Post-acute sequelae of COVID infection and cerebral venous outflow disorders: Overlapping symptoms and mechanisms?

Neurological long Covid (NLC) is a major post-acute sequela of SARS-CoV-2 infection, affecting up to 10% of infected patients. The clinical presentation of patients with NLC is varied, but general NLC symptoms have been noted to closely mimic symptoms of cerebral venous outflow disorders (CVD). Here we review key literature and discuss evidence supporting this comparison. We also aimed to describe the similarity between CVD symptomatology and neuro-NLC symptoms from two perspectives: a Twitter-distributed survey for long covid sufferers to estimate nature and frequency of neurological symptoms, and through a small cohort of patients with long covid who underwent CVD work up per our standard workflow. Over 700 patients responded, and we argue that there is a close symptom overlap with those of CVD. CVD workup in a series of 6 patients with neurological long COVID symptoms showed jugular vein stenosis by CT venography and varying degrees of increased intracranial pressure. Finally, we discuss the potential pathogenic association between vascular inflammation, associated with COVID-19 infection, venous outflow congestion, and its potential involvement in NLC.

Reversible cerebral vasoconstriction syndrome due to teprotumumab: two case reports.

BACKGROUND: Reversible Cerebral Vasoconstriction Syndrome (RCVS) involves cerebral vasculature constriction and dilation. While the exact pathophysiology of RCVS is still not fully understood, there are multiple etiological factors suggested to be implicated in triggering RCVS. We report two RCVS cases potentially linked to teprotumumab. Case 1: A 59-year-old female with Graves' eye disease (GED) developed leg weakness and headache after initiating teprotumumab, and neuroimaging studies revealed multifocal cerebral vasospasm (CVS). Verapamil mitigated vasospasm and the patient overall improved. Case 2: A 71-year-old female with GED developed thunderclap headache two months after starting teprotumumab, with subarachnoid hemorrhage (SAH) and CVS revealed on neuroimaging studies. The patient improved on verapamil and was discharged without deficits. CONCLUSIONS: The temporal correlation between teprotumumab initiation and RCVS's symptom onset raises concern for the potential involvement of teprotumumab in triggering RCVS via disrupting cerebrovascular modulation. Further research is needed to investigate this proposed association.

Vertebral Artery Access Considerations in Coil Embolization of Small Superior Cerebellar Artery Aneurysm.

BACKGROUND: Coiling of small superior cerebellar artery aneurysms (sSCAAs) is challenging. We aimed to describe anatomic considerations in the vertebral and basilar artery (VA and BA) morphology for decision making in the coiling of sSCAAs. METHODS: Eleven patients with sSCAAs (<5 mm) treated at our institution between April 2015 and February 2022 were included to show our concept of deciding access routes in the coiling of sSCAAs. The access route was decided on the basis of VA characteristics, BA curvature, and aneurysm laterality. Adequate aneurysm occlusion on angiography (Raymond-Roy grading scale I and II), good outcome (modified Rankin Score 0-2) at the last follow-up, and adverse outcomes were evaluated. RESULTS: Simple coiling (n = 2), a balloon-assisted technique (n = 3), and stent-assisted technique (n = 6) were selected. At the last follow-up (median 13.0 months), adequate aneurysm occlusion and good outcome were obtained in all 9 patients (n = 10). Adverse outcomes were not observed. When VA dominance was equal, in the straight BA, the microcatheter insertion into the ipsilateral VA to the aneurysm was favorable to form a "fulcrum" on the contralateral side and obtain microcatheter stability. When an aneurysm was on the concave aspect of the curved BA, microcatheter insertion into the ipsilateral VA was favorable. As for the convex aspect's aneurysm location, the microcatheter insertion into the contralateral VA can be favored. Further, we described the VA origin classification as it relates to ease of access from a transradial approach. CONCLUSIONS: Vertebrobasilar morphology may be important in deciding access routes in the coiling of sSCAAs.

Image-localized biopsy mapping of brain tumor heterogeneity: A single-center study protocol.

Brain cancers pose a novel set of difficulties due to the limited accessibility of human brain tumor tissue. For this reason, clinical decision-making relies heavily on MR imaging interpretation, yet the mapping between MRI features and underlying biology remains ambiguous. Standard (clinical) tissue sampling fails to capture the full heterogeneity of the disease. Biopsies are required to obtain a pathological diagnosis and are predominantly taken from the tumor core, which often has different traits to the surrounding invasive tumor that typically leads to recurrent disease. One approach to solving this issue is to characterize the spatial heterogeneity of molecular, genetic, and cellular features of glioma through the intraoperative collection of multiple image-localized biopsy samples paired with multi-parametric MRIs. We have adopted this approach and are currently actively enrolling patients for our 'Image-Based Mapping of Brain Tumors' study. Patients are eligible for this research study (IRB #16-002424) if they are 18 years or older and undergoing surgical intervention for a brain lesion. Once identified, candidate patients receive dynamic susceptibility contrast (DSC) perfusion MRI and diffusion tensor imaging (DTI), in addition to standard sequences (T1, T1Gd, T2, T2-FLAIR) at their presurgical scan. During surgery, sample anatomical locations are tracked using neuronavigation. The collected specimens from this research study are used to capture the intra-tumoral heterogeneity across brain tumors including quantification of genetic aberrations through whole-exome and RNA sequencing as well as other tissue analysis techniques. To date, these data (made available through a public portal) have been used to generate, test, and validate predictive regional maps of the spatial distribution of tumor cell density and/or treatment-related key genetic marker status to identify biopsy and/or treatment targets based on insight from the entire tumor makeup. This type of methodology, when delivered within clinically feasible time frames, has the potential to further inform medical decision-making by improving surgical intervention, radiation, and targeted drug therapy for patients with glioma.

Failed mechanical thrombectomy: prevalence, etiology, and predictors.

OBJECTIVE: Despite advances in endovascular techniques, mechanical thrombectomy (MT) fails to achieve successful reperfusion in approximately 20% of patients. This study aimed to identify common etiologies and predictors of failed thrombectomy in a contemporary series. METHODS: A prospectively maintained database of MT patients between January 2013 and August 2021 was interrogated. Failed MT was defined as a final modified Thrombolysis in Cerebral Infarction score < 2b. Demographic data, procedural details, stroke etiology, and anatomical data in patients who underwent MT with subsequent failed reperfusion were collected. RESULTS: Of a total 1010 MT procedures, 120 (11.9%) were unsuccessful. The mean patient age was 66.8 years; 51.5% of patients were male, and 61.1% were White. The most common failure location was intracranial (93.3%) followed by failure at the arch (3.3%) and neck (3.3%). Among patients with intracranial failure, underlying intracranial atherosclerosis (ICAS) was the cause of failure in 84 patients (70%). Compared with patients with successful MT, patients with failed MT had a longer onset to puncture time (p = 0.012) and onset to groin time (p = 0.04). Rescue stenting was performed in 45 cases: 39 patients (4.4%) with successful MT and 6 (5.0%) with MT failure (p = 0.765). Multivariate analysis demonstrated that diabetes mellitus (p = 0.009) was independently associated with unsuccessful reperfusion. CONCLUSIONS: Failed MT was encountered in approximately 12% of MT procedures. The most common cause of failed MT was underlying ICAS. Further studies to evaluate better ways of early identification and treatment of ICAS-related large-vessel occlusion are warranted.

Giant Pediatric Dural Arteriovenous Fistula Management Using a Combined Operative Approach in a Hybrid Neuroendovascular Surgery Suite: Technical Nuances and Review of Literature.

BACKGROUND: Pediatric intracranial dural arteriovenous fistulas (dAVFs) are rare, complex entities usually presenting with macrocephaly from increased intracranial pressures at a young age. In the setting of a symptomatic intracranial dAVF that has undergone multiple endovascular treatments with subsequent recurrence or failed embolization attempts, the intracranial venous system can become inaccessible by traditional transvenous and transarterial routes. Direct puncture of the venous sinus for endovascular access after surgical exposure is a viable option. OBJECTIVE: To describe the technical nuances and available literature for direct puncture of the venous sinus for endovascular access in a pediatric patient with dAVF. METHODS: The clinical characteristics were reviewed and reported for a patient who underwent direct puncture of the venous sinus for endovascular access. In addition, a literature review was conducted for relevant literature pertaining to this technique and its associated indications, outcomes, and complications. RESULTS: Only 2 other reports of direct puncture of venous sinus for endovascular access after surgical exposure were found in the literature. Our patient achieved a favorable outcome with complete dAVF obliteration. CONCLUSION: Direct puncture of the venous sinus for endovascular access after surgical exposure for complex dAVFs that are inaccessible by transvenous or transarterial routes is a practical and safe approach to intracranial venous access that should be part of the vascular neurosurgeon's arsenal.

