A comparative study of transradial versus transfemoral approach for flow diversion.

PURPOSE: Data in neurointerventional literature is extremely limited regarding the safety and efficacy of flow diversion using transradial access (TRA). We aim to demonstrate the safety and efficacy of intracranial aneurysm treatment with the Pipeline Embolization Device (PED) using TRA compared to transfemoral access (TFA). METHODS: We conducted a retrospective analysis of a prospectively maintained database and identified 79 consecutive patients who underwent neuroendovascular embolization for cerebral aneurysms using the PED from April 2018 through October 2019. Patients were divided into 2 groups: TRA (32 patients) and TFA (47 patients). A comparative analysis was performed between the two groups. RESULTS: There was no significant difference in postoperative intracranial hemorrhage (p>.99), symptomatic ischemic stroke (p=.512), access site complications (p=.268), or other complications (p=.512). However, there was a significant increase in overall complications (14.9% vs. 0.0%, p=.038) and procedure duration (71.4 min ± 31.2 vs. 58.5 ± 20.3, p=.018) in the TFA group. There was no significant difference in complete occlusion at latest follow-up (19/25, 76.0% vs. 35/40, 87.5%; p=.311), 6-month follow-up (17/23, 73.9% vs. 33/38, 86.8%; p=.303), or 12-month follow-up (8/8, 100.0% vs. 5/6, 83.3%; p=.429). There was also no significant difference in rate of retreatment (p>.99), morbidity (p=.512), mortality (p>.99), latest follow-up (p=.985), or loss of follow-up (p=.298). CONCLUSIONS: The feasibility and efficacy of flow diversion with the PED via TRA for the treatment of intracranial aneurysms is comparable to TFA. Widespread adoption of this approach may be facilitated by improvements in device navigation and manipulation via radial-specific engineering.

Off-label uses of the Pipeline embolization device: a review of the literature.

The Pipeline embolization device (PED) is the most widely used flow diverter in endovascular neurosurgery. In 2011, the device received FDA approval for the treatment of large and giant aneurysms in the internal carotid artery extending from the petrous to the superior hypophyseal segments. However, as popularity of the device grew and neurosurgeons gained more experience, its use has extended to several other indications. Some of these off-label uses include previously treated aneurysms, acutely ruptured aneurysms, small aneurysms, distal circulation aneurysms, posterior circulation aneurysms, fusiform aneurysms, dissecting aneurysms, pseudoaneurysms, and even carotid-cavernous fistulas. The authors present a literature review of the safety and efficacy of the PED in these off-label uses.

Comparison of PED/PED Flex and PED Shield in the treatment of unruptured intracerebral aneurysms.

OBJECTIVE: The object of this study was to compare the efficacy and safety profile of the Pipeline embolization device (PED)/Pipeline Flex embolization device (PED Flex) with that of the Pipeline Flex embolization device with Shield Technology (PED Shield). After introducing the first-generation PED and the second-generation PED Flex with its updated delivery system, the PED Shield was launched with a synthetic layer of phosphorylcholine surface modification to reduce thrombogenicity. METHODS: This is a retrospective review of unruptured aneurysms treated with PED/PED Flex versus PED Shield between 2017 and 2022 at the authors' institution. Patients with ruptured aneurysms, adjunctive treatment, failed flow diverter deployment, and prior treatment of the target aneurysm were excluded. Baseline characteristics were collected for all patients, including age, sex, past medical history (hypertension, hyperlipidemia, diabetes mellitus), smoking status, aneurysm location, and aneurysm dimensions (neck, width, height) and morphology (saccular, nonsaccular). The primary outcome was procedural and periprocedural complication rates. RESULTS: The study cohort comprised 200 patients with 200 aneurysms, including 150 aneurysms treated with the PED/PED Flex and 50 treated with the PED Shield. With respect to intraprocedural and periprocedural complications, length of stay, length of follow-up, and functional outcome at discharge, there was no significant difference between the two cohorts. At the midterm follow-up, the rate of in-stent stenosis (PED/PED Flex: 14.2% vs PED Shield: 14.6%, p = 0.927), aneurysm occlusion (complete occlusion: 79.5% vs 80.5%, respectively; neck remnant: 4.7% vs 12.2%; dome remnant: 15.7% vs 7.3%; p = 0.119), and the need for retreatment (5.3% vs 0%, p = 0.097) were comparable between the two cohorts. CONCLUSIONS: This study suggests that, as compared to first- and second-generation PED and PED Flex, the third-generation PED Shield offers similar rates of complications, aneurysm occlusion, and in-stent stenosis at the midterm follow-up.

Causes and Predictors of 30-Day Readmission in Patients With Stroke Undergoing Mechanical Thrombectomy: A Large Single-Center Experience.

BACKGROUND AND OBJECTIVES: The 30-day readmission rate has emerged as a metric of quality care and is associated with increased health care expenditure. We aim to identify the rate and causes of 30-day readmission after mechanical thrombectomy and provide the risk factors of readmission to highlight high-risk patients who may require closer care. METHODS: This is a retrospective study from a prospectively maintained database of 703 patients presenting for mechanical thrombectomy between 2017 and 2023. All patients who presented with a stroke and underwent a mechanical thrombectomy were included in this study. Patients who were deceased on discharge were excluded from this study. RESULTS: Our study comprised 703 patients, mostly female (n = 402, 57.2%) with a mean age of 70.2 years ±15.4. The most common causes of readmission were cerebrovascular events (stroke [n = 21, 36.2%], intracranial hemorrhage [n = 9, 15.5%], and transient ischemic attack [n = 1, 1.7%]).Other causes of readmission included cardiovascular events (cardiac arrest [n = 4, 6.9%] and bradycardia [n = 1, 1.7%]), infection (wound infection postcraniectomy [n = 3, 5.2%], and pneumonia [n = 1, 1.7%]). On multivariate analysis, independent predictors of 30-day readmission were history of smoking (odds ratio [OR]: 2.2, 95% CI: 1.1-4.2) P = .01), distal embolization (OR: 3.2, 95% CI: 1.1-8.7, P = .03), decompressive hemicraniectomy (OR: 9.3, 95% CI: 3.2-27.6, P < .01), and intracranial stent placement (OR: 4.6, 95% CI: 2.4-8.7) P < .01). CONCLUSION: In our study, the rate of 30-day readmission was 8.3%, and the most common cause of readmission was recurrent strokes. We identified a history of smoking, distal embolization, decompressive hemicraniectomy, and intracranial stenting as independent predictors of 30-day readmission in patients with stroke undergoing mechanical thrombectomy.

Predictors of occlusion, long-term outcomes, and safety in a cohort of 674 aneurysms treated with the Pipeline embolization device.

OBJECTIVE: By providing a more physiological approach to the treatment of intracranial aneurysms, the Pipeline embolization device (PED) has revolutionized the endovascular treatment of aneurysms. Although there are many flow diverters on the market, the authors report their experience with the PED, the first flow diverter to be approved by the Food and Drug Administration. They aimed to assess the efficacy and safety of PED flow diversion for the treatment of a wide range of aneurysms, as well as to look at factors affecting occlusion. METHODS: This is a retrospective study of a prospectively maintained database of patients treated with the PED between January 2011 and December 2019. Charts were reviewed for patient, aneurysm, and procedure characteristics. The primary outcomes of interest were complication rates, occlusion outcomes (O'Kelly-Marotta grading scale), and functional outcomes (modified Rankin Scale [mRS]). Secondary outcomes included predictors of incomplete occlusion at 6 and 24 months of follow-up. RESULTS: The study cohort included 581 patients with 674 aneurysms. Most aneurysms (90.5%) were in the anterior circulation and had a saccular morphology (85.6%). Additionally, 638 aneurysms (94.7%) were unruptured, whereas 36 (5.3%) were acutely ruptured. The largest mean aneurysm diameter was 8.3 ± 6.1 mm. Complications occurred at a rate of 5.5% (n = 32). The complete occlusion rate was 89.3% at 24 months' follow-up, and 94.8% of patients had a favorable neurological outcome (mRS score 0-2) at the last follow-up. On multivariate analysis, predictors of incomplete aneurysm occlusion at 6 months were hypertension (OR 1.7, p = 0.03), previous aneurysm treatment (OR 2.4, p = 0.001), and increasing aneurysm neck diameter (OR 1.2, p = 0.02), whereas a saccular morphology was protective (OR 0.5, p = 0.05). Predictors of incomplete occlusion at 24 months were increasing aneurysm neck diameter (OR 1.2, p = 0.01) and previous aneurysm treatment (OR 2.3, p = 0.01). CONCLUSIONS: The study findings are corroborated by those of previous studies and trials. The complete occlusion rate was 89.3% at 24 months' follow-up, with 94.8% of patients having favorable functional outcomes (mRS score 0-2). Aneurysm treatment before PED deployment and an increasing aneurysm neck diameter increase the risk of incomplete occlusion at 6 and 24 months.

Venous sinus stenting for idiopathic intracranial hypertension patients with functioning ventriculoperitoneal shunts: A case series.

Idiopathic intracranial hypertension (IIH) is a disease defined by increased intracranial pressure and associated with a variety of symptoms ranging from headaches to tinnitus. Ventricular peritoneal shunting has been the mainstay treatment for patients with IIH. Although VPS's have shown efficacy in treating IIH, some patients complain of refractory symptoms even with functioning VPS's. Venus stenting has emerged as a new technique for treating these refractory symptoms. Despite the scarce literature pertaining its efficacy and safety profile, several small studies have shown promising results. In this case series, four patients with IIH complained of refractory symptoms despite functioning VPS's and were treated with venous stenting.

A Comparison of Outcomes Between Transfemoral Versus Transradial Access for Carotid Stenting.

BACKGROUND: The transradial (TR) approach has emerged as an alternative to the transfemoral (TF) approach in carotid artery stenting (CAS) because of its perceived benefits in access site complications and overall patient experience. OBJECTIVE: To assess outcomes of TF vs TR approach for CAS. METHODS: This is a retrospective single-center review of patients receiving CAS through the TR or TF route between 2017 and 2022. All patients with symptomatic and asymptomatic carotid disease who underwent attempted CAS were included in our study. RESULTS: A total of 342 patients were included in this study: 232 underwent CAS through TF approach vs 110 through the TR route. On univariate analysis, the rate of overall complications was more than double for the TF vs TR cohort; however, this did not achieve statistical significance (6.5% vs 2.7%, odds ratio [OR] = 0.59 P = .36). The rate of cross-over from TR to TF was significantly higher on univariate analysis (14.6 % vs 2.6%, OR = 4.77, P = .005) and on inverse probability treatment weighting analysis (OR = 6.11, P < .001). The rate of in-stent stenosis (TR: 3.6% vs TF: 2.2%, OR = 1.71, P = .43) and strokes at follow-up (TF: 2.2% vs TR: 1.8%, OR = 0.84, P = .84) was not significantly different. Finally, median length of stay was comparable between both cohorts. CONCLUSION: The TR approach is safe, feasible, and provides similar rates of complications and high rates of successful stent deployment compared with the TF route. Neurointerventionalists adopting the radial first approach should carefully assess the preprocedural computed tomography angiography to identify patients amenable to TR approach for carotid stenting.

The Impact of Weather and Mode of Transport on Outcomes of Patients With Acute Ischemic Stroke Undergoing Mechanical Thrombectomy.

BACKGROUND: Efficient transfer to mechanical thrombectomy (MT)-capable centers is essential for patients with stroke. Weather may influence stroke risk, transportation, and outcomes. OBJECTIVE: To investigate how weather affects stroke patient transfer and outcomes after MT. METHODS: We retrospectively collected data for patients with stroke transferred from spoke to our hub hospital to undergo MT between 2017 and 2021. We examined associations between weather, transportation, and patient outcomes. RESULTS: We included 543 patients with a mean age of 71.7 years. The median National Institutes of Health Stroke Score increased from 14 to 15 after transportation. The median modified Rankin Scale was 4 at discharge and 90 days, and 3 at the final follow-up (mean 91.7 days). Higher daily temperatures were associated with good outcome, whereas daily drizzle was associated with poor outcome. More patients were transferred by air when visibility was better, and by ground during heavier precipitation, higher humidity, rain, mist, and daily drizzle, fog, and thunder . Patient outcomes were not associated with transportation mode. Among the independent predictors of good outcome, none was a weather variable. Lower hourly relative humidity ( P = .003) and longer road distance ( P < .001) were independent predictors of using air transportation, among others. CONCLUSION: During transportation, higher temperature was associated with good outcome, whereas daily drizzle was associated with poor outcome after MT. Although weather was associated with transportation mode, no differences in outcomes were found between transportation modes. Further studies are needed to modify transfer protocols, especially during cold and rainy days, and potentially improve outcomes.

Comparison of Flow-Redirection Endoluminal Device and Pipeline Embolization Device in the Treatment of Intracerebral Aneurysms.

BACKGROUND: The use of flow diverters for treating intracranial aneurysms has been widely used in the past decade; however, data comparing pipeline embolization device (PED; Medtronic Inc) and flow-redirection endoluminal device (FRED; MicroVention) in the treatment of intracranial aneurysms remain scarce. OBJECTIVE: To compare the outcomes of PED and FRED in the treatment of intracranial aneurysms. METHODS: This is a single-center retrospective review of aneurysms treated with PED and FRED devices. Patients treated with PED or FRED were included. Cases requiring multiple or adjunctive devices were excluded. Primary outcome was complete aneurysm occlusion at 6 months. Secondary outcomes included good functional outcome, need for retreatment, and any complication. RESULTS: The study cohort comprised 150 patients, including 35 aneurysms treated with FRED and 115 treated with PED. Aneurysm characteristics including location and size were comparable between the 2 cohorts. 6-month complete occlusion rate was significantly higher in the PED cohort (74.7% vs 51.5%; P = .017) but lost significance after inverse probability weights. Patients in the PED cohort were associated with higher rates of periprocedural complications (3.5% vs 0%; P = .573), and the rate of in-stent stenosis was approximately double in the FRED cohort (15.2% vs 6.9%; P = .172). CONCLUSION: Compared with PED, FRED offers modest 6-month occlusion rates, which may be due to aneurysmal and baseline patient characteristics differences between both cohorts. Although not significant, FRED was associated with a higher complication rate mostly because of in-stent stenosis. Additional studies with longer follow-up durations should be conducted to further evaluate FRED thrombogenicity.

Safety of Mechanical Thrombectomy in Patients on Antiplatelet/Anticoagulation.

BACKGROUND: Mechanical thrombectomy (MT) is performed in patients who are already on anticoagulation (AC)/antiplatelet therapy (AP). However, data are insufficient regarding MT's safety and efficacy profiles in these patients. OBJECTIVE: Investigate the outcome of stroke patients already on anticoagulation/antiplatelet receiving MT. METHODS: We included consecutive acute ischemic stroke patients treated with MT for 10 years (2012-2022) in a comprehensive stroke center. Baseline variables, efficacy (recanalization [Thrombolysis in Cerebral Infraction] ≥ 2b), good functional outcome (modified Ranking Scale ≤ 2 at 3 months), and safety (symptomatic intracranial hemorrhage [sICH], mortality rates) were evaluated. Additionally, we conducted a subgroup analysis of patients with prior single-AP versus DAPT. RESULTS: Six hundred forty-six patients were included (54.5% women, median age 71 years), 84 (13%) were on AC, 196 (30.3%) on AP, and 366 (56.7%) in the control group. The AC and AP groups were older and had more comorbidities. sICH occurred in 7.3% of cases. There was no significant difference in sICH incidence across the groups. The AC group had a lower rate of intravenous thrombolysis (15.9%; P < 0.001), a higher rate of sICH (11.9% vs. AP 7.7% and control 6%; P = 0.172), and higher mortality at discharge (17.9% vs. AP 8.7% and control 10.4%; P = 0.07). However, the groups had similar functional outcomes and mortality rates at 3 months. Successful recanalization was achieved in 92.7% and was similar across groups. Multivariable logistic regression and the subgroup analysis (single-AP vs. dual AP) did not reveal statistically significant associations. CONCLUSIONS: MT in patients with prior anticoagulation and AP presenting with acute ischemic strokeis feasible, effective, and safe.

Transradial versus transfemoral access routes for diagnostic cerebral angiography: a large single-center comparative cost-analysis study.

OBJECTIVE: Recently, the transradial (TR) approach has become a common alternative because of its safety profile and increased patient satisfaction compared with the transfemoral (TF) route. Both routes are associated with their respective associated costs, and differences typically emerge on the basis of patient anatomy, operator expertise, and occurrence of complications. The authors' objective was to compare the overall costs of diagnostic cerebral angiography via both routes and to shed light on the individual equipment costs of each route. METHODS: This retrospective single-center study of 926 elective diagnostic angiograms was performed between December 2019 and March 2022. RESULTS: The study comprised of 314 and 612 angiograms performed through the TF and TR routes, respectively. A significantly greater proportion of female patients were included in the TF cohort (79.3% vs 67.8%, p < 0.001), and most other demographic characteristics and baseline modified Rankin Scale scores were comparable between cohorts. The overall cost of patients utilizing the TR route was comparable to that of the TF route (mean ± SD $12,591.80 ± $19,128.00 vs $12,789.50 ± 18,424.00, p = 0.88). However, the median cost of catheters was significantly higher in TR group ($55.20 vs $12.40, p = 0.03), while the median costs of closure devices ($87.00 vs $20.20 p < 0.001) and sheaths ($44.60 ± 11.3 vs $41.10 ± 3.10, p < 0.001) were significantly higher in the TF group. CONCLUSIONS: Overall, the authors' study showed that the TR approach can be a less expensive option for patients undergoing diagnostic cerebral angiography, especially if complications occur. Future studies may corroborate these findings and potentially lead to the adoption of TR as a low-cost, efficient, gold-standard technique for cerebral angiography.

The Effect of COVID-19 Vaccines on Stroke Outcomes: A Single-Center Study.

BACKGROUND: One of the defining narratives of the COVID-19 pandemic has been the acceptance and distribution of vaccine. To compare the outcomes of COVID-19 positive vaccinated and unvaccinated stroke patients. METHODS: This is a single-center retrospective study of COVID-19-vaccinated and unvaccinated stroke patients between April 2020 and March 2022. All patients presenting with stroke regardless of treatment modalities were included. National Institutes of Health Stroke Scale was used to assess stroke severity. The primary outcome was functional capacity of the patients at discharge. RESULTS: The study cohort comprised 203 COVID-19 positive stroke patients divided into 139 unvaccinated and 64 fully vaccinated patients. At discharge, the modified Rankin scale score was significantly lower in the vaccinated cohort (3[1-4] vs. 4[2-5], odds ratio = 0.508, P = 0.011). At 3 months of follow-up, the median modified Rankin scale score was comparable between both cohorts. CONCLUSIONS: Although vaccination did not show any significant difference in stroke patient outcomes on follow-up, vaccines were associated with lower rates of morbidity and mortality at discharge among stroke patients during the pandemic.

The Rate and Predictors of 30-Day Readmission in Patients Treated for Unruptured Cerebral Aneurysms: A Large Single-Center Study.

BACKGROUND AND OBJECTIVES: Numerous studies of various populations and diseases have shown that unplanned 30-day readmission rates are positively correlated with increased morbidity and all-cause mortality. In this study, we aim to provide the rate and predictors of 30-day readmission in patients undergoing treatment for unruptured intracranial aneurysms. METHODS: This is a retrospective study of 525 patients presenting for aneurysm treatment between 2017 and 2022. All patients who were admitted and underwent a successful treatment of their unruptured intracerebral aneurysms were included in the study. The primary outcome was the rate and predictors of 30-day readmission. RESULTS: The rate of 30-day readmission was 6.3%, and the mean duration to readmission was 7.8 days ± 6.9. On univariate analysis, factors associated with 30-day readmission were antiplatelet use on admission (odds ratio [OR]: 0.4, P = .009), peri-procedural rupture (OR: 15.8, P = .007), surgical treatment of aneurysms (OR: 2.2, P = .035), disposition to rehabilitation (OR: 9.5, P < .001), and increasing length of stay (OR: 1.1, P = .0008). On multivariate analysis, antiplatelet use on admission was inversely correlated with readmission (OR: 0.4, P = .045), whereas peri-procedural rupture (OR: 9.5, P = .04) and discharge to rehabilitation (OR: 4.5, P = .029) were independent predictors of 30-day readmission. CONCLUSION: In our study, risk factors for 30-day readmission were aneurysm rupture during the hospital stay and disposition to rehabilitation, whereas the use of antiplatelet on admission was inversely correlated with 30-day readmission. Although aneurysm rupture is a nonmodifiable risk factor, more studies are encouraged to focus on the correlation of antiplatelet use and rehabilitation disposition with 30-day readmission rates.

Long-Term Follow-Up of Cerebral Aneurysms Completely Occluded at 6 Months After Intervention with the Woven EndoBridge (WEB) Device: a Retrospective Multicenter Observational Study.

The Woven EndoBridge (WEB) device has been widely used to treat intracranial wide neck bifurcation aneurysms. Initial studies have demonstrated that approximately 90% of patients have same or improved long-term aneurysm occlusion after the initial 6-month follow up. The aim of this study is to assess the long-term follow-up in aneurysms that have achieved complete occlusion at 6 months. We also compared the predictive value of different imaging modalities used. This is an analysis of a prospectively maintained database across 13 academic institutions. We included patients with previously untreated cerebral aneurysms embolized using the WEB device who achieved complete occlusion at first follow-up and had available long-term follow-up. A total of 95 patients with a mean age of 61.6 ± 11.9 years were studied. The mean neck diameter and height were 3.9 ± 1.3 mm and 6.0 ± 1.8 mm, respectively. The mean time to first and last follow-up was 5.4 ± 1.8 and 14.1 ± 12.9 months, respectively. Out of all the aneurysms that were completely occluded at 6 months, 84 (90.3%) showed complete occlusion at the final follow-up, and 11(11.5%) patients did not achieve complete occlusion. The positive predictive value (PPV) of complete occlusion at first follow was 88.4%. Importantly, this did not differ between digital subtraction angiography (DSA), magnetic resonance angiography (MRA), or computed tomography angiography (CTA). This study underlines the importance of repeat imaging in patients treated with the WEB device even if complete occlusion is achieved short term. Follow-up can be performed using DSA, MRA or CTA with no difference in positive predictive value.

Rotational angiography for diagnosis and surgical planning in the management of spinal vascular lesions.

OBJECT: The management of spinal vascular malformations has undergone significant evolution with the advent of advanced endovascular and angiographic technology. Three-dimensional rotational spinal angiography is an advanced tool that allows the surgeon to gain a better appreciation of the anatomy of these spinal vascular lesions and their relation to surrounding structures. This article describes the use of rotational angiography and 3D reconstructions in the diagnosis and management of spinal vascular malformations. METHODS: The authors present representative cases involving surgical treatment planning for spinal vascular malformations with focus on the utility and technique of rotational spinal angiography. They report the use of rotational spinal angiography for a heterogeneous collection of vascular pathological conditions. RESULTS: Eight patients underwent rotational spinal angiography in addition to digital subtraction angiography (DSA) for the diagnosis and characterization of various spinal vascular lesions. Postprocessed images were used to characterize the lesion in relation to surrounding bone and to enhance the surgeon's ability to precisely localize and obliterate the abnormality. The reconstructions provided superior anatomical detail compared with traditional DSA. No associated complications from the rotational angiography were noted, and there was no statistically significant difference in the amount of radiation exposure to patients undergoing rotational angiography relative to traditional angiography. CONCLUSIONS: The use of rotational spinal angiography provides a rapid and powerful diagnostic tool, superior to conventional DSA in the diagnosis and preoperative planning of a variety of spinal vascular pathology. A more detailed understanding of the anatomy of such lesions provided by this technique may improve the safety of the surgical approach.

Access Site Complications and Management of the Transradial Approach for Neurointerventions.

BACKGROUND: The transradial approach has increasingly been used for neurointerventions because of the improved safety profile compared with transfemoral. However, it is important to be aware of potential complications such as radial artery (RA) spasm, RA occlusion, pseudoaneurysm, extravasation, arteriovenous fistula, and wrist hematoma as well as their management. OBJECTIVE: To present our institution's experience with the prevention and management of local access site complications associated with the transradial approach for neuroendovascular interventions. METHODS: We conducted a retrospective analysis of a prospectively maintained database and identified 1524 consecutive neuroendovascular procedures performed using transradial access from April 2018 to February 2021. RESULTS: Among 1524 procedures, local transradial complications occurred in 1.7%. Major complications occurred at a rate of 1.2% including RA extravasation (0.3%), delayed RA occlusion (0.6%), pseudoaneurysm (0.1%), compartment syndrome (0.1%), infection (0.1%), and avulsion of the RA in 0.1% (1 of 1524) with no serious clinical consequence. Although RA occlusion is included in major complications, all cases were asymptomatic and did not require any intervention. Minor complications occurred at a rate of 0.5% including severe RA spasm (0.3%) and hematoma (0.3%). No patient in the cohort died or suffered from permanent disability from a complication related to the transradial approach. CONCLUSION: Transradial access for neurointervention has a low rate of local complications, particularly when taking appropriate prevention measures. Appropriate management of complications can prevent procedural failure and has low morbidity rates demonstrating the overall safety profile of transradial access even when complications occur.

Woven EndoBridge versus stent-assisted coil embolization of cerebral bifurcation aneurysms.

OBJECTIVE: Stent-assisted coil (SAC) embolization has been the mainstay endovascular treatment for bifurcation aneurysms. The recent introduction of the Woven EndoBridge (WEB) device has presented an alternative endovascular treatment modality for these aneurysms. Direct comparisons of outcomes between these two modalities are limited in the literature. Here, the authors compared the outcomes of bifurcation aneurysms treated with SAC and WEB devices. METHODS: This retrospective single-center study comprised 148 bifurcation aneurysms that were treated endovascularly with SAC or WEB devices between 2011 and 2019. The primary outcome was complete occlusion of the aneurysm at 6 months on catheter angiography. RESULTS: The SAC and WEB cohorts comprised 85 and 63 aneurysms, respectively. The baseline characteristics were well balanced after inverse probability weight (IPW) adjustment, except for smoking status. The 6-month complete occlusion rate was higher in the WEB cohort than the SAC cohort (67.4% vs 40.6%; unadjusted OR [95% CI] 3.014 [1.385-6.563], p = 0.005). However, this difference in complete occlusion rates did not remain significant after IPW adjustment and multiple imputations. The neck remnant rate was lower in the WEB cohort than the SAC cohort (20% vs 50%; OR [95% CI] 0.250 [0.107-0.584], p = 0.001), and this difference remained significant after IPW adjustment (OR [95% CI] 0.304 [0.116-0.795], p = 0.015) and multiple imputations. CONCLUSIONS: Use of SAC and WEB demonstrated comparable 6-month complete occlusion rates for bifurcation aneurysms. WEB appeared to be associated with a lower rate of neck remnant at 6 and 12 months compared with SAC. WEB was also associated with fewer complications and decreased retreatment rates compared with SAC.

Rescue stenting for acute ischemic stroke with refractory emergent large vessel occlusion in the modern thrombectomy era.

BACKGROUND AND PURPOSE: Rescue stenting is used as a bailout technique during mechanical thrombectomy for stroke. We performed a retrospective study analyzing outcomes of patients that received a stent as a bailout measure and compared results to a control group. METHODS: We identified all patients who underwent a mechanical thrombectomy for a large vessel occlusion between January 2010 and October 2019. Subjects with mTICI 0-2 A after at least three passes were defined as failed MT and constituted the control group (NSG-controls). Patients that received a rescue stent (RSG) formed the study group. RESULTS: Comparative analysis of patient demographics between NSG-controls and SRG was performed. Baseline characteristics and comorbidities were not significantly different between both groups. NIHSS at admission and IV t-PA were not significantly different among both groups (16.5 vs. 14.2, p = 0.19) and (39.4% vs. 29.4%, p = 0.30), respectively. There was no significant difference in procedural and post-procedural complications between both the groups. In the RSG, 24 patients (82.4%) achieved favorable revascularization outcomes. NIHSS at discharge (p = 0.01) was higher in the NSG-controls, while favorable functional outcome at three months (12% vs. 39.2%, p = 0.01) was observed at a higher proportion in the RSG. There was also a significant mortality difference, with 15.2% mortality in the RSG compared to 35.1% mortality in the NSG-controls (p = 0.03). In multivariate analysis, stenting was an independent predictor of favorable outcome (OR: 10.0, p = 0.009). CONCLUSION: Herein, we demonstrated that rescue stenting is a feasible, safe, and effective procedure to improve stroke outcomes and should be seriously considered if the primary mechanical thrombectomy is not successful.

Early experience with a novel 088 long sheath in transradial neurointerventions.

BACKGROUND: Transradial access (TRA) for neuroendovascular procedures has several clear benefits compared to transfemoral access. In this study, we report our initial experience with neuroendovascular procedures performed via transradial access using the novel Ballast 088 long sheath. METHODS: We conducted a retrospective analysis and identified 91 consecutive patients who underwent neuroendovascular procedures via TRA using the Ballast 088 long sheath. Data collection was performed on indication for procedure, number of vessels selectively catheterized, fluoroscopy time, procedure duration, radiation exposure, failure of radial access and conversion to transfemoral access, periprocedural complications, and procedural outcomes. RESULTS: Amongst 91 patients, the average age was 65.5 years ± 14.2 with 45 (49.5 %) female patients. 25 (27.5 %) patients underwent aneurysm treatment, 2 (2.2 %) AVM/AVF embolization, 28 (30.8 %) intracranial or extracranial stenting, 31 (34.1 %) stroke treatment, and 5 (5.5 %) underwent diagnostic angiogram. The mean number of target vessels catheterized was 1.07 ± 0.25, the mean procedure duration (minutes) was 96.5 ± 57.2, mean fluoroscopy time (minutes) was 21.9 ± 14.2, mean contrast dose (ml) was 112.7 ± 66.7, and mean radiation exposure (Gycm2) was 54.82 ± 41.37. The success rate of target vessel catheterization was 100 %. There were no complications resulting in long term sequelae. Access complications occurred in 1 (1.1 %) patients. Transfemoral conversion was required in 3 (3.3 %) patients. CONCLUSIONS: The Ballast 088 long sheath is safe and effective for TRA in neuroendovascular procedures with a low rate of complications and conversion.

Battle-Tested Guidelines and Operational Protocols for Neurosurgical Practice in Times of a Pandemic: Lessons Learned from COVID-19.

The COVID-19 outbreak has led to fundamental disruptions of health care and its delivery with sweeping implications for patients and physicians of all specialties, including neurosurgery. In an effort to conserve hospital resources, neurosurgical procedures were classified into tiers to determine which procedures have to be performed in a timely fashion and which ones can be temporarily suspended to aid in the hospital's reallocation of resources when equipment is scarce. These guidelines were created quickly based on little existing evidence, and thus were initially variable and required refinement. As the early wave can now be assessed in retrospect, the authors describe the lessons learned and the protocols established based on published global evidence to continue to practice neurosurgery sensibly and minimize disruptions. These operational protocols can be applied in a surge of COVID-19 or another airborne pandemic.