Current Indications, Trends, and Long-Term Results of 233 Bypasses to Treat Complex Intracranial Aneurysms: A Location-Specific Analysis.

BACKGROUND AND OBJECTIVES: Advances in endovascular flow diverters have led to a secular shift in the management of brain aneurysms, causing debate on current bypass indications. We therefore sought to investigate the long-term results, current indications, and trends of bypasses for brain aneurysms. METHODS: We retrospectively reviewed bypasses performed between 2005 and 2022 to treat brain aneurysms. Demographic, clinical, and radiological data were collected till the most recent follow-up. Aneurysm occlusion and graft patency was noted on cerebral angiogram in the immediate postoperative, 3-month, and most recent follow-up periods. Clinical outcomes (modified Rankin scores) and complications were assessed at 3 month and most recent follow-up. Trends in bypass volume and graft patency were assessed in 5-year epochs. Results were dichotomized based on aneurysm location to generate location-specific results and trends. RESULTS: Overall, 203 patients (mean age 50 years, 57% female patients) with 207 cerebral aneurysms were treated with 233 cerebral bypasses with a mean follow-up of 2 years. Fusiform morphology was the most common bypass indication. Aneurysm occlusion on immediate postoperative and final follow-up angiogram was 89% (184/207) and 96% (198/207), respectively. Graft patency rate in the immediate postoperative period and most recent follow-up was 95% (222/233) and 92% (215/233), respectively. Of 207 aneurysms, 5 (2%) recurred. Of 203 patients, 81% (165) patients had modified Rankin scores of 0-2 at the 3-month follow-up and 11 patients died (mortality 5%). Although there was a steady decrease in the bypass volume over the study period, the proportion of bypasses for recurrent aneurysms increased serially. Posterior circulation aneurysms had lower rates of aneurysm occlusion and significantly higher incidence of postoperative strokes and deaths (P = .0035), with basilar artery aneurysms having the worst outcomes. CONCLUSION: Bypass indications have evolved with the inception of novel flow diverters. However, they remain relevant in the cerebrovascular surgeon's armamentarium, and long-term results are excellent.

A comparison of computed tomography angiography and digital subtraction angiography for the diagnosis of penetrating cerebrovascular injury: a prospective multicenter study.

OBJECTIVE: In this research, the authors sought to characterize the incidence and extent of cerebrovascular lesions after penetrating brain injury in a civilian population and to compare the diagnostic value of head computed tomography angiography (CTA) and digital subtraction angiography (DSA) in their diagnosis. METHODS: This was a prospective multicenter cohort study of patients with penetrating brain injury due to any mechanism presenting at two academic medical centers over a 3-year period (May 2020 to May 2023). All patients underwent both CTA and DSA. The sensitivity and specificity of CTA was calculated, with DSA considered the gold standard. The number of DSA studies needed to identify a lesion requiring treatment that had not been identified on CTA was also calculated. RESULTS: A total of 73 patients were included in the study, 33 of whom had at least 1 penetrating cerebrovascular injury, for an incidence of 45.2%. The injuries included 13 pseudoaneurysms, 11 major arterial occlusions, 9 dural venous sinus occlusions, 8 dural arteriovenous fistulas, and 6 carotid cavernous fistulas. The sensitivity of CTA was 36.4%, and the specificity was 85.0%. Overall, 5.6 DSA studies were needed to identify a lesion requiring treatment that had not been identified with CTA. CONCLUSIONS: Cerebrovascular injury is common after penetrating brain injury, and CTA alone is insufficient to diagnosis these injuries. Patients with penetrating brain injuries should routinely undergo DSA.

Five-year outcome of a staged giant Shamblin type III carotid body tumor excision.

