Background:Clinical intracranial vessel wall imaging (VWI) requires high spatial resolution leading to long scan times and artifacts. Purpose:To accelerate standard-of-care (SOC) 3D T1-weighted variable-flip-angle turbo-spin-echo (VFA-TSE) sequence with parallel imaging (Generalized Autocalibrating Partially Parallel Acquisitions, GRAPPA) using compressed sensing (CS) or Controlled Aliasing in Parallel Imaging Results in Higher Acceleration (CAIPIRINHA, CAIPI) with either standard or large field-of-view (FOV) configurations to reduce scan time, artifacts and accommodate head sizes. Study Type:Prospective study. Subjects:Ten healthy volunteers. Field Strength/Sequence:3 Telsa, 20-channel head coil, T1-weighted VFA-TSE. Assessment:Accelerated sequences were compared to SOC GRAPPA (R=2), including standard FOV CAIPI (SFCAIPI, R=4), CS (SFCS7, R=7), and large FOV CS (LFCS7, R=7; LFCS10, R=10). Four neuroradiologists rated image quality (IQ) and signal-to-noise ratio (SNR) using a 4-point Likert scale. Scores of 3-4 were categorized as clinically interpretable. Lumen and wall diameters were measured. Statistical Analysis:Descriptive statistics are reported. McNemar's test compared proportions of IQ- and SNR-based clinically interpretable scans between relevant sequences of interest. Inter- and intra-rater reliabilities were calculated with Fleiss Kappa and weighted Cohen's Kappa, respectively. Lumen and wall diameters of the CS- and CAIPI-accelerated sequences were compared to SOC using paired t-tests. Results:SFCAIPI showed the lowest mean IQ and SNR scores. SFCS7 showed no significant difference in the proportion of IQ-based clinically interpretable scans compared to SFGRAPPA. When testing FOV, LFCS7 (35/40 scans; time of acquisition (TA)=3:45) showed a significantly higher proportion of IQ-based clinically interpretable scans compared to SFCS7 (27/40, p=0.03; TA=6:37). Upon increasing acceleration (R=10), there was no difference in the proportion of IQ-based clinically interpretable scans between LFCS7 and LFCS10 (36/40, p=0.65). Large FOV eliminated aliasing artifacts compared standard FOV (aliasing in 7 of 10 subjects). LFCS10 (TA=4:55) achieved a 50.6% reduction in TA relative to SFGRAPPA (TA=9:57). Conclusion:Large FOV CS VWI sequence with 10x acceleration achieved a 50.6% reduction in scan time while delivering image quality comparable to SOC standard FOV GRAPPA.

A patient presented with acute onset headache and subsequent unconsciousness. The neurologic exam showed left-sided myoclonic jerking and right flaccid hemiparalysis. Noncontrast computed tomography revealed diffuse subarachnoid hemorrhage (SAH) with acute hydrocephalus. Initial digital subtraction angiography (DSA) showed no culprit source for SAH. Repeat DSA on day 7 after initial presentation raised suspicion for left internal carotid artery ophthalmic segment and left lateral lenticulostriate artery (LSA) aneurysms. A magnetic resonance vessel wall imaging (VWI) exam was performed given the presence of multiple potential culprit aneurysms. Vessel wall enhancement around the dome of the left LSA aneurysm suggested rupture, which then facilitated treatment with surgical clipping. LSA aneurysms are exceedingly rare and challenging to treat. Given the associated high degree of morbidity, expedient diagnosis is critical to direct management. VWI could be a valuable tool for detecting ruptured aneurysms in the setting of angiogram-negative SAH.

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.

Direct carotid cavernous fistulas (dCCF) are high-flow shunts between the internal carotid artery (ICA) and cavernous sinus and are commonly caused by traumatic injuries. Endovascular intervention using detachable coils, with or without stenting, is often the treatment of choice; however, migration or compaction of the coils can occur due to high-flow nature of dCCFs. Alternatively, deployment of a covered stent in ICA can be considered for treatment of dCCFs. We report a case of dCCF with tortuous intracranial ICA successfully treated by placement of a covered stent graft and we will illustrate the technical aspects of the procedure. In the presence of a tortuous ICA navigation and deployment of covered stents is technically complicated and requires modified maneuvers.

