Middle meningeal artery embolization with subdural evacuating port system for primary management of chronic subdural hematomas.

Optimal treatment for chronic subdural hematomas remains controversial and perioperative risks and comorbidities may affect management strategies. Minimally invasive procedures are emerging as alternatives to the standard operative treatments. We evaluate our experience with middle meningeal artery (MMA) embolization combined with Subdural Evacuating Port System (SEPS) placement as a first-line treatment for patients with cSDH. A single institution retrospective review was performed of all patients undergoing intervention. Patients were stratified by treatment with MMA embolization and SEPS placement, MMA embolization and surgery, SEPS placement only, and surgery only for cSDH from 2017 to 2020, and cohorts were compared against each other. Patients treated with MMA/SEPS were more likely to be older, be on anticoagulation, have significant comorbidities, have shorter length of stay, and less likely to have symptomatic recurrence compared to SEPS only cohort. Thus, MMA/SEPS appears to be a safe and equally effective minimally invasive treatment for cSDH patients with significant comorbidities who are poor surgical candidates.

Early Fevers and Elevated Neutrophil-to-Lymphocyte Ratio are Associated with Repeat Endovascular Interventions for Cerebral Vasospasm in Patients with Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND: Patients with aneurysmal subarachnoid hemorrhage (aSAH) may develop refractory arterial cerebral vasospasm requiring multiple endovascular interventions. The aim of our study is to evaluate variables associated with need for repeat endovascular treatments in refractory vasospasm and to identify differences in outcomes following one versus multiple treatments. METHODS: We retrospectively reviewed patients treated for aSAH between 2017 and 2020 at two tertiary care centers. We included patients who underwent treatment (intraarterial infusion of vasodilatory agents or mechanical angioplasty) for radiographically diagnosed vasospasm in our analysis. Patients were divided into those who underwent single treatment versus those who underwent multiple endovascular treatments for vasospasm. RESULTS: Of the total 418 patients with aSAH, 151 (45.9%) underwent endovascular intervention for vasospasm. Of 151 patients, 95 (62.9%) underwent a single treatment and 56 (37.1%) underwent two or more treatments. Patients were more likely to undergo multiple endovascular treatments if they had a Hunt-Hess score > 2 (odds ratio [OR] 5.10 [95% confidence interval (CI) 1.82-15.84]; p = 0.003), a neutrophil-to-lymphocyte ratio > 8.0 (OR 3.19 [95% CI 1.40-7.62]; p = 0.028), and more than two fevers within the first 5 days of admission (OR 7.03 [95% CI 2.68-20.94]; p < 0.001). Patients with multiple treatments had poorer outcomes, including increased length of stay, delayed cerebral ischemia, in-hospital complications, and higher modified Rankin scores at discharge. CONCLUSIONS: A Hunt-Hess score > 2, a neutrophil-to-lymphocyte ratio > 8.0, and early fevers may be predictive of need for multiple endovascular interventions in refractory cerebral vasospasm after aSAH. These patients have poorer functional outcomes at discharge and higher rates of in-hospital complications.

Rapid Apparent Diffusion Coefficient Evolution After Early Revascularization.

Background and Purpose- In this era of endovascular therapy (EVT) with early, complete recanalization and reperfusion, we have observed an even more rapid apparent diffusion coefficient (ADC) normalization within the acute ischemic lesion compared with the natural history or IV-tPA-treated patient. In this study, we aimed to evaluate the effect of revascularization on ADC evolution within the core lesion in the first 24 hours in acute ischemic stroke patients. Methods- This retrospective study included anterior circulation acute ischemic stroke patients treated with EVT with or without intravenous tPA (IVT) from 2015 to 2017 compared with a consecutive cohort of IVT-only patients treated before 2015. Diffusion-weighted imaging and ADC maps were used to quantify baseline core lesions. Median ADC value change and core reversal were determined at 24 hours. Diffusion-weighted imaging lesion growth was measured at 24 hours and 5 days. Good clinical outcome was defined as modified Rankin Scale score of 0 to 2 at 90 days. Results- Twenty-five patients (50%) received IVT while the other 25 patients received EVT (50%) with or without IVT. Between these patient groups, there were no differences in age, sex, baseline National Institutes of Health Stroke Scale, interhospital transfer, or IVT rates. Thirty-two patients (64%) revascularized with 69% receiving EVT. There was a significant increase in median ADC value of the core lesion at 24 hours in patients who revascularized compared with further ADC reduction in nonrevascularization patients. Revascularization patients had a significantly higher rate of good clinical outcome at 90 days, 63% versus 9% (P=0.003). Core reversal at 24 hours was significantly higher in revascularization patients, 69% versus 22% (P=0.002). Conclusions- ADC evolution in acute ischemic stroke patients with early, complete revascularization, now more commonly seen with EVT, is strikingly different from our historical understanding. The early ADC normalization we have observed in this setting may include a component of secondary injury and serve as a potential imaging biomarker for the development of future adjunctive therapies. Clinical Trial Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT00009243.