Giant carotid body tumors, defined as those >8 cm in size, are extremely rare. Definitive surgical management is a complex undertaking because these large tumors tend to have grown to envelop cranial nerves and the carotid artery, and few data exist regarding the long-term outcomes for these patients. We present the case of a patient with bilateral giant carotid body tumors who underwent staged embolization and excision of a >10-cm carotid body tumor. After 5 years of follow-up, we demonstrated that elective open repair can provide long-term symptomatic relief. We describe and illustrate the crucial steps and considerations regarding the excision of complex Shamblin type III carotid body tumors.

Distal Basilar Artery "Umbrella Aneurysm" Treated by Radial Artery Graft Bypass From the External Carotid Artery to Posterior Cerebral Artery and Clip Trapping: 2-Dimensional Operative Video.

A 71-yr-old woman was discovered to have an incidental distal basilar artery (BA) fusiform aneurysm 7 × 5 mm in dimension, shaped like an "umbrella handle" with critical stenosis distal to the aneurysm. The right posterior cerebral artery (PCA) P1 segment was small; the left posterior communicating artery (PComA) was miniscule. Because the natural history of fusiform BA aneurysms is poorly defined, this was equated to a saccular aneurysm, with an estimated 10-yr rupture rate of 29%.1-8 After discussion of alternative treatments, the patient decided upon surgery. Because of inadequate collateral circulation, a bypass to the left PCA was deemed necessary. The aneurysm was exposed by an extended trans-sylvian approach, and the left PCA P2 segment was visualized subtemporally. The left radial artery (RAG) was extracted, and pressure distended to prevent vasospasm. The RAG bypass was sutured first to the P2, and then to the cervical external carotid artery (ECA); the BA aneurysm was then clipped. The proximal anastomosis of the bypass needed revision because of poor flow; a 4-mm punch hole was made to widen the arteriotomy on the ECA. The patient was discharged home with mild memory loss and partial left cranial nerve III palsy. After discharge, she developed a severe left hemicrania, resolved with gabapentin. At 6-wk follow-up, she was asymptomatic, and computed tomography (CT) angiogram demonstrated patency of the bypass. The patient gave informed consent for surgery and video recording. All relevant patient identifiers have been removed from the video and accompanying radiology slides.

Radiation dose reduction during intra-arterial chemotherapy for retinoblastoma: a retrospective analysis of 96 consecutive pediatric interventions using five distinct protocols.

BACKGROUND: Intra-arterial chemotherapy (IAC) represents a mainstay of retinoblastoma treatment in children. Patients with retinoblastoma are uniquely at risk for secondary malignancies and are sensitive to the ionizing effects of radiation. OBJECTIVE: To retrospectively review a single institution's experience with IAC for retinoblastoma and the effect of variable intra-procedural imaging techniques on radiation exposure. MATERIALS AND METHODS: Twenty-four consecutive patients, with a mean age of 30.8±16.3 months (range: 3.2-83.4 months), undergoing IAC for retinoblastoma between May 2014 and May 2020 (72 months) were included. No patients were excluded. The primary outcome was radiation exposure and secondary outcomes included technical success and procedural adverse events. Technical success was defined as catheterization of the ophthalmic or meningolacrimal artery and complete delivery of chemotherapy. Each procedure was retrospectively reviewed and categorized as one of five imaging protocol types. Protocol types were characterized by uniplanar versus multiplanar imaging and digital subtraction angiographic versus roadmap angiographic techniques. Radiation exposure, protocol utilization, the association of protocol and radiation exposure were assessed. RESULTS: During 96 consecutive interventions, 109 ocular treatments were performed. Thirteen of the 96 (15.5%) treatments were bilateral. Ocular technical success was 106 of 109 (97.2%). All three treatment failures were successfully repeated within a week. Mean fluoroscopy time was 6.4±6.2 min (range: 0.7-31.1 min). Mean air kerma was 36.2±52.2 mGy (range: 1.4-215.0 mGy). There were two major (1.8%) complications and four (3.7%) minor complications. Of the 96 procedures, 10 (10.4%), 9 (9.4%), 13 (13.5%), 28 (29.2%) and 36 (37.5%) were performed using protocol types A, B, C, D and E, respectively. For protocol type A, mean fluoroscopy time was 10.3±6.8 min (range: 3.0-25.4 min) and mean air kerma was 118.2±61.2 mGy (range: 24.5-167.3 mGy). For protocol type E, mean fluoroscopy time was 3.1±3.2 min (range: 0.7-15.1 min) and mean air kerma was 5.4±4.2 mGy (range: 1.4-19.5 mGy). Fluoroscopy time and air kerma decreased over time, corresponding to the reduced use of multiplanar imaging and digital subtraction angiography. In the first quartile (procedures 1-24), 8 (33.3%), 7 (29.2%), 2 (8.3%), 6 (25.0%) and 1 (4.2%) were performed using protocol types A, B, C, D and E, respectively. Mean fluoroscopy time was 10.5±8.2 min (range: 2.4-28.1 min) and mean air kerma was 84.2±71.6 mGy (range: 12.8-215.0 mGy). In the final quartile (procedures 73-96), 24 (100%) procedures were performed using protocol type E. Mean fluoroscopy time was 3.5±4.0 min (range: 0.7-15.1 min) and mean air kerma was 5.0±4.3 mGy (range: 1.4-18.0 mGy), representing 66.7% and 94.1% reductions from the first quartile, respectively. Technical success in the second half of the experience was 100%. CONCLUSION: Sequence elimination, consolidation from biplane imaging to lateral-only imaging, and replacing digital subtraction with roadmap angiography dramatically reduced radiation exposure during IAC for retinoblastoma without adversely affecting technical success or safety.

Endovascular strategies for stroke management after subacute in-stent thrombosis.

Subacute in-stent thrombosis is a rare but potentially fatal condition that can occur after treatment for intracranial aneurysms or stenosis. While immediate and late thromboembolic post-stent complications are well-described, subacute (2-30 days post-intervention) thrombosis is unusual. The administration of peri-operative dual anti-platelet therapy (DAPT) has significantly reduced the risk for thrombosis, but questions remain as to the choice of agents and treatment of thromboembolic complications in this setting. We present our acute endovascular management strategies for three patients who suffered thromboembolic complications.

Republished: Successful treatment of direct carotid-cavernous fistula in a patient with Ehlers-Danlos syndrome type IV without arterial puncture: the transvenous triple-overlay embolization (TAILOREd) technique.

We report successful transvenous treatment of direct carotid-cavernous fistula in a patient with Ehlers-Danlos syndrome type IV using a novel triple-overlay embolization (TAILOREd) technique without the need for arterial puncture, which is known to be highly risky in this patient group. The TAILOREd technique allowed for successful treatment using preoperative MR angiography as a three-dimensional overlay roadmap combined with cone beam CT and live fluoroscopy, precluding the need for an arterial puncture.

Three strikes? Failed vascular access in mechanical thrombectomy.

Anatomic variability in the posterior circulation and small, fragile, or otherwise treacherous origins of vertebral arteries can create a challenge to acute endovascular intervention. We report a case of unsuccessful reperfusion due to inability to access the posterior circulation in a patient with acute basilar artery occlusion.

Surgical Versus Endovascular Management of Ruptured and Unruptured Intracranial Aneurysms: Emergent Issues and Future Directions.

Ideal management of unruptured intracranial aneurysms (UIAs) and ruptured intracranial aneurysms (RIAs) is a controversial issue. Over the last few decades, a significant paradigm shift has occurred away from open microsurgical clipping toward endovascular coil embolization. Multiple studies have been performed with mixed results. Some studies suggest that endovascular treatment produces better clinical and functional outcomes, but is associated with increased need for retreatment. Other studies report increased durability in aneurysms treated with microsurgical clipping, but that clipping may be associated with worse functional outcomes in some cases. Further complicating the dialogue are variable costs associated with different treatment modalities, including country-dependent cost differences. Here we provide a review of some of the major studies comparing open surgery versus endovascular treatment for both RIAs and UIAs to distill their key findings and corresponding implications for clinical practice. We relate these research results to our institution's experience with RIAs and UIAs and describe our approach to treatment of these conditions. Finally, we discuss implications of the paradigm shift for both open and endovascular surgery, including educational initiatives directed toward preserving important microsurgical tenets in the setting of diminishing surgical volume.

Brain Bypass Surgery for Complex Middle Cerebral Artery Aneurysms: Evolving Techniques, Results, and Lessons Learned.

OBJECTIVE: To analyze a consecutive series of patients with middle cerebral artery (MCA) aneurysms who needed an adjunctive cerebral revascularization procedure to achieve aneurysm occlusion with preservation of flow through all MCA branches. METHODS: A total of 42 patients with 43 MCA aneurysms underwent 52 bypass procedures over 13 years. The location of the aneurysm were M1 trunk, M1 bifurcation, M2 and beyond. The bypasses performed included intracranial bypasses (resection with end to end anastomosis, end to side implantation, side to side anastomosis, and short interposition graft), extraintracranial bypasses (superficial temporal to middle cerebral artery anastomosis, and radial artery bypass graft, or saphenous vein graft), double bypasses, Y-grafts, and combined techniques. RESULTS: Forty-two of 43 aneurysms (98%) had patent bypasses at long-term follow-up. All 43 aneurysms were completely occluded at last follow-up. Six patients (14%) developed strokes related to the surgical treatment. At last follow-up, 36 patients had a modified Rankin score of 0-2, 5 patients had modified Rankin score 3-5, and 1 died. In this series, 31 (73.8%) patients improved, 8 (19%) patients had same functional status, and 3 (7.2%) patients deteriorated, including 1 patient who expired due to sepsis. The mean clinical follow-up duration was 39.3 months (0.4-124 months) and the mean radiological follow-up was 37 months (0.4-134 months). CONCLUSIONS: Cerebral revascularization is an important adjunct for treating MCA aneurysms and can be done safely. The article provides the insights we gained by rising through the learning curve.

Resection of Meningiomas Involving Major Dural Venous Sinuses: Classification, Technique, and Long-Term Results.

OBJECTIVE: Management of meningiomas with major dural venous sinus involvement is challenging. We present our case series and perspective on reconstruction of the sinuses. METHODS: Fifty-five patients underwent operations between 2005 and 2016 and the retrospective data were collected and analyzed. RESULTS: The cohort was younger with a mean of 51.3 years (range, 19-72 years) predominantly involving the superior sagittal sinus (44 patients). Sinus involvement was classified into group 1 (<50% of sinus, n = 28), group 2 (50%-99%, n = 8), and group 3 (total occlusion, n = 19). Venous collateralization was present in 100% of group 2 and 3 and in 36% of group 1 occlusions. Sinus pericranii was seen in 22 patients. Gross total resection was achieved in 87.2%, and sinus reconstruction followed in 38 patients (24 by direct suture and 14 by a patch graft). Pathology showed 36 (65%) World Health Organization grade I, 18 (33%) grade II, and 1 (2%) grade III tumors. During the mean follow-up of 60 months (range, 1-132 months), sinus was patent (74%) or narrowed but patent (24%) in 98%; 2 recurrences (3.6%) were observed (at 24 and 120 months). The mean preoperative/postoperative Karnofsky Performance Status and Kaplan-Meier cumulative overall/recurrence-free survival were 84.2%/88.1% and 90.9%/80.1%, respectively. CONCLUSIONS: These meningiomas present in a younger population, are more likely to be World Health Organization grade II or III, necessitating a more aggressive tumor resection strategy. Aggressive resection coupled with sinus reconstruction results in good long-term surgical outcome and low recurrence rates.

Predictors of Recurrence, Progression, and Retreatment in Basilar Tip Aneurysms: A Location-Controlled Analysis.

BACKGROUND: Endovascular treatment of intracranial aneurysms is associated with higher rates of recurrence and retreatment, though contemporary rates and risk factors for basilar tip aneurysms (BTAs) are less well-described. OBJECTIVE: To characterize progression, retreatement, and retreated progression of BTAs treated with microsurgical or endovascular interventions. METHODS: We retrospectively reviewed records for 141 consecutive BTA patients. We included 158 anterior communicating artery (ACoA) and 118 middle cerebral artery (MCA) aneurysms as controls. Univariate and multivariate analyses were used to calculate rates of progression (recurrence of previously obliterated aneurysms and progression of known residual aneurysm dome or neck), retreatment, and retreated progression. Kaplan-Meier analysis was used to characterize 24-mo event rates for primary outcome prediction. RESULTS: Of 141 BTA patients, 62.4% were ruptured and 37.6% were unruptured. Average radiographical follow-up was 33 mo. Among ruptured aneurysms treated with clipping, there were 2 rehemorrhages due to recurrence (6.1%), and none in any other cohorts. Overall rates of progression (28.9%), retreatment (28.9%), and retreated progression (24.7%) were not significantly different between surgical and endovascular subgroups, though ruptured aneurysms had higher event rates. Multivariate modeling confirmed rupture status (P = .003, hazard ratio = 0.14) and aneurysm dome width (P = .005, hazard ratio = 1.23) as independent predictors of progression requiring retreatment. In a separate multivariate analysis with ACoA and MCA aneurysms, basilar tip location was an independent predictor of progression, retreatment, and retreated progression. CONCLUSION: BTAs have higher rates of progression and retreated progression than other aneurysm locations, independent of treatment modality. Rupture status and dome width are risk factors for progression requiring retreatment.

Knot my problem: Overcoming transradial catheter complications.

Not all complications from transradial access can be prevented, even with diligent patient selection and preprocedure planning. This brief visual report offers technical suggestions to reverse knots and kinks encountered during catheter manipulation for endovascular transradial cerebral procedures.

Microsurgical Excision of T12-L1 Pial Arteriovenous Malformation: 3-Dimensional Operative Video.

This 29-yr-old man presented with progressive paraparesis, sensory loss, allodynia, bowel, and bladder dysfunction for 9 mo, acutely exacerbated in the preceding 24 h. Magnetic resonance imaging scan showed multiple dilated vessels involving the thoracic cord. Spinal angiogram revealed a T12-L1 pial arteriovenous malformation (AVM)/arteriovenous fistula on the left side. It was fed by an L1 radicular artery that filled the anterior spinal artery, which in turn had multiple feeders to a pial AVM. Because of the supply from the anterior spinal artery with multiple feeders to the AVM, and the danger of infarction of the conus, embolization was not performed. He underwent T11-L1 laminectomy laterally to the pedicles and excision of AVM. There was one large arterialized vein in the midline that had a fistulous connection with an artery coursing up from inferiorly. Despite occlusion of this fistula, the vein was still arterialized. On further exploration, there was a large artery coming in to the subarachnoid space at the T11 level and coursing inferiorly, and entering the intradural pial AVM with a glomus of vessels located at the T12 level in the left anterolateral subpial aspect of the cord. This major artery as well as multiple smaller vessels going into it were cauterized and divided, and the AVM was totally excised. Postoperative angiogram showed complete excision of the nidus. At 1 mo follow-up, he had complete recovery of motor and bladder functions but bowel dysfunction persisted. He was independent for his daily activities. Informed consent was obtained from the patient prior to the surgery that included videotaping of the procedure and its distribution for educational purposes. All relevant patient identifiers have also been removed from the video and accompanying radiology slides.

Microsurgical Clipping of a Ruptured Basilar Apex Aneurysm: 3-Dimensional Operative Video.

A 59-yr-old woman presented with a sudden onset of headache with neck pain and stiffness, Hunt and Hess grade 2. Brain computed tomography (CT) showed subarachnoid hemorrhage, Fisher Grade 2. Intra-arterial digital subtraction angiography (IADSA) showed a basilar artery apex aneurysm, dome size 9 mm and neck 3 mm, leaning towards the right, and a dominant right artery of Percheron. Endovascular treatment and microsurgical clipping were both explained to the patient, but she decided to undergo microsurgery due to the durability of treatment. She underwent a right frontotemporal craniotomy and orbital osteotomy. We performed optic nerve decompression and intradural anterior clinoidectomy to enhance the exposure. Working through the carotid-oculomotor space, the posterior communicating artery was traced back to the posterior cerebral artery. The basilar artery was temporarily occluded for aneurysm dissection after burst suppression to protect the brain. The aneurysm was irregular, multilobulated, and projecting upward. The dominant thalamoperforate artery (artery of Percheron) was arising from the right P1, and densely adherent to the sac of the aneurysm. After dissection of the artery of Percheron away from the aneurysm, it was completely occluded by a side-curved titanium clip. The patient had right oculomotor nerve paresis and headache postoperatively, but at discharge 2 wk later the headache and paresis had completely resolved. The postoperative IADSA showed total occlusion of the aneurysm with patency of the artery of Percheron. This 3-dimensional video shows the technical nuances of microsurgical clipping of a ruptured basilar apex aneurysm and intraoperative dissection of the artery of Percheron. Informed consent was obtained from the patient prior to the surgery that included videotaping of the procedure and its distribution for educational purposes. All relevant patient identifiers have also been removed from the video and accompanying radiology slides.

Long-Term Outcomes of Endovascular Treatment of Indirect Carotid Cavernous Fistulae: Superior Efficacy, Safety, and Durability of Transvenous Coiling Over Other Techniques.

BACKGROUND: Endovascular surgery is the first-line treatment for indirect cavernous carotid fistulae (CCFs). This study compares multiple treatment techniques. OBJECTIVE: To compare endovascular techniques for indirect CCF treatment. METHODS: Retrospective analysis was performed of prospectively maintained records at 4 centers, identifying patients undergoing indirect CCF embolization. Demographics, symptoms, and lesion characteristics were recorded. Medical records were reviewed for changes in symptoms, delayed complications, and angiographically proven recurrence. Univariate and multivariate analyses were performed to identify impacts of the above characteristics on outcomes. RESULTS: Sufficient records were available for 267 patients treated between January 1987 and December 2016. Obliteration was achieved in 86.5% patients, occurring in 86.9% of exclusively transvenous treatments and 79.5% of other treatments. Obliteration rates were highest following transvenous embolization using coils compared to all other materials (likelihood ratio [LR] 5.0, P = .024). Complications were less common with coil embolization compared to other materials (LR 0.070, P < .001). Embolization with liquid embolics resulted in higher complication rates (LR 10.2, P = .002), although risk was reduced when used in conjunction with coils. Angiographically confirmed recurrence was more common following embolization with polyvinyl alcohol (LR 9.9, P = .004) and when multiple embolic agents were used (LR 6.6, P = .018). Delayed development of symptoms following embolization was less common following embolization with coils (LR 0.20, P = .030) and more common following embolization with liquids (LR 6.5, P = .014). CONCLUSION: To treat indirect CCFs, transvenous coil embolization is the safest and most effective technique. Liquid embolics are less effective and have more complications and should be carefully considered only in extenuating circumstances.

Surgery for very large and giant intracranial aneurysms: Results and complications.

BACKGROUND: Results of and the complications encountered during surgery for very large and giant intracranial aneurysms are illustrated. OBJECTIVE: To analyze a consecutive series of patients with very large and giant aneurysms treated with microsurgery. METHODS: This retrospective study included seventy six very large and giant aneurysms which were managed by clipping and bypass technique. Sixty two (82%) aneurysms were located in anterior circulation, and 14 (18%) aneurysms were located in posterior circulation. The bypasses performed included local bypasses, extra-intracranial bypasses, double bypasses and combination techniques of external carotid-internal carotid (EC-IC) bypass and local bypasses. RESULTS: 73 patients with 76 aneurysms were treated over 13 years. There were 44 very large and 32 giant aneurysms. Twenty-four patients presented with subarachnoid hemorrhage [SAH] (32%) while forty nine patients with 52 aneurysms (68%) were unruptured. These 73 patients underwent 63 bypass procedures with aneurysm occlusion and 13 clipping procedures. Out of 62 anterior circulation aneurysms, bypass surgery was performed in 49 patients while 13 underwent clipping. In posterior circulation aneurysms, all patients were treated with bypass procedures with proximal occlusion or trapping. In the ruptured group, 16 (67%) patients had postoperative modified Rankin Scale (mRs) 0-2, six patients (25%) had mRs 3-5, and two patients (8.4%) died. In the unruptured group, 45 patients (87%) had mRs 0-2, 3 patients (6%) had mRs 3-5, and four patients (7.6%) died. CONCLUSIONS: In this large series of very large and giant aneurysms treated with microsurgical clipping and bypasses, excellent results were obtained in the long term, in regards to aneurysm occlusion, functional status, and graft patency. Our experience will be very useful to other neurosurgeons who treat these complex lesions.

Targeted Embolization of Aneurysms Associated With Brain Arteriovenous Malformations at High Risk for Surgical Resection: A Case-Control Study.

BACKGROUND: High-risk components of brain arteriovenous malformations (BAVMs) can be targeted to reduce the risk of lesion rupture. OBJECTIVE: To evaluate targeted embolization of aneurysms against other means of treatment with a case-control analysis; we previously investigated this approach associated with BAVMs. METHODS: Retrospective analysis of patients with BAVMs was performed, identifying patients treated with intention to occlude only an aneurysm associated with a BAVM. For each targeted aneurysm embolization (TAE) patient identified, 4 control patients were randomly selected, controlling for rupture status, age, and Spetzler-Martin plus Lawton-Young supplemental score. Analysis was performed to compare rates of adverse events (hemorrhage, new seizure, and death) between the 2 groups. RESULTS: Thirty-two patients met inclusion criteria, and 128 control patients were identified, out of 1103 patients treated during the study period. Thirty-four adverse events occurred (15 ruptures, 15 new seizures, and 11 deaths) during the follow-up period (mean 1157 d for the TAE cohort and 1036 d for the non-TAE cohort). Statistically lower associations were noted for the TAE group for any adverse event (hazard ratio 0.28, P = .037) and the composite outcome of hemorrhage or new seizure (hazard ratio 0.20, P = .029). CONCLUSION: For BAVMs at high risk for surgical resection, TAE can be performed safely and effectively. Patients treated with TAE had better outcomes than matched patients undergoing other combinations of treatment. TAE can be considered for BAVMs with high operative risk prior to radiosurgery or when no other treatment options are available.

Retrograde 3D rotational venography (3DRV) for venous sinus stent placement in idiopathic intracranial hypertension.

BACKGROUND: Dural venous sinus stenting has emerged as an effective and durable treatment for idiopathic intracranial hypertension (IIH). Improved visualization of the venous sinuses can improve stent placement. METHODS: We present two cases of IIH treated with venous sinus stenting in which retrograde three-dimensional rotational venography (3DRV) provided superior anatomical details of the venous sinuses for optimal sizing and positioning of stent. RESULTS: Comparison of pre-stent 3DRV with post-stent contrast-enhanced flat panel detector CT allowed confirmation of stent placement and the result of stenosis dilation. CONCLUSION: This 3DRV technique provides precise visualization of venous sinus stenosis prior to stenting without the need for arterial cerebral angiography during the treatment course.