Contrast conservation measures during the global iohexol contrast shortage crisis did not affect stroke thrombectomy outcomes.

BACKGROUND: The current global shortage in iohexol contrast material (Omnipaque) used in performing CT-based triage images and mechanical thrombectomy (MT) represents a challenge to the healthcare system. A study was undertaken to assess the safety and feasibility of implementing protocol-based changes in pre-MT and MT workflow at a comprehensive stroke center. METHODS: A retrospective cohort study was undertaken of all patients with stroke who underwent MT during a 3-week period before implementing the contrast shortage protocol and for 3 weeks while implementing the protocol. The contrast shortage protocol included not performing perfusion images for MT selection and using diluted iohexol (50% contrast mixed with 50% heparinized saline) during the MT procedure. Procedural variables were compared between the two groups. RESULTS: A total of 27 patients underwent MT during the study period, 12 pre-contrast shortage and 15 post-contrast shortage. The average contrast volume used during the MT procedure was reduced from 83 mL to 68 mL after implementing the contrast shortage protocol (p=0.04). No difference was noted in the rate of successful reperfusion (11/15 vs 10/12), average time to recanalization (21 vs 23 min), average radiation dose (1143 vs 1117mGy) and time under fluoroscopy (20.7 vs 20.5 min) in the pre- and post-contrast shortage groups. A favorable discharge outcome was observed in 3/12 patients and 4/15 patients in the pre- and post-shortage periods, respectively (p=0.92). CONCLUSIONS: Modifying stroke workflow to adapt to the current global shortage in iohexol is feasible. Using diluted iohexol (50% contrast mixed with 50% heparinized saline) did not affect MT outcomes.

Angiographic Evaluation of Cranial Venous Outflow Patterns in Patients With and Without Idiopathic Intracranial Hypertension.

BACKGROUND: Several collateral venous pathways exist to assist in cranial venous drainage in addition to the internal jugular veins. The important extrajugular networks (EJN) are often readily identified on diagnostic cerebral angiography. However, the angiographic pattern of venous drainage through collateral EJN has not been previously compared among patients with and without idiopathic intracranial hypertension (IIH). OBJECTIVE: To quantify EJN on cerebral angiography among patients both with and without IIH and to determine whether there is a different EJN venous drainage pattern in patients with IIH. METHODS: Retrospective imaging review of 100 cerebral angiograms (50 IIH and 50 non-IIH patients) and medical records from a single academic medical center was performed by 2 independent experienced neuroendovascular surgeons. Points were assigned to EJN flow from 0 to 6 using an increasing scale (with each patient's dominant internal jugular vein standardized to 5 points to serve as the internal reference). Angiography of each patient included 11 separately graded extrajugular networks for internal carotid and vertebral artery injections. RESULTS: Patients in the IIH group had statistically significant greater flow in several of the extrajugular networks. Therefore, they preferentially drained through EJN compared with the non-IIH group. Right transverse-sigmoid system was most often dominant in both groups, yet there was a significantly greater prevalence of codominant sinus pattern on posterior circulation angiograms. CONCLUSION: Patients with IIH have greater utilization of EJN compared with patients without IIH. Whether this is merely an epiphenomenon or possesses actual cause-effect relationships needs to be determined with further studies.

Predictors and outcomes of first pass efficacy in posterior circulation strokes: Insights from STAR collaboration.