Introduction Dual antiplatelet therapy (DAPT) is necessary to minimize the risk of periprocedural thromboembolic complications associated with aneurysm embolization using Pipeline embolization device (PED). We sought 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 prior to treatment, periprocedural DAPT regimen, and intracranial complications occurring within 72‐hours of embolization were identified from the medical record. 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 Chi‐square tests. A p‐value <0.05 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 non‐responders requiring changes in their pre‐embolization DAPT regimen. 5% of PFT group patients experienced thromboembolic complications versus 1.6% of patients in the non‐PFT group (p=0.019). Two (15.4%) PFT group patients with thromboembolic complications experienced permanent neurological disability versus 4 (80%) non‐PFT group patients. 2.2% of PFT group patients and 3.5% of non‐PFT group patients experienced hemorrhagic intracranial complications (p>0.9). Conclusion Pre‐procedural PFT prior to PED treatment of intracranial aneurysms in patients pre‐medicated with an aspirin and clopidogrel DAPT regimen may not be necessary to significantly reduce the risk of procedure‐related intracranial complications.

Introduction/Purpose Pre-shaped neuroangiography catheters have shapes constrained to the 2D plane despite the complex 3D geometry of the arch and great vessels. 3D shapes may enable more efficient and safer selection of the great vessels when accessing the arch from a radial approach. We developed a process for generating arbitrary tip shapes, created two 3D variations of the classic Simmons 2, and tested the performance of these catheters in a silicone aortic arch model. Materials and Methods The standard reverse curve catheter shape was used as a rubric for channel-based heat shaping forms. Right- and left-handed (LH and RH) forms were designed in Onshape by taking the baseline shape and turning the distal tip 90 degrees into or out of the plane (see figure 1). The forms were 3D printed in aluminum by Shapeways. A 2D baseline form was created using the standard reverse curve shape. Straight 5 Fr Terumo GLIDECATH catheters were used as stock, heated in the forms at 160 degrees Celsius for 15 minutes, and rapidly quenched in a room temperature water bath. Catheter performance was evaluated with two tasks: catheter reformation at the arch and great vessel selection from the arch. Three trainee operators performed 10 timed trials of each task with each catheter. Results The LH catheter reformation times were similar to the Simmons 2 for two operators (all values in median (IQR): operator A, 12s (9–15) vs 24s (13.5–29.75), operator B, 16s (12.25–20) vs 13s (12.25–26.5)), but slower for the third operator (operator C, 16s (13.25–20.25) vs 9.5s (9–10.75). Selection of the left common carotid and right vertebral arteries was similar to slightly faster for all operators and selection of the right common carotid and left vertebral arteries was similar to slightly slower with the LH catheter compared to the Simmons 2. The RH catheter performed significantly slower than the Simmons 2 and LH catheter for all tasks and operators, and no operator was able to select the left vertebral artery with the RH catheter. Conclusion 3D catheter shapes can be rapidly prototyped with 3D printed aluminum forms and evaluated in a silicone aortic arch model. In our preliminary trial, the left-handed catheter was comparable to the standard Simmons 2 for most maneuvers and even faster for selection of certain vessels. The right-handed catheter was inferior for all maneuvers. Disclosures J. Boyle: None. K. Zerebiec: None. L. Silveira: None. J. Muse: None. G. Kreuser: None. T. Paris: None. R. Floreani: None. D. Johnson: None. S. Raymond: None.

Background Neuroendovascular practices are transitioning from transfemoral to a radial‐first approach for cerebral angiography. Developing radial‐specific devices requires a comprehensive understanding of vessel size and geometry encountered from a right radial approach. We developed a database of aortic arch and vessel measurements relevant for radial‐specific device development. Methods The database contained 100 consecutive neck computed tomographic angiograms conducted on a 256‐slice emergency department computed tomographic scanner. Arch characteristics and measurements obtained from 1‐cm maximum intensity projection reformats included arch type and diameter, bifurcation angles, and distances from the arch to vessel origins. Statistical analysis was conducted using Excel and R. Results The database contained 56 female and 44 male patients; the average age was 62 years. A total of 46% had type 2 or 3 arch configuration, 19% had bovine configuration, and 5% had a left vertebral artery originating directly from the arch. Median angles at the arch from the innominate ranged from 20° to 47° and at branch vessels from 16° to 63° with large variation. The left carotid bifurcation was ≈8 cm further than the right carotid bifurcation. The left vertebral artery origin was median 3.8 cm from the arch. Conclusions We cataloged aortic arch and vessel geometries that have implications for catheter and device performance from a transradial approach. For example, a standard guide catheter that is adequate length for the right anterior circulation must be at least 8 cm longer for comparable distal support on the left because of the difference in distance from the right to the left. Catheter tip shape may be further optimized to improve vessel selection. Currently used catheters make a reverse curve angle of ≈15°, although most great vessels are at between 15° and 45°. Finally, the length of the distal arm of reverse curve catheters is just >4 cm, frequently inadequate to easily reach the left vertebral artery origin (median distance, 3.8 cm in this study). Transradial devices should be developed with these constraints in mind. This database provides benchmarks for future catheter design.

Introduction/Purpose Many practitioners have transitioned from transfemoral to a radial first approach for cerebral angiography due to the improved safety profile and patient satisfaction. The Simmons 2 catheter is the most commonly used and is adequate but not optimized for transradial cerebral angiography. In this study, we built a library of reverse curve catheter shapes based on variations in the Simmons 2 design and tested library performance in a silicone transradial aortic arch model. Materials and Methods The reverse curve shape is defined by 9 parameters that describe three curves and adjacent segments (figure 1): the three angles (A1–3), the radius of curvature at each of the angles (R1–3) and the segment lengths (D1–3). For the classic Simmons 2 shape, A1 is 180 degrees, A2 is 15 degrees and A3 is approximately 245 degrees. We designed shaping forms with varying A1 (180, 210, and 240 degrees, figure 2) using the parameterized model in Onshape, a browser-based computer aided design platform, to draw plates with 5 Fr width grooves following the desired catheter tip shape. These shaping forms were then produced in aluminum by CNC-milling (Xometry). The straight 5 Fr Terumo GLIDECATH was used as a stock catheter and shaped by heating the catheter in the form at 160 degrees Celsius for 15 minutes with immediate quenching in room temperature water. Catheter performance was evaluated with two tasks: catheter reforming at the arch (without a wire) and great vessel selection from the arch using a silicone transradial aortic arch model (Mentice). Three trainee operators performed 10 timed trials of each task with each catheter. Results Catheter reformation at the arch was slightly faster for the 210 degree catheter but similar to slightly slower for the 240 degree catheter. Vessel selection was similar for all of the catheters with some variation between operators. Conclusions Catheter tip shape affects performance of maneuvers including tip reformation at the arch and vessel selection. We demonstrated an approach for rapid tip shape prototyping and performance evaluation in a silicone arch model and used the approach to optimize one parameter in a model of the Simmons 2 catheter. Future work is needed to evaluate additional shape parameters. Disclosures K. Zerebiec: None. J. Boyle: None. L. Silveira: None. J. Muse: None. G. Kreuser: None. T. Paris: None. R. Floreani: None. D. Johnson: None. S. Raymond: None.

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.

A stroke volume of arterial blood that arrives to the brain housed in the rigid cranium must be matched over the cardiac cycle by an equivalent volume of ejected venous blood. We hypothesize that the brain maintains this equilibrium by organizing coherent arterial and venous pulse waves. To test this hypothesis, we applied wavelet computational methods to diagnostic cerebral angiograms in four human patients, permitting the capture and analysis of cardiac frequency phenomena from fluoroscopic images acquired at faster than cardiac rate. We found that the cardiac frequency reciprocal phase of a small region of interest (ROI) in a named artery predicts venous anatomy pixel-wise and that the predicted pixels reconstitute venous bolus passage timing. Likewise, a small ROI in a named vein predicts arterial anatomy and arterial bolus passage timing. The predicted arterial and venous pixel groups maintain phase complementarity across the bolus travel. We thus establish a novel computational method to analyze vascular pulse waves from minimally invasive cerebral angiograms and provide the first direct evidence of arteriovenous coupling in the intact human brain. This phenomenon of arteriovenous coupling may be a physiologic mechanism for how the brain precisely maintains mechanical equilibrium against volume displacement and kinetic energy transfer resulting from cyclical deformations with each heartbeat. The study also paves the way to study deranged arteriovenous coupling as an underappreciated pathophysiologic disturbance in a myriad of neurological pathologies linked by mechanical disequilibrium.