Awake transradial middle meningeal artery embolization and twist drill craniostomy for chronic subdural hematomas in the elderly: case series and technical note.

BACKGROUND: Due to prohibitive perioperative risk factors, optimal treatment for chronic subdural hematomas (cSDH) in the elderly remains unclear. Minimally invasive techniques are a viable option and include bedside subdural evacuation port system (SEPS), as well as prevention of recurrence with middle meningeal artery (MMA) embolization. We present a case series of elderly patients undergoing combined transradial MMA embolization and bed-side craniostomy as primary treatment for cSDH. METHODS: Patients 70 years and older from 2019 to 2020 that underwent single setting, awake transradial MMA embolization with concurrent SEPS placement under local anesthesia were included. Those with prior treatments, interventions performed under general anesthesia, or with less than 60-day follow-up were excluded. Descriptive analyses of baseline characteristics, radiologic parameters, comorbidities, and outcome measures were completed. RESULTS: Twenty elderly patients (mean age of 81.0 years) with multiple comorbidities underwent 28 MMA embolization+SEPS procedures as primary treatment for cSDH. Mean cSDH thickness was 1.8cm±0.6 cm with 7.3±3.9 mm midline shift. All patients tolerated the procedure well. 1/20 (5.0%) patients died within 30 days of the procedure. A majority of patients were discharged to home (12/20; 60.0%). There was an average of 3.6-month follow-up and one patient (5.0%) developed recurrence in the follow-up period requiring further intervention. CONCLUSIONS: In select elderly patients with high perioperative risk factors, primary treatment of cSDH using awake transradial MMA embolization+SEPS placement is a minimally invasive, feasible, and safe option. Further comparative studies are warranted to evaluate efficacy of the treatment.

De Novo dural arteriovenous fistulas after endovascular treatment: Case illustration and literature review.

Intracranial dural arteriovenous fistulas (dAVF) account for nearly 10-15% of all arteriovenous malformations. Although the majority of dAVF are effectively cured after endovascular intervention, there are cases of dAVFs that may recur after radiographic cure. We present the case of a 69-year-old female with de novo formation of three dAVFs in different anatomic locations after successive endovascular treatments. The patient's initial dAVF was identified in the right posterior frontal convexity region and obliterated with transarterial and transvenous embolization. The patient returned eight years later due to left-sided pulsatile tinnitus and a new dAVF in the left greater sphenoid wing region was seen on angiography. This was treated with transvenous embolization with complete resolution. One year later, she developed left sided pulsatile tinnitus again and was found to have a left carotid-cavernous dAVF. This is the first case report to our knowledge of the formation of three de novo dAVFs over multiple years in distinct anatomical locations. We also review the literature regarding de novo dAVFs after endovascular treatment which includes 16 cases. De novo dAVF formation is likely due to numerous factors including changes in venous flow and aberrant vascular development. It is important to further understand the relationship between endovascular treatment and recurrent dAVF formation to prevent subsequent malformations.

Direct Vertebral Artery Access for Coil Embolization of a Partially Thrombosed Mid-Basilar Trunk Aneurysm: Technical Limitations.

BACKGROUND AND IMPORTANCE: Partially thrombosed basilar aneurysms have a high morbidity from the rupture risk and mass effect prompting early treatment. Depending on the size and location, they pose a surgical challenge often requiring multiple endovascular treatment modalities. Here we present a partially thrombosed mid-basilar aneurysm successfully coil embolized with direct vertebral artery access and discuss the technical limitations of direct V1 access. CLINICAL PRESENTATION: A 70-yr-old woman presented with acute onset headache, nausea, and vomiting. A computed tomography (CT) head demonstrated a hyperdense prepontine mass which was further characterized as a partially thrombosed basilar aneurysm on CT angiography. After multiple failed attempts to access the vertebral artery via femoral and radial access the patient was taken to the operating room (OR) for surgical exposure of the right V1 segment and direct cannulation of the vertebral artery. The aneurysm was successfully coiled and the vertebral artery closed primarily. The patient was discharged home without any neurological deficits. CONCLUSION: Partially thrombosed mid-basilar aneurysms are difficult to treat both surgically and endovascularly. We present a case where endovascular access to the aneurysm was very challenging requiring direct exposure and cannulation of the V1 segment to successfully embolize with coils and discuss the technical limitations of this approach.

Treatment of In-Stent Stenosis Following Flow Diversion of Intracranial Aneurysms with Cilostazol and Clopidogrel.