Background: First-pass efficacy (FPE) has been established as an important predictor of favorable functional outcomes after endovascular thrombectomy (ET) in anterior circulation strokes. In this retrospective cohort study, we investigate predictors and clinical outcomes of FPE in posterior circulation strokes (pcAIS). Methods: The Stroke Thrombectomy and Aneurysm Registry database was used to identify pcAIS patients who achieved FPE. Their baseline characteristics and outcomes were compared with the non-FPE group. The primary outcome was a 90-day modified Rankin Scale (mRS) of 0-3. Univariate (UVA) and multivariate (MVA) analyses were done to evaluate predictors of FPE. Safety outcomes included distal emboli, vessel rupture, symptomatic intracranial hemorrhage, and mortality. Results: Of 359 patients, 179 (50%) achieved FPE. Clot burden, occlusion site, and ET technique-related variables were similar between the two groups except for shorter procedure time with FPE. The primary outcome was significantly better with FPE (56.4% vs. 32.8%, p < 0.001). Complications were similar except for a higher rate of distal emboli in non-FPE group (11.1% vs. 3.2%, p = 0.032). Atrial fibrillation (Afib) had increased odds (aOR: 2.06, 95% CI; 1.24, 3.4, p = 0.005) and prior ischemic stroke had decreased odds (aOR: 0.524, 95% CI; 0.28, 0.97, p = 0.04) of FPE. Afib was the only independent predictor of FPE on MVA (1.94, 95% CI; 1.1, 3.43, p = 0.022). Conclusions: Higher rate of FPE in Afib-related pcAIS could possibly be explained by the differences in clot composition and degree of in-situ atherosclerotic disease burden. Future studies are warranted to explore the relationship of clot composition with ET outcomes.

Infratentorial retroclival and tentorial subdural hematoma from posterior communicating artery aneurysm rupture: A case report and systematic review of literature.

Background: The objective of this systematic review is to evaluate the pathogenesis, clinical course, and prognosis of patients who suffer from aneurysm rupture, leading to subdural hematoma (SDH) of the infratentorial space without associated subarachnoid hemorrhage (SAH). Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a literature review was conducted in PubMed and Scopus electronic databases for relevant published cases of aneurysmal SDH (AnSDH) of the infratentorial compartment without associated SAH. The presentation, treatment, clinical course, and outcome of identified cases are compiled. In addition, a patient suffering from an infratentorial SDH following aneurysm rupture is presented with an illustrative case. Results: Three articles were identified and met inclusion criteria. All cases occurred from ruptured posterior communicating artery aneurysms. All patients arrived with a Hunt and Hess classification of 2 or less. Only one case was managed with operative aneurysm clipping and hematoma evacuation while the other three cases were managed endovascularly. There were no reported postoperative complications, vasospasm, or seizures reported. All patients had a final Modified Rankin score of 3 or less at last reported follow-up. Conclusion: Infratentorial AnSDH without associated SAH is an etiology rarely reported in the literature. Here, we present a case report and systematic review demonstrating a relatively benign clinical course and outcome compared to report aneurysm rupture associated with SAH or mixed SAH and SDH. Moreover, there appear to be lower rates of vasospasm and improved outcomes in patients with isolated AnSDH compared to the literature aneurysmal SAH rates.

Stand-Alone Large Bore Aspiration Catheter (0.072 Inch) for Both Guide Support and Clot Aspiration in Transradial Posterior Circulation Stroke Thrombectomy: Technical Series.

BACKGROUND: The large size of guide catheters in the traditional triaxial configuration can prove limiting during transradial vertebrobasilar thrombectomy. This is especially important for the direct aspiration technique because of the large aspiration catheters that can reach an inner diameter of 0.072 in. A strategy that strikes a balance between stable proximal vessel support and distal navigation for aspiration is conceptually attractive. OBJECTIVE: To describe a series of transradial posterior circulation thrombectomy procedures in which the aspiration catheter served a dual role of guide support and clot aspiration in a coaxial configuration, thus obviating a larger guide catheter. METHODS: Patients selected in the series underwent radial artery access and direct over-the-wire navigation of the aspiration catheter into the vertebral artery. With coaxial microcatheter navigation, the aspiration catheter reached distal enough to ingest the clot successfully. Along with clinical and angiographic data, imaging features such as angle of vertebral artery origin were calculated. RESULTS: Five patients underwent a stand-alone aspiration catheter technique for basilar artery occlusion through transradial access. All procedures resulted in thrombolysis in cerebral infarction 3 recanalization. The mean time to basilar artery recanalization was 10 minutes. No access site complications or vertebral artery dissection were noted. The mean subclavian artery-vertebral origin angle was 84.06° (range 78.2-90.2°). CONCLUSION: For patients selected properly based on vascular anatomy and a careful technique, a large bore aspiration catheter can fulfil a stand-alone dual-role, thus obviating the need for a guide catheter. This can potentially improve the technical feasibility and success of transradial vertebrobasilar thrombectomy.

SMART Registry: Safety and Performance of the Penumbra SMART COIL System for Patients With Intracranial Aneurysms 4 mm and Smaller.

BACKGROUND: The Penumbra SMART COIL System includes a novel generation of embolic coils composed of complex and WAVE shape properties with varying levels of softness. OBJECTIVE: To assess safety and efficacy of the SMART COIL System through a 1-year follow-up in patients with small intracranial aneurysms. METHODS: This subset analysis of the SMART Registry, a prospective, multicenter study, includes patients with small intracranial aneurysms (≤4 mm) treated with the SMART COIL System. Registry end points include retreatment rates through 1 year, procedural device-related serious adverse events, and adequate occlusion postprocedure. RESULTS: Of 905 enrolled patients with aneurysms, 172 (19.0%) had small (≤4 mm) aneurysms (75.6% female; mean age 57.2 ± 13.4 years). 30.8% (53/172) of small aneurysms were ruptured, of which 50.9% (27/53) had Hunt and Hess ≥3. 79.5% (132/166) were wide-necked. Stent-assisted coiling and balloon-assisted coiling were performed in 37.2% (64/172) and 22.1% (38/172) of patients, respectively. The mean packing density for very small aneurysms was 44.9 (SD 25.23). Raymond Class I and Class II were achieved in 89.5% (154/172) postprocedure and 97.2% (137/141) at 1 year. The retreatment rate through 1 year was 5.6% (8/142), and the recanalization rate was 7.1% (10/141). The periprocedural device-related serious adverse event rate was 2.9% (5/172). Intraprocedural aneurysm rupture occurred in 0.8% of patients. CONCLUSION: This analysis suggests that the SMART COIL System is safe and efficacious in small aneurysms with satisfactory occlusion rates and low rates of rupture or rerupture. At 1 year, patients had low retreatment rates and good clinical outcomes.

Impact of Increasing Aspiration Catheter Size and Refinement of Technique: Experience of Over 1000 Strokes Treated With ADAPT.

BACKGROUND: We present longitudinal data regarding the outcomes and evolution of mechanical thrombectomy (MT) using a direct aspiration first pass technique. OBJECTIVE: To evaluate the impact of increasing aspiration catheter size. METHODS: This is a planned analysis of a prospective cohort study that enrolled all patients who underwent a direct aspiration first pass technique MT in a comprehensive stroke center from January 2013 to December 2020. We did exploratory analysis of the characteristics and outcomes of patients who had intracranial internal carotid artery or M1 segment of middle cerebral artery occlusion based on the aspiration catheter bore size (small [041, 054, 058, and 060 inch] vs medium [0.064 and 0.068 inch] and medium vs large [0.071, 0.072, and 0.074 inch]). RESULTS: During the 8-year study period, a total of 1004 patients were included. Median age was 69 years, 49% were female patients, and 60.6% were White. Symptomatic hemorrhagic transformation was observed in 47 patients (4.7%), and 366 patients (36.5%) achieved the modified Rankin scale of 0 to 2 at 90 days after the stroke. For patients with intracranial internal carotid artery or M1 occlusion, medium-bore aspiration catheters were more likely to achieve successful recanalization after first aspiration attempt (63.9% vs 51.4%, P = .015) and had a faster groin-to-reperfusion time (16 vs 20 minutes, P = .001) when compared with small-bore catheters. However, these differences were not significant when comparing medium-bore with large-bore catheters. CONCLUSION: Medium-bore catheters had better performance measures compared with small-bore catheters. However, large-bore catheters did not show significantly better performance results that suggest a plateau effect.

The Middle Meningeal Artery: Branches, Dangerous Anastomoses, and Implications in Neurosurgery and Neuroendovascular Surgery.

The middle meningeal artery (MMA) has always been the workhorse corridor for devascularization of dural-based intracranial lesions and, more recently, has been established as a target for the endovascular management of chronic subdural hematomas. The MMA anatomy is complex and deceitful, and its territory of irrigation (including cranial nerves) is poorly understood. Furthermore, MMA variations and anastomoses are more frequent than expected, which may predispose to procedure-related morbidity. A literature search was conducted in electronic databases per PRISMA guidelines for studies describing normal and abnormal MMA anatomy including variations in MMA origin and dangerous anastomoses. Our institutional case series of greater than 100 MMA embolizations for management of chronic subdural hematomas were reviewed for abnormal MMA anatomy, and clinically relevant case examples are presented. In this article, we provide a comprehensive review of the MMA to provide a better understanding and appreciation of this artery, including pearls and pitfalls, that we hope will aid the neurosurgeon and neurointerventionalist in safely tackling these lesions.

A proposed framework for cerebral venous congestion.

BACKGROUND: While venous congestion in the peripheral vasculature has been described and accepted, intracranial venous congestion remains poorly understood. The characteristics, pathophysiology, and management of cerebral venous stasis, venous hypertension and venous congestion remain controversial, and a unifying conceptual schema is absent. The cerebral venous and lymphatic systems are part of a complex and dynamic interaction between the intracranial compartments, with interplay between the parenchyma, veins, arteries, cerebrospinal fluid, and recently characterized lymphatic-like systems in the brain. Each component contributes towards intracranial pressure, occupying space within the fixed calvarial volume. This article proposes a framework to consider conditions resulting in brain and neck venous congestion, and seeks to expedite further study of cerebral venous diagnoses, mechanisms, symptomatology, and treatments. METHODS: A multi-institution retrospective review was performed to identify unique patient cases, complemented with a published case series to assess a spectrum of disease states with components of venous congestion affecting the brain. These diseases were organized according to anatomical location and purported mechanisms. Outcomes of treatments were also analyzed. Illustrative cases were identified in the venous treatment databases of the authors. CONCLUSION: This framework is the first clinically structured description of venous pathologies resulting in intracranial venous and cerebrospinal fluid hypertension. Our proposed system highlights unique clinical symptoms and features critical for appropriate diagnostic work-up and potential treatment. This novel schema allows clinicians effectively to approach cases of intracranial hypertension secondary to venous etiologies, and furthermore provides a framework by which researchers can better understand this developing area of cerebrovascular disease.

Endovascular Management of Distal Anterior Cerebral Artery Aneurysms: A Multicenter Retrospective Review.

INTRODUCTION: Distal anterior cerebral artery aneurysms (DACAA) are a rare and difficult entity to manage. Endovascular treatment has evolved for safe and durable treatment of these lesions. The objective of this study is to report the safety, efficacy, and outcomes of endovascular treatment of DACAA. METHODS: A retrospective review of DACAA endovascularly treated at 5 different institutions was performed. Data included demographics, rupture status, radiographic features, endovascular technique, complication rates, and long-term angiographic and clinical outcomes. A primary endpoint was a good clinical outcome (modified Rankin scale 0-2). Secondary endpoints included complications and radiographic occlusion at follow-up. RESULTS: A total of 84 patients were reviewed. The mean age was 56, and 64 (71.4%) were female. Fifty-two (61.9%) aneurysms were ruptured. A good functional outcome was achieved in 59 patients (85.5%). Sixty (71.4%) aneurysms were treated with primary coiling, and the remaining 24 were treated with flow diversion. Adequate occlusion was achieved in 41 (95.3%) aneurysms treated with coiling, and 17 (89.5%) with flow diversion. There were total 11 (13%) complications. In the flow diversion category, there were 2, both related to femoral access. In the coiling category, there were 9: 5 thromboembolic, 3 ruptures, and 1 related to femoral access. CONCLUSION: Endovascular treatment, and in particular, flow diversion for DACAA, is safe, feasible, and associated with good long-term angiographic and clinical outcomes.

Mechanical Thrombectomy of Carotid Terminus Occlusion Using Direct Aspiration Technique-Video Illustration: 2-Dimensional Operative Video.

Acute carotid terminus occlusion (CTO) is responsible for up to 5% of acute ischemic strokes secondary to emergent large vessel occlusion (ELVO) and up to 20% of acute internal carotid artery (ICA) occlusions.1 The term "CTO" has also been used to describe occlusions in the supra-clinoid segment or at the bifurcation of the ICA. Compared to other ELVOs, patients with CTO present with higher stroke severity and larger infarct volume, likely to be a result of disruption of direct Circle of Willis collaterals across the anterior communicating artery (AComA) and posterior communicating artery (PComA).2,3 Similary, CTO is usually associated with worse prognosis compared to other ELVOs in general. With regard to response to treatment, previous studies have reported significantly lower recanalization rates with intravenous alteplase with CTO compared to M1 segment occlusion. With regard to the safety and efficacy of mechanical thrombectomy, prior reports provide conflicting results with some reporting lower successful recanalization rates with CTO compared to M1 occlusion, and others reporting similar results. In our experience, we have found that successful recanalization of CTO can be achieved with a similar approach to M1 occlusions utilizing a direct aspiration first pass technique (ADAPT).3,4 Herein, we present a case of CTO for which we performed mechanical thrombectomy using ADAPT. This procedure was an emergent standard of care procedure for which a consent was not required and so not obtained.

Neuroendovascular Management of Acute Ischemic Basilar Strokes: 2-Dimensional Operative Video.

Basilar artery occlusions (BAOs) are devastating ischemic strokes that account for 1% of all strokes with high morbidity and mortality; however, neuroendovascular techniques such as ADAPT have recently revolutionized the clinical outcomes of these patients.1-3 Common underlying pathology in patients with BAO include intracranial atherosclerotic disease (ICAD) as well as thromboembolic origin.4 Basilar artery ICAD in a setting of acute stroke portends a poor prognosis and post-thrombectomy residual critical flow limiting stenosis treatment options, including balloon angioplasty with or without stent placement.5-7 We present a video illustration of neuroendovascular technique and challenges encountered when managing this pathology. Image at 5:42 reprinted with permission from Alawieh et al, Lessons learned over more than 500 stroke thrombectomies using ADAPT with increasing aspiration catheter size, Neurosurgery, 86(1), 2020, pp. 61-70, with permission from the Congress of Neurological Surgeons.1.

Superior sagittal sinus-to-internal jugular vein bypass shunt with covered stent construct for intractable intracranial hypertension resulting from iatrogenic supratorcular sinus occlusion: technical note.

BACKGROUND: Acute occlusion of the posterior sagittal sinus may lead to dramatic increase in intracranial pressure (ICP), refractory to standard treatment. Hybrid vascular bypass of cranial venous outflow into the internal jugular vein (IJV) has seldom been described for this in recent neurosurgical literature. OBJECTIVE: To describe creation of a novel vascular bypass shunt from the superior sagittal sinus (SSS) to internal jugular vein (IJV) utilizing a covered stent-Dacron graft construct for control of refractory ICP. METHODS: We illustrate a patient with refractory ICP increases after acute sinus ligation that was performed to halt torrential bleeding from intraoperative injury. A temporary shunt was created that successfully controlled ICP. From the promising results of the temporary shunt, we utilized a prosthetic hybrid bypass graft to function as a shunt from the sagittal sinus to IJV. Yet the associated anticoagulation led to complications and a poor outcome. RESULTS: Rapid and sustained ICP reduction can be expected after sagittal sinus-to-jugular bypass shunt placement in acute sinus occlusion. Details of the surgical technique are described. Heparin anticoagulation, while imperative, is also associated with worrisome complications. CONCLUSION: Acute occlusion of posterior third of sagittal sinus carries a very malignant clinical course. Intractable intracranial hypertension from acute sinus occlusion may be effectively treated with a SSS-IJV bypass shunt. A covered stent construct provides an effective vascular bypass conduit. However, the anticoagulation risk can lead to fatal outcomes. The neurosurgeon must always strive for primary repair of an injured sinus.

Endovascular Management of a Giant Skull Base Cavernous Aneurysm: Parent Artery Occlusion Is Still a Relevant Strategy.

Cavernous carotid aneurysms (CCAs) are usually considered benign as the natural history of the condition is often asymptomatic; however, CCAs can reach giant proportions and become symptomatic, thus requiring treatment. The introduction of flow diverters has revolutionized management of this condition. However, the parent artery geometry in giant lesions may prove exceedingly difficult to navigate and deploy stents satisfactorily. In such cases, indirect surgical treatment such as proximal occlusion of internal carotid artery (ICA) should be employed. Preoperative balloon test occlusion is indicated before permanent occlusion to identify patients who demonstrate hemispheric ischemia (for possible bypass), but it requires understanding of important operative complications and technical nuances. Endovascular parent artery sacrifice is an effective modality to achieve proximal occlusion. Here, we describe the step-wise management approach in a 53-year-old female with a giant, left CCA presenting with headache and cavernous sinus syndrome who was ultimately successfully treated with endovascular coiling and ICA occlusion. The management of complex lesions such as giant skull base aneurysms requires a sound understanding of vascular anatomy, tools available for evaluation, and physiological interpretation of diagnostic and therapeutic modalities to obtain excellent clinical results and patient satisfaction.