Multicenter investigation of technical and clinical outcomes after thrombectomy for distal vessel occlusion by frontline technique.

BACKGROUND: Endovascular thrombectomy (EVT) is the standard-of-care for proximal large vessel occlusion (LVO) stroke. Data on technical and clinical outcomes in distal vessel occlusions (DVOs) remain limited. METHODS: This was a retrospective study of patients undergoing EVT for stroke at 32 international centers. Patients were divided into LVOs (internal carotid artery/M1/vertebrobasilar), medium vessel occlusions (M2/A1/P1) and isolated DVOs (M3/M4/A2/A3/P2/P3) and categorized by thrombectomy technique. Primary outcome was a good functional outcome (modified Rankin Scale ≤2) at 90 days. Secondary outcomes included recanalization, procedure-time, thrombectomy attempts, hemorrhage, and mortality. Multivariate logistic regressions were used to evaluate the impact of technical variables. Propensity score matching was used to compare outcome in patients with DVO treated with aspiration versus stent retriever RESULTS: We included 7477 patients including 213 DVOs. Distal location did not independently predict good functional outcome at 90 days compared with proximal (p=0.467). In distal occlusions, successful recanalization was an independent predictor of good outcome (adjusted odds ratio (aOR) 5.11, p<0.05) irrespective of technique. Younger age, bridging therapy, and lower admission National Institutes of Health Stroke Scale (NIHSS) were also predictors of good outcome. Procedure time ≤1 hour or ≤3 thrombectomy attempts were independent predictors of good outcomes in DVOs irrespective of technique (aOR 4.5 and 2.3, respectively, p<0.05). There were no differences in outcomes in a DVO matched cohort of aspiration versus stent retriever. Rates of hemorrhage and good outcome showed an exponential relationship to procedural metrics, and were more dependent on time in the aspiration group and attempts in the stent retriever group. CONCLUSIONS: Outcomes following EVT for DVO are comparable to LVO with similar results between techniques. Techniques may exhibit different futility metrics; stent retriever thrombectomy was influenced by attempts whereas aspiration was more dependent on procedure time.

ACR Appropriateness Criteria® Cranial Neuropathy: 2022 Update.

Cranial neuropathy can result from pathology affecting the nerve fibers at any point and requires imaging of the entire course of the nerve from its nucleus to the end organ in order to identify a cause. MRI with and without intravenous contrast is often the modality of choice with CT playing a complementary role. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Is a picture-perfect thrombectomy necessary in acute ischemic stroke?

BACKGROUND: The benefit of complete reperfusion (modified Thrombolysis in Cerebral Infarction (mTICI) 3) over near-complete reperfusion (≥90%, mTICI 2c) remains unclear. The goal of this study is to compare clinical outcomes between mechanical thrombectomy (MT)-treated stroke patients with mTICI 2c versus 3. METHODS: This is a retrospective study from the Stroke Thrombectomy and Aneurysm Registry (STAR) comprising 33 centers. Adults with anterior circulation arterial vessel occlusion who underwent MT yielding mTICI 2c or mTICI 3 reperfusion were included. Patients were categorized based on reperfusion grade achieved. Primary outcome was modified Rankin Scale (mRS) 0-2 at 90 days. Secondary outcomes were mRS scores at discharge and 90 days, National Institutes of Health Stroke Scale score at discharge, procedure-related complications, and symptomatic intracerebral hemorrhage. RESULTS: The unmatched mTICI 2c and mTICI 3 cohorts comprised 519 and 1923 patients, respectively. There was no difference in primary (42.4% vs 45.1%; p=0.264) or secondary outcomes between the unmatched cohorts. Reperfusion status (mTICI 2c vs 3) was also not predictive of the primary outcome in non-imputed and imputed multivariable models. The matched cohorts each comprised 191 patients. Primary (39.8% vs 47.6%; p=0.122) and secondary outcomes were also similar between the matched cohorts, except the 90-day mRS which was lower in the matched mTICI 3 cohort (p=0.049). There were increased odds of the primary outcome with mTICI 3 in patients with baseline mRS ≥2 (36% vs 7.7%; p=0.011; pinteraction=0.014) and a history of stroke (42.3% vs 15.4%; p=0.027; pinteraction=0.041). CONCLUSIONS: Complete and near-complete reperfusion after MT appear to confer comparable outcomes in patients with acute stroke.

Pivotal trial of the Neuroform Atlas stent for treatment of posterior circulation aneurysms: one-year outcomes.

BACKGROUND: Stent-assisted coiling of wide-necked intracranial aneurysms (IAs) using the Neuroform Atlas Stent System (Atlas) has shown promising results. OBJECTIVE: To present the primary efficacy and safety results of the ATLAS Investigational Device Exemption (IDE) trial in a cohort of patients with posterior circulation IAs. METHODS: The ATLAS trial is a prospective, multicenter, single-arm, open-label study of unruptured, wide-necked, IAs treated with the Atlas stent and adjunctive coiling. This study reports the results of patients with posterior circulation IAs. The primary efficacy endpoint was complete aneurysm occlusion (Raymond-Roy (RR) class I) on 12-month angiography, in the absence of re-treatment or parent artery stenosis >50%. The primary safety endpoint was any major ipsilateral stroke or neurological death within 12 months. Adjudication of the primary endpoints was performed by an imaging core laboratory and a Clinical Events Committee. RESULTS: The ATLAS trial enrolled and treated 116 patients at 25 medical centers with unruptured, wide-necked, posterior circulation IAs (mean age 60.2±10.5 years, 81.0% (94/116) female). Stents were placed in all patients with 100% technical success rate. A total of 95/116 (81.9%) patients had complete angiographic follow-up at 12 months, of whom 81 (85.3%) had complete aneurysm occlusion (RR class I). The primary effectiveness outcome was achieved in 76.7% (95% CI 67.0% to 86.5%) of patients. Overall, major ipsilateral stroke and secondary persistent neurological deficit occurred in 4.3% (5/116) and 1.7% (2/116) of patients, respectively. CONCLUSIONS: In the ATLAS IDE posterior circulation cohort, the Neuroform Atlas Stent System with adjunctive coiling demonstrated high rates of technical and safety performance. Trial registration number https://clinicaltrials.gov/ct2/show/NCT02340585.

The Rist radial access system: a multicenter study of 152 patients.

BACKGROUND: Transradial access (TRA) for neurointervention is becoming increasingly popular as experience with the technique grows. Despite reasonable efficacy using femoral catheters off-label, conversion to femoral access occurs in approximately 8.6-10.3% of TRA cases, due to an inability of the catheter to track into the vessel of interest, lack of support, or radial artery spasm. METHODS: This is a multicenter, retrospective case series of patients undergoing neurointerventions using the Rist Radial Access System. We also present our institutional protocol for using the system. RESULTS: 152 patients were included in the cohort. The most common procedure was flow diversion (28.3%). The smallest radial diameter utilized was 1.9 mm, and 44.1% were performed without an intermediate catheter. A majority of cases (96.1%) were completed successfully; 3 (1.9%) required conversion to a different radial catheter, 2 (1.3%) required conversion to femoral access, and 1 (0.7%) was aborted. There was 1 (0.7%) minor access site complication and 4 (2.6%) neurological complications. CONCLUSIONS: The Rist catheter is a safe and effective tool for a wide range of complex neurointerventions, with lower conversion rates than classically reported.

Pre-operative embolization followed by clipping of Cognard type V dural arteriovenous fistula.

This article has been retracted because it describes the use of an investigative agent that has not been approved by the Food and Drug Administration.

Upper extremity transvenous access for neuroendovascular procedures: an international multicenter case series.

BACKGROUND: Radial artery access for transarterial procedures has gained recent traction in neurointerventional due to decreased patient morbidity, technical feasibility, and improved patient satisfaction. Upper extremity transvenous access (UETV) has recently emerged as an alternative strategy for the neurointerventionalist, but data are limited. Our objective was to quantify the use of UETV access in neurointerventions and to measure failure and complication rates. METHODS: An international multicenter retrospective review of medical records for patients undergoing UETV neurointerventions or diagnostic procedures was performed. We also present our institutional protocol for obtaining UETV and review the existing literature. RESULTS: One hundred and thirteen patients underwent a total of 147 attempted UETV procedures at 13 centers. The most common site of entry was the right basilic vein. There were 21 repeat puncture events into the same vein following the primary diagnostic procedure for secondary interventional procedures without difficulty. There were two minor complications (1.4%) and five failures (ie, conversion to femoral vein access) (3.4%). CONCLUSIONS: UETV is safe and technically feasible for diagnostic and neurointerventional procedures. Further studies are needed to determine the benefit over alternative venous access sites and the effect on patient satisfaction.

International experience of mechanical thrombectomy during the COVID-19 pandemic: insights from STAR and ENRG.

BACKGROUND: In response to the COVID-19 pandemic, many centers altered stroke triage protocols for the protection of their providers. However, the effect of workflow changes on stroke patients receiving mechanical thrombectomy (MT) has not been systematically studied. METHODS: A prospective international study was launched at the initiation of the COVID-19 pandemic. All included centers participated in the Stroke Thrombectomy and Aneurysm Registry (STAR) and Endovascular Neurosurgery Research Group (ENRG). Data was collected during the peak months of the COVID-19 surge at each site. Collected data included patient and disease characteristics. A generalized linear model with logit link function was used to estimate the effect of general anesthesia (GA) on in-hospital mortality and discharge outcome controlling for confounders. RESULTS: 458 patients and 28 centers were included from North America, South America, and Europe. Five centers were in high-COVID burden counties (HCC) in which 9/104 (8.7%) of patients were positive for COVID-19 compared with 4/354 (1.1%) in low-COVID burden counties (LCC) (P<0.001). 241 patients underwent pre-procedure GA. Compared with patients treated awake, GA patients had longer door to reperfusion time (138 vs 100 min, P=<0.001). On multivariate analysis, GA was associated with higher probability of in-hospital mortality (RR 1.871, P=0.029) and lower probability of functional independence at discharge (RR 0.53, P=0.015). CONCLUSION: We observed a low rate of COVID-19 infection among stroke patients undergoing MT in LCC. Overall, more than half of the patients underwent intubation prior to MT, leading to prolonged door to reperfusion time, higher in-hospital mortality, and lower likelihood of functional independence at discharge.

Transradial approach for neurointerventions: a systematic review of the literature.

BACKGROUND: Despite the recent increase in the number of publications on diagnostic cerebral angiograms using transradial access (TRA), there have been relatively few regarding TRA for neurointerventional cases. Questions of feasibility and safety may still exist among physicians considering TRA for neurointerventional procedures. METHODS: A systematic literature review was performed following PRISMA guidelines. Three online databases (MedLine via PubMed, Scopus and Embase) were searched for articles published between January 2000 and December 2019. Search terms included "Transradial access", "Radial Access", "Radial artery" AND "Neurointerventions". The reference lists of selected articles and pertinent available non-systematic analysis were reviewed for other potential citations. Primary outcomes measured were access site complications and crossover rates. RESULTS: Twenty-one studies (n=1342 patients) were included in this review. Two of the studies were prospective while the remaining 19 were retrospective. Six studies (n=616 patients) included TRA carotid stenting only. The rest of the studies included treatment for cerebral aneurysms (n=423), mechanical thrombectomy (n=127), tumor embolization (n=22), and other indications (n=154) such as angioplasty and stenting for vertebrobasilar stenosis, balloon test occlusion, embolization of dural arteriovenous fistula and arteriovenous malformation, chemotherapeutic drug delivery, intra-arterial thrombolysis, and arterial access during a venous stenting procedure. Two (0.15%) major complications and 37 (2.75%) minor complications were reported. Sixty-four (4.77%) patients crossed over to transfemoral access for completion of the procedure. Seven (0.52%) patients crossed over due to access failure and 57 (4.24%) patients crossed over to TFA due to inability to cannulate the target vessel. CONCLUSION: This systematic review demonstrates that TRA has a relatively low rate of access site complications and crossovers. With increasing familiarity, development of TRA-specific neuroendovascular devices, and the continued reports of its success in the literature, TRA is expected to become more widely used by neurointerventionalists.

ACR Appropriateness Criteria® Headache.

Headache is one of the most common human afflictions. In most cases, headaches are benign and idiopathic, and resolve spontaneously or with minor therapeutic measures. Imaging is not required for many types of headaches. However, patients presenting with headaches in the setting of "red flags" such as head trauma, cancer, immunocompromised state, pregnancy, patients 50 years or older, related to activity or position, or with a corresponding neurological deficit, may benefit from CT, MRI, or noninvasive vascular imaging to identify a treatable cause. This publication addresses the initial imaging strategies for headaches associated with the following features: severe and sudden onset, optic disc edema, "red flags," migraine or tension-type, trigeminal autonomic origin, and chronic headaches with and without new or progressive features. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Pipeline Embolization Device for the Treatment of Intracranial Pseudoaneurysms.

BACKGROUND: Intracranial pseudoaneurysms (PSAs) are associated with high rupture and mortality rates and have traditionally been treated by parent vessel sacrifice. There has been recent interest in using flow-diverting devices for treatment of these complex lesions while preserving flow through the parent artery. The objective of this study is to examine the safety and efficacy of these devices in the treatment of intracranial PSA. METHODS: We performed a multi-institutional retrospective study of intracranial PSAs treated with the Pipeline Embolization Device (PED) between 2014 and 2017 at 7 institutions. Complications and clinical and radiographic outcomes were reviewed. RESULTS: A total of 19 patients underwent PED placement for intracranial PSA. Iatrogenic injury and trauma comprised most etiologies in our series. The mean pseudoaneurysm diameter was 8.8 mm, and 18 of 19 PSAs (95%) involved the internal carotid artery (ICA). Multiple PEDs were deployed in a telescoping fashion in 7 patients (37%). Of the 18 patients with follow up imaging, 14 (78%) achieved complete pseudoaneurysm obliteration and 2 achieved near-complete obliteration (11%). Two patients (11%) were found to have significant pseudoaneurysm progression on short-term follow-up and required ICA sacrifice. No patients experienced new neurologic deficits or deterioration secondary to PED placement. No patients experienced bleeding or rebleeding from PSA. CONCLUSIONS: In well-selected patients, the use of flow-diverting stents may be a feasible alternative to parent vessel sacrifice. Given the high morbidity and mortality associated with PSA, we recommend short- and long-term radiographic follow-up for patients treated with flow-diverting stents.

Recommendations for the selection and treatment of patients with idiopathic intracranial hypertension for venous sinus stenting.

INTRODUCTION: Although venous sinus stenting (VSS) has emerged as a promising treatment option for patients with idiopathic intracranial hypertension (IIH) and associated venous sinus stenosis, there is considerable ambiguity regarding patient selection criteria, treatment protocols, and management strategies. METHODS: An extensive literature review was performed to identify all reports of VSS in patients with IIH using PubMed. Recommendations for the selection and treatment of patients with IIH with VSS are outlined as determined based on author opinion from supporting studies. Due to the lack of randomized trials and few published prospective studies, standard grading scales for recommendations and level of evidence are not fully applicable and therefore a revised grading scale has been provided for recommendations. RESULTS: The literature review identified a total of eight systematic reviews or meta-analyses and 29 published patient series on VSS. Recommendations for patient selection for diagnostic catheter angiography, angiography procedural considerations, stenting procedural considerations, and retreatment are provided based on the literature. Recommendations that were considered strong included: performance of venous sinus manometry to assess candidacy for treatment prior to stenting; administration of antiplatelet agents prior to stenting and for a follow-up period of at least 3-6 months; performance of post-stenting manometry to confirm resolution of pressure gradient; and performance of repeat angiography and manometry on patients with recurrence of symptoms after resolution with stenting to evaluate for recurrent stenosis. CONCLUSION: VSS for patients with IIH with venous sinus stenosis is now an established and effective treatment option. These recommendations have been provided, based on a summative review of the available published literature, to assist in standardizing care for patients with IIH undergoing VSS.

Posterior circulation perforator aneurysms: a proposed management algorithm.

INTRODUCTION: Subarachnoid hemorrhage (SAH) from posterior circulation perforator aneurysms (PCPAs) is rare and its natural history is unknown. Diagnosis may be difficult, acute management is poorly defined, and long-term recurrent SAH rates and clinical outcome data are lacking. METHODS: We searched our institution's records for cases of PCPA rupture and analyzed patient demographics, Hunt and Hess (HH) grades, diagnostic imaging, management, and clinical outcomes. We conducted telephone interviews to calculate modified Rankin Scale (mRS) scores. RESULTS: We identified 9 patients (6 male, 3 female) with a ruptured PCPA who presented to the University of Virginia Health System (Charlottesville, VA, USA) between 2010 and 2016. Median and mean ages were 62 and 63 years, respectively. Median HH grade was 3. Seven of nine (78%) PCPAs were angiographically occult on initial imaging and median time to diagnosis was 5 days. Three conservatively managed patients had a mean mRS score of 0.67 (range 0-1) at mean follow-up of 35.3 months. Antifibrinolytic therapy was administered to all conservatively managed patients without thrombotic complication. Six patients receiving endovascular treatment had a mean mRS score of 2.67 (range 0-6) at mean follow-up of 49.2 months. No cases of recurrent SAH were seen in the study. CONCLUSIONS: The rarity of PCPA has precluded long-term clinical follow-up until now. Our experience suggests low recurrent SAH rates. Until further studies are performed, conservative management, possibly combined with antifibrinolytic therapy, may be a viable treatment with acceptable long-term outcome.

Effect of Body Mass Index on Venous Sinus Pressures in Idiopathic Intracranial Hypertension Patients Before and After Endovascular Stenting.

BACKGROUND: Elevated body mass index (BMI) has been correlated with worse outcomes after treatment for idiopathic intracranial hypertension (IIH). Venous sinus stenting (VSS) has emerged as a safe and effective treatment for a subset of patients with IIH and evidence of venous sinus stenosis. However, the association between BMI and the efficacy of VSS remains poorly characterized. OBJECTIVE: To determine, in a retrospective cohort study, the effect of BMI on preoperative mean intracranial venous pressure (MVP) and post-VSS outcomes. METHODS: We performed a retrospective evaluation of a prospectively collected database of patients with IIH and intracranial venous sinus stenosis who underwent VSS. Patient demographics and treatment factors, including pre- and postprocedural trans-stenosis pressure gradients, were analyzed to identify the relationship between BMI and outcomes after VSS. RESULTS: Increasing BMI was significantly correlated with higher maximum MVP (P = .013) and higher trans-stenosis pressure gradient (P = .043) prior to treatment. The degrees of improvement in maximum MVP and pressure gradient after VSS were greatest for obese and morbidly obese patients (BMI > 30 kg/m2). Maximum poststent MVP, clinical outcomes, and stent-adjacent stenosis requiring retreatment after VSS were not significantly associated with BMI. CONCLUSION: We provide direct evidence for a positive correlation between BMI and intracranial venous pressure in patients with IIH. VSS affords a significantly greater amelioration of intracranial venous hypertension and stenosis for IIH patients with higher BMIs. As such, obesity should not be a deterrent for the use of VSS in the management of IIH.

A pilot study and novel angiographic classification for superior sagittal sinus stenting in patients with non-thrombotic intracranial venous occlusive disease.

OBJECTIVE: Safety and efficacy of superior sagittal sinus (SSS) stenting for non-thrombotic intracranial venous occlusive disease (VOD) is unknown. The aim of this retrospective cohort study is to evaluate outcomes after SSS stenting. METHODS: We evaluated an institutional database to identify patients who underwent SSS stenting. Radiographic and clinical outcomes were analyzed and a novel angiographic classification of the SSS was proposed. RESULTS: We identified 19 patients; 42% developed SSS stenosis after transverse sinus stenting. Pre-stent maximum mean venous pressure (MVP) in the SSS of 16.2 mm Hg decreased to 13.1 mm Hg after stenting (p=0.037). Preoperative trans-stenosis pressure gradient of 4.2 mm Hg decreased to 1.5 mm Hg after stenting (p<0.001). No intraprocedural complication or junctional SSS stenosis distal to the stent construct was noted. Improvement in headache, tinnitus, and visual obscurations was reported by 66.7%, 63.6%, and 50% of affected patients, respectively, at mean follow-up of 5.2 months. We divided the SSS into four anatomically equal segments, numbered S1-S4, from the torcula to frontal pole. SSS stenosis typically occurs in the S1 segment, and the anterior extent of SSS stents was deployed at the S1-S2 junction in all but one case. CONCLUSIONS: SSS stenting is reasonably safe, may improve clinical symptoms, and significantly reduces maximum MVP and trans-stenosis pressure gradients in patients with VOD with SSS stenosis. The S1 segment is most commonly stenotic, and minimum pressure gradients for symptomatic SSS stenosis may be lower than for transverse or sigmoid stenosis. Additional studies and follow-up are necessary to better elucidate appropriate clinical indications and long-term efficacy of SSS stenting.

Eyebrow Incision for Surgical Evacuation of a Lobar Intracerebral Hematoma with a Novel Endoport System.

Large lobar intracerebral hemorrhages (ICHs) can cause rapid neurological deterioration, and affected patients have low rates of survival and functional independence. Currently, the role of surgical intervention in the management patients with lobar ICHs is controversial. Minimally invasive technologies have been developed which may potentially decrease the operative morbidity of ICH surgery. The aim of this case report is to describe the technical aspects of the use of a novel minimally invasive endoport system, the BrainPath (NICO, Indianapolis, IN, USA), through an eyebrow incision for evacuation of a large lobar hematoma. An 84-year-old female presented with a left frontal ICH, measuring 7.5 cm in maximal diameter and 81 cm3 in volume, secondary to cerebral amyloid angiopathy. Through a left eyebrow incision, a miniature modified orbitozygomatic craