ≥2 strokes in the vascular territory of the stenotic lesion with at least 1 stroke while on medical therapy, and stenting of the lesion ≥8 days after the last stroke. The primary analysis assessed the periprocedural stroke, bleed, and death rate within 72 hours of the procedure with adjudication by a core study Stroke Neurologist. Results— The trial was stopped early after interim analysis of 152 consecutive patients demonstrated a lower than expected 2.6% (4/152 patients) periprocedural stroke, bleed, and death rate. This was lower than the 4% periprocedural primary event safety benchmark set for the interim analysis in the study. A total of 97.4% (148/152) patients were event-free at 72 hours, 1.3% (2/152) had nonfatal strokes, and 1.3% (2/152) of patients died. Conclusions— With experienced interventionalists, and proper patient selection following the on-label usage guidelines, the use of the Wingspan stent for intracranial atherosclerotic disease demonstrated a low periprocedural complication rate and excellent safety profile. This is the largest on-label, multicenter, prospective trial of the Wingspan stent system to date with the lowest reported complication rate. Clinical Trial Registration— URL: https://www.clinicaltrials.gov . Unique identifier: NCT02034058.

Introduction The WEAVE Trial was a post-market surveillance study evaluating the peri-procedural stroke and death rate in 152 consecutive patients who were stented with the Wingspan stent under its current on-label FDA indication for symptomatic intracranial atherosclerotic stenosis (ICAS), eight days or longer after stroke. This trial demonstrated a 2.6% peri-procedural event rate at 72 hours. The WEAVE Registry was a companion registry for 46 consecutive patients stented in an off-label usage of the Wingspan stent at the same centers as the WEAVE Trial patients. The registry demonstrated a 23.4% peri-procedural event rate that was significantly higher than the on-label trial event rate (p less than 0.0001). Methods The peri-procedural event rate of stroke, symptomatic bleed, or death was recorded for all patients in the Trial and the Registry at 72 hours, and the clinical outcomes were verified by core study Neurologists. We evaluated potential risk factors of the stenting procedure to determine which elements were associated with a higher likelihood of peri-procedural complications, including time to stenting from last stroke, and other factors. A total of 195 patients were included in the analysis. The remaining three patients, in whom the qualifying events were not well documented, were excluded. Results Six of 24 patients (25.0%) had events who were stented 0 to 7 days post-stroke, six of 69 patients (8.7%) had events who were stented 8 to 14 days post-stroke, and 3 of 102 patients (2.9%) had events who were stented 15 days or greater following their last stroke. Comparing the event rate in patients who were stented in the recommended time period of 8 days or longer after their last stroke (5.3%) to the event rate in patients who were stented early in the 0–7 day period (25.0%), there was a significant difference in clinical outcomes between the two groups (p = 0.0044). Other factors did not reach statistical significance independently. Conclusions Early stenting of patients with symptomatic ICAS was the strongest predictor of poor outcome in the WEAVE Registry cohort. These results indicate that efforts should be made to temporize patients medically until day 8 or longer post-stroke to reduce the peri-procedural morbidity associated with intracranial stenting. Disclosures M. Alexander: 2; C; Stryker Neurovascular. J. Chaloupka: 2; C; Stryker Neurovascular. A. Zauner: 2; C; Stryker Neurovascular. B. Baxter: 2; C; Stryker Neurovascular. W. Yu: 2; C; Stryker Neurovascular.

Introduction: Angioplasty and stenting for intracranial atherosclerotic disease can re-establish adequate luminal diameter in highly stenotic arteries and improve cerebral blood flow. As in other vascular territories, intracranial stented arteries may develop delayed re-stenosis due to progression of atherosclerotic disease or endothelial hyperplasia. The primary strategies for management of re-stenosis have included aggressive medical therapy, angioplasty only, and repeat angioplasty and stenting. Materials and Methods: A total of 226 patients underwent intracranial angioplasty and stenting for symptomatic ICAD from 2000-2017. Patients were treated with balloon expandable coronary stents until 2002, when self-expanding intracranial nitinol stents became available. The series included: 21 balloon expandable coronary stents, 33 Neuroform stents, 37 Enterprise stents, and 135 Wingspan stents. Of this group, 210 patients had delayed follow up intracranial vascular imaging at 6 months, 1 year, and longer. In follow up, 24 of the 210 patients (11.4 %) developed significant re-stenosis, defined as 70% or greater. Eleven of the patients were symptomatic and 13 had no symptoms. A total of 17 patients underwent endovascular treatment of their re-stenosis, and 7 had medical management only. Results: The mean time interval for re-stenosis was 8.7 months. Of the 17 patients treated with endovascular therapy for re-stenosis, 4 patients had angioplasty only and 13 patients had angioplasty and stenting. There was one peri-procedural stroke in this group (5.9%) and no other strokes in the follow up period (mean 2.4 years, range 6 months - 7 years). Of the 7 patients who were managed medically, 1 patient had a stroke (14.3%) in the follow up period at 10 months (mean follow up 2.1 years, range 3 months - 5 years). Discussion: The preliminary data from this study suggests that patients with severe re-stenosis may be at significant risk of stroke, even if the re-stenosis is currently asymptomatic. As with other vascular territories, re-stenosis can be managed with multiple modalities, but repeat angioplasty and stenting in this series appears to be a low risk and viable option for these patients compared with medical therapy alone.

Introduction: Cognitive decline after transient ischemic attacks (TIA) or stroke is common. Evaluation with the Montreal Cognitive Assessment (MoCA) tool has shown a decrease in cognitive scores in more than 30% of patients at 1 year. We hypothesize that indirect revascularization with EDAS plus intensive medical management (IMM) would decrease the rate of decline. Methods: This is a prospective study of EDAS plus IMM in symptomatic patients with intracranial arterial stenosis of more than 70%. Patients had MoCA evaluations at baseline, 1 month, 6 months, and 12 months after EDAS. Differences in MoCA at baseline and follow-up were compared using mixed model repeated measures ANOVA. Results: Thirty-one patients with no aphasia or neglect were included. Mean age was 48.3 +/- 16.6 years. Twenty-one were females (70%). The mean MoCA scores at baseline and 12-months were 23.6 +/- 4.3 and 25.5 +/- 4.1, respectively. MoCA ≥ 1 improvement was seen in 78.9% at 12 months. However, differences in MoCA scores at these time points did not reach statistical significance (p= 0.49, Fig. 1). Only 9% of patients had a decline of ≥2 MoCA points at 12 months. These results are comparable to the twelve month MoCA data from the SAMMPRIS trial, which showed a mean MoCA for IMM of 25.4 +/- 3.73 and for percutaneous angioplasty and stenting (PTAS) of 25.6 +/- 3.89. The rate of decline of MoCA scores after EDAS plus IMM was significantly less than the reported natural history after TIA or strokes outside the SAMMPRIS trial (9% vs. 30%, p=0.03). Conclusion: Compared to historical data, the decline in MoCA scores after TIA and stroke was lower in patients treated with EDAS plus maximum medical therapy and has similar effects to those reported in the SAMMPRIS IMM and PTAS groups.

Background Aneurysmal subarachnoid hemorrhage (aSAH) is the most severe type of stroke. In 2012, the Joint Commission, in collaboration with the American Heart Association/American Stroke Association (AHA/ASA), launched the Advanced Certification for Comprehensive Stroke Centers (CSCs). This new level of certification was designed to promote higher standard of care for patients with complex stroke. Objective The goal of this study was to examine the treatment modality and quality benchmarks of aSAH at one of the first five certified CSCs in the United States. Methods Consecutive patients with aSAH at Cedars-Sinai Medical Center between April 1, 2012 and May 30, 2014 were included for this retrospective study. The ruptured aneurysm was treated with coiling or clipping within 24 h. All patients were managed per AHA guidelines. Discharge outcomes were assessed using modified Rankin Scale (mRS). The rate of aneurysm treatment, door-to-treatment time, rate of posttreatment rebleed, hospital length of stay (LOS), discharge outcome, and mortality rates were evaluated as quality indicators. Results The median age (interquartile range) of the 118 patients with aSAH was 55 (19). Among them, 84 (71.2%) were females, 94 (79.7%) were transfers from outside hospitals, and 74 (62.7%) had Hunt and Hess grades 1–3. Sixty patients (50.8%) were treated with coiling, 52 (44.1%) with clipping, and 6 (5.1%) untreated due to ictal cardiac arrest or severe comorbidities. The rate of aneurysm treatment was 95% (112/118) with median door-to-treatment time at 12.5 (8.5) h and 0.9% (1/112) posttreatment rebleed. The median ICU and hospital LOS were 12.5 (7) and 17.0 (14.5) days, respectively. Coiling was associated with significantly shorter LOS than clipping. There were 59 patients (50%) with favorable outcome and 19 deaths (16.1%) at hospital discharge. There was no significant difference in discharge outcome between coiling and clipping. Conclusion Care of aSAH at one of the early CSCs in the United States was associated with high rate of aneurysm treatment, fast door-to-treatment time, low posttreatment rebleed, excellent outcome, and low mortality rate. Coiling was associated with significant shorter LOS than clipping. There was no significant difference in discharge outcomes between treatment modalities.

Background Simultaneous vasospasm and endovascular aneurysm treatment (SVAT) has been shown to be effective with good clinical outcomes in small series, but these studies have not examined predictive factors for clinical outcome after treatment. Objective To identify the safety and efficacy of SVAT in a large multicenter patient cohort and evaluate prognostic markers of clinical outcome following SVAT. Methods This study retrospectively enrolled 50 consecutive patients undergoing SVAT at 11 different centers. We analyzed Hunt and Hess and Fisher grades, aneurysm location, angiographic vasospasm grade, Glasgow Outcome Scale (GOS) at discharge, and 90-day modified Rankin Scale (mRS) scores. Results A total of 50 patients undergoing SVAT between the years 2003 and 2009 were identified. Patients presented, on average, 6.48±4.45 days after subarachnoid hemorrhage. Hunt and Hess and Fisher grades were 1 (n=7), 2 (n=12), 3 (n=14), 4 (n=15), 5 (n=2), and 3 and 4 (n=33), respectively. Aneurysm location was distributed as follows: anterior (n=32), posterior (n=16), anterior and posterior (n=2). Patients with good clinical condition (Hunt and Hess score 1–3) had significantly higher odds of surviving (OR=17.5, 95% CI 1.9 to 161.5), favorable GOS (OR=4.2, 95% CI 1.2 to 14.8), and favorable 90-day mRS (OR=4.2, 95% CI 1.2 to 14.8). Conclusions SVAT is safe, with the majority of patients achieving good clinical outcome. Patients with lower Hunt and Hess grades have higher odds of surviving and favorable clinical prognosis.