Introduction/Purpose In the last 10 years, many practices have transitioned from femoral to a radial-first approach for cerebral angiography. Despite this change in practice, operators continue to use devices, including diagnostic and guide catheters, developed for a femoral approach. To date, only a single radial-specific catheter, the RIST, has come to market. Development of radial-specific devices requires a comprehensive understanding of the geometries, including vessel lengths and angles encountered from a right radial approach. This abstract reports an aortic arch database to assist in radial-specific device development. Materials and Methods Neck CTAs from 100 consecutive patients acquired on a single emergency department 256 slice CT scanner were analyzed retrospectively. Arch characteristics and measurements were obtained from 1 cm MIP reformatted images using McKesson PACs. Data included arch type, angles between the innominate artery and the common carotids, angles at the carotid bifurcations, angles of the vertebral artery origins, and distance from the innominate to the right carotid bifurcation and arch to the left carotid bifurcation and left vertebral origin. Statistical analysis was performed using Excel and R. Results Of the 100 consecutive patients, 1 was excluded due to poor contrast bolus timing. Our database contains 56 female and 43 male patients, average age 63 years old. 45% had type II or III arch configuration, 19% had bovine configuration, and 5% had a left vertebral artery originating directly from the arch. Vessel angles and distances are detailed in table 1. Angles encountered at the arch from the innominate average from 26-54 degrees with a large range, mostly accessible via a reverse curve catheter. Conclusions Trans-radial cerebrovascular angiography presents unique anatomical challenges compared to a traditional trans-femoral approach. For example, the left vertebral artery is often just beyond the reach of a standard Simmons 2 catheter. The geometries and lengths outlined in this abstract will inform bio-inspired design of radial-specific catheters and other devices. Disclosures K. Zerebiec: None. P. Heidari: None. D. Johnson: None. S. Raymond: 1; C; The University of Vermont Health Network Medical Group.

Intracranial vessel wall MR imaging (VWI) is increasingly being used as a valuable adjunct to conventional angiographic imaging techniques. This article will provide an updated review on intracranial VWI protocols and image interpretation. We review VWI technical considerations, describe common VWI imaging features of different intracranial vasculopathies and show illustrative cases. We review the role of VWI for differentiating among steno-occlusive vasculopathies, such as intracranial atherosclerotic plaque, dissections and Moyamoya disease. We also highlight how VWI may be used for the diagnostic work-up and surveillance of patients with vasculitis of the central nervous system and cerebral aneurysms.

Objectives: Endovascular thrombectomy (EVT) has revolutionized stroke care for large vessel occlusions (LVOs). However, over half treated remain functionally disabled or die. Patients with tandem lesions, or severe stenosis/occlusion of the cervical internal carotid artery (ICA) with intracranial LVO, may have technical EVT challenges and worse outcomes. We sought to compare treatments and outcomes for patients with anterior circulation tandem lesions versus isolated LVOs. Materials and Methods: Consecutive tandem lesion and isolated intracranial LVO patients were identified at a single center. Demographics, medical history, presentations, treatments, and outcomes were collected and analyzed. Results: From 381 EVT patients, 62 had tandem lesions related to atherosclerosis (74%) or dissection (26%). Compared to isolated intracranial LVOs, they were younger (63 vs 70, p = 0.003), had less atrial fibrillation (13% vs 40%, p < 0.0001), less adequate reperfusion (TICI 2b-3, 58% vs 82%, p < 0.0001), more intracranial hemorrhage (ICH, 13% vs 5%, p = 0.037), but similar 90-day functional independence (mRS 0-2, 34% vs 43%, p = 0.181). The cervical ICA was treated before intracranial EVT (57%), after (13%), not acutely (22%), or was inaccessible (8%). Acute cervical ICA treatments were stenting (57%) or angioplasty alone (13%). Neither acute stenting nor order of treatment was associated with outcomes (TICI 2b-3, ICH, or 90-day mRS 0-2). Among acutely stented, neither alteplase nor antiplatelets were associated with outcomes or stent patency. Conclusions: Tandem lesions were associated with less reperfusion, more ICH, but similar 90-day functional independence. No treatment approach was associated with outcomes. These data illustrate the technical challenges of tandem lesion treatment and underscore the importance of developing new approaches.

If you have ever surveyed the angiographic procedural suite after the patient has left the room, you likely have been struck by the pile of garbage bags at the end of the case. Do you know what is in your garbage, where it goes when it leaves your suite, and what the cost is for clean up? In this issue, Shum et al go ‘dumpster diving’, measuring and classifying the trash generated by an angiographic suite.1 They find that a typical neurointerventional procedure generates approximately 8 kg of waste, similar to hip arthroscopy for femoroacetabular impingement. Embolization procedures, however, can produce nearly twice this, largely from packaging and user manuals. In addition to weighing the trash, Shum et al classified the types of waste produced: roughly 65% was regulated medical waste and sharps, 20% was general waste, and the remainder was recyclable paper and plastics.1 Current procedural care is far from environmentally green. Operating rooms and procedural suites generate an enormous amount of garbage, responsible for 30%–70% of all healthcare waste.2 …

Background The Penumbra SMART coil is a novel device that becomes progressively softer from its distal to proximal end to maximize coil packing and prevent microcatheter prolapse or coil migration. Here, we report a large series of patients detailing the long-term experience of a single institution using the SMART coil among patients with intracranial aneurysms (IAs). Methods Prospective data of 105 consecutive patients with 106 IAs treated using SMART coils was collected between March 2015 and July 2018. Clinical and angiographic data were analyzed. Results Forty-nine patients (46.7%) presented with subarachnoid hemorrhage and 16 (14.2%) had recurrent aneurysms. Two patients had minor intraprocedural ruptures and remained neurologically stable. One patient had a thromboembolic complication with progressive neurologic decline. There was only one case microcatheter prolapse related to placement of a stent before coiling. An initial post-treatment modified Raymond-Roy Occlusion Classification (mRROC) I or II closure was achieved in 56 (52.8%) aneurysms. The average time to last follow-up was 8.4 months at which 70 (81.4%) aneurysms had mRROC I or II occlusion and a major recurrence was seen in 5 (5.8%) patients. Thirteen (12.3%) aneurysms required re-treatment of which one aneurysm was clipped. Conclusions The Penumbra SMART coil is safe and effective for the endovascular treatment of appropriately selected IAs. Additional studies at multiple centers comparing safety and efficacy profile over long-term periods to other mainstream coils are necessary.

Flow diversion fundamentally changes the treatment approach towards intracranial aneurysms.Most currently available devices established efficacy and safety data in the proximal anterior circulation; the distal and posterior circulations remain areas of active research.LVIS Blue is a stent with 28% metal coverage approved for use as a coil adjuvant.Some studies indicate potential "flow diverter" properties.We sought to evaluate the LVIS Blue as a stand-alone "flow diverter" for the treatment of intracranial aneurysms.We performed an observational single-center study to evaluate initial occlusion and occlusion at six months follow-up for patients with distal or posterior circulation aneurysms treated with the LVIS Blue as a "flow diverter" at our institution.Ten aneurysms were treated over the course of two years with six-month angiographic follow-up.Seven lesions were in the distal anterior circulation and were unruptured (five anterior communicating artery, one M2 middle cerebral artery, one pericallosal).Three were posterior circulation (two basilar tip aneurysms, one P2 posterior cerebral artery aneurysm).Follow up demonstrated treatment effect in nine of ten aneurysms (four complete aneurysm occlusions, five lesions with decreased size and flow).One lesion showed no treatment response.No ischemic or hemorrhagic complications were noted during placement or clinical follow-up.LVIS Blue can function safely as a "flow diverter" in the distal and posterior circulations.Further data regarding long-term efficacy is needed.

Residents and Fellows: Teaching Images in Headache Spontaneous Intracranial Hypotension Caused by Thoracic Disc Disease Robert Fuino MD, Corresponding Author Robert Fuino MD drfuino@gmail.com Department of Neurological Sciences, University of Vermont Medical Center, Burlington, VT, USA Address all correspondence to R. Fuino, Department of Neurological Sciences, University of Vermont Medical Center, 111 Colchester Avenue, Burlington, VT 05401, USA, email: drfuino@gmail.comSearch for more papers by this authorScott Raymond MD, PhD, Scott Raymond MD, PhD Department of Radiology, University of Vermont Medical Center, Burlington, VT, USASearch for more papers by this authorRobert Shapiro MD, Robert Shapiro MD Department of Neurological Sciences, University of Vermont Medical Center, Burlington, VT, USASearch for more papers by this author Robert Fuino MD, Corresponding Author Robert Fuino MD drfuino@gmail.com Department of Neurological Sciences, University of Vermont Medical Center, Burlington, VT, USA Address all correspondence to R. Fuino, Department of Neurological Sciences, University of Vermont Medical Center, 111 Colchester Avenue, Burlington, VT 05401, USA, email: drfuino@gmail.comSearch for more papers by this authorScott Raymond MD, PhD, Scott Raymond MD, PhD Department of Radiology, University of Vermont Medical Center, Burlington, VT, USASearch for more papers by this authorRobert Shapiro MD, Robert Shapiro MD Department of Neurological Sciences, University of Vermont Medical Center, Burlington, VT, USASearch for more papers by this author First published: 06 August 2020 https://doi.org/10.1111/head.13916Citations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume60, Issue8September 2020Pages 1830-1831 RelatedInformation