In-stent stenosis is a feared complication of flow diversion treatment for cerebral aneurysms. We present 2 cases of patients treated with pipeline flow diversion for unruptured cerebral aneurysms. Initial perioperative dual antiplatelet therapy (DAPT) consisted of standard aspirin plus clopidogrel. At 6-month follow-up cerebral angiography, the patients were noted to have developed significant in-stent stenosis (63% and 53%). The patients were treated with cilostazol and clopidogrel for at least 6 months. Subsequent angiography at 1-year post-treatment showed significant improvement of the in-stent stenosis from 63% to 34% and 53% to 21%. The role of cilostazol as treatment of intracranial in-stent stenosis has not been previously described. Cilostazol's vasodilatory effect and suppression of vascular smooth muscle proliferation provides ideal benefits in this setting. Cilostazol plus clopidogrel may be a safe and effective alternative to standard DAPT for treatment of in-stent stenosis following flow diversion and warrants further consideration and investigation.

Spontaneous Occlusion of a Complex Brain Arteriovenous Malformation Following Partial Embolization.

BACKGROUND: Curative embolization for cerebral arteriovenous malformation (AVM) cannot always be achieved. Rather, embolization plays a role in AVM treatment as an adjuvant therapy before radiosurgery and microsurgery. Curative embolization for large, complex AVMs is not commonly seen. CASE DESCRIPTION: A man in his 30s with an unruptured left cerebral AVM underwent radiosurgery in 2014 and was lost to follow-up. He presented with intracerebral hemorrhage in 2019, and diagnostic cerebral angiography demonstrated a large, complex AVM. The patient was scheduled for 2-stage embolization in preparation for microsurgical resection. Initial embolization targeted and occluded 20% of the AVM nidus involving primarily the anteroinferior portion. A cerebral angiogram obtained 5 weeks following initial embolization revealed spontaneous occlusion of the remaining AVM. CONCLUSIONS: There are few reported cases of spontaneous occlusion of a large, complex AVM following embolization with previous radiation therapy. The spontaneous occlusion in this case suggests that at least some AVMs that receive embolization after radiation, rather than before, may have a potential for spontaneous, curative thrombosis.

Head Repositioning during Neurointerventional Procedures to Optimize Biplanar Imaging.

BACKGROUND AND PURPOSE: Head positioning is an important aspect for surgical planning in any cranial procedure. However, in neurointerventional cases, this is an afterthought due to advances in biplane imaging. We aim to present that the concept of head positioning may be applied to neurointerventional procedures to obtain optimal working projections to aide in the treatment of neurovascular pathology. METHODS: The operative log of the senior author was reviewed between 2016 and 2019. Seventeen patients were identified who required readjustment of head position to allow for ideal working projection during treatment. The reports and imaging of these patients were reviewed and categorized based on repositioning adjustments applied. RESULTS: Three specific head adjustments were performed to obtain working projections using biplanar angiography: head flexed position, head extended position, or extended-tilt positioning. All patients underwent endovascular coiling treatment for a variety of intracranial aneurysms. CONCLUSION: In select cases, ideal views of vascular pathology can be difficult to obtain due to limitations of biplane rotation or patient-specific anatomy. Simple maneuvers in head positioning can be done to achieve better working projections for optimized endovascular treatment.

Transcranial Doppler velocity and associations with delayed cerebral ischemia in aneurysmal subarachnoid Hemorrhage.

BACKGROUND AND PURPOSE: We evaluated optimal transcranial Doppler (TCD) measures for predicting delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH). MATERIAL AND METHODS: Consecutive patients with aSAH and daily middle cerebral artery (MCA) TCD recordings were retrospectively analyzed. Change in TCD velocity was obtained by creating a smoothing curve. Change in TCD velocity was determined with a linear regression model that confirmed greatest change in velocity associated with DCI occurred at days 2-7. Multivariate logistic regression analysis was then completed. RESULTS: 95 patients were evaluated. Increase in TCD velocity at days 2-7 proved to be the best predictor for DCI with an optimal cutoff of 8.9 cm/s/day (p = .019) and AUC 0.651. Multivariate logistic regression analysis using DCI as outcome showed that poor admission Hunt-Hess scores (OR 5.02, 95%CI 1.22-22.67, p = .028) and increases in TCD velocity (OR 5.32, 95%CI 1.41-23.33, p = .018) were independently associated with DCI. CONCLUSIONS: We found that relative increases in TCD velocities in the MCAs during the first 7 days (with a threshold increase of 53.4 cm/s from days 2 to 7) after aSAH admission were independently associated with DCI. This association requires independent confirmation.

Endovascular Treatment of Large Unruptured Fusiform Fenestrated Vertebrobasilar Junction Aneurysm.

Fenestrated vertebrobasilar junction aneurysms are rare vascular lesions. Microsurgical intervention is extremely difficult due to the complex anatomy in the vicinity of these aneurysms. Endovascular neurosurgery appears to be safe and should be considered as the first modality of treatment. This case study details the treatment of an unruptured fusiform fenestrated vertebrobasilar junction aneurysm with endovascular occlusion with stent-assisted coiling. The optimal angiographic exposure and selective microcatheterization of the aneurysm were challenging due to the patient's body habitus, and the aneurysm was large with one dominant fenestrated limb.

Endovascular Management of Stroke Patients with Large Vessel Occlusion and Minor Stroke Symptoms.

Endovascular mechanical thrombectomy for stroke patients with large vessel occlusion (LVO) in the anterior circulation has become the standard of care based on several major randomized clinical trials. The successful result reported by these trials constitutes what may be the largest achievement in the history of neurological sciences. However, most of these mechanical thrombectomy trials (except for the multicenter randomized clinical trial of endovascular treatment for acute ischemic stroke in the Netherlands, i.e., MR CLEAN and Extending the Time for Thrombolysis in Emergency Neurological Deficits-Intra-Arterial, i.e., EXTEND-IA) excluded stroke patients with minor to mild stroke symptoms with National Institutes of Health Stroke Scale (NIHSS) scores of six to eight or lower. The median NIHSS score for patients who underwent acute endovascular thrombectomy was approximately 15 to 17 in all trials. To date, the evidence is lacking to support the mechanical thrombectomy in patients with acute stroke and LVO with minor to mild severity on NIHSS score. The purpose of this review was to assess the current data, safety and clinical outcomes in stroke patients with minor to mild symptoms who were treated with endovascular thrombectomy.

Onyx Embolization of a Meningioma with a Dysplastic Aneurysmal Anterior Cerebral Artery Vessel.

Preoperative embolization of meningiomas can be safely performed using a variety of embolic agents. Most commonly, the vascular supply from branches of the external carotid artery is the target of embolization. In our report, we detail the treatment of a patient with a parafalcine meningioma that received its supply via branches of the anterior cerebral artery. One of the feeder vessels appeared to contain a dysplastic aneurysmal dilatation of the vessel. Due to patient circumstances, embolization was performed using standard microcatheterization techniques to minimize intraoperative blood loss. We report a rare instance of endovascular treatment of a pial vessel to treat an intracranial meningioma using Onyx.

Vertebral-venous fistula: an unusual cause for ocular symptoms mimicking a carotid cavernous fistula.

Vertebral-venous fistulas (VVF), or vertebral-vertebral arteriovenous fistulas, are an uncommon clinical entity. Typically, they present as a result of a direct vascular connection between an extracranial branch of the vertebral artery or its radicular components and the epidural venous plexus. These may manifest with signs and symptoms referable to cervical myelopathy secondary to compression or steal phenomenon. To our knowledge, this is the first case to identify a patient who presented with classic ocular symptoms attributable to a carotid cavernous fistula but secondary to a VVF. We present its treatment and clinical outcome. In addition, we present a brief literature review surrounding this uncommon disease.

Embolization of Carotid Body Tumors: Revisiting Direct Puncture Technique, Preliminary Experience and Literature Review.

Preoperative embolization via transarterial route is an acceptable adjunct to the treatment of carotid body tumors (CBT). Direct tumor puncture for embolization has been previously described as a safe and feasible option. We revisit this technique and present our initial experience treating CBT via direct puncture. We identified six patients that underwent preoperative embolization of CBT using a direct puncture technique embolized with Onyx (EV3 Micro Therapeutics Inc., Irvine, CA, USA). After defining the angioarchitecture via digital subtraction angiography, the tumor was targeted with Onyx. Using a 21-gauge needle, the tumor was punctured using a fluoroscopic road mask. There were no immediate post-procedural complications following embolization. All patients underwent definitive resection within 24 hours. During surgery, the embolization material did not affect surgical maneuvers. In addition, the estimated blood loss was noted to average 50 ml.  Although early in our experience, direct percutaneous embolization of CBT appears to be a reproducible and well-tolerated endovascular treatment option. Overall, the reported body of evidence available confirms the safety and efficacy of direct intralesional embolization with Onyx.

Vertebral-venous fistula: an unusual cause for ocular symptoms mimicking a carotid cavernous fistula.

Vertebral-venous fistulas (VVF), or vertebral-vertebral arteriovenous fistulas, are an uncommon clinical entity. Typically, they present as a result of a direct vascular connection between an extracranial branch of the vertebral artery or its radicular components and the epidural venous plexus. These may manifest with signs and symptoms referable to cervical myelopathy secondary to compression or steal phenomenon. To our knowledge, this is the first case to identify a patient who presented with classic ocular symptoms attributable to a carotid cavernous fistula but secondary to a VVF. We present its treatment and clinical outcome. In addition, we present a brief literature review surrounding this uncommon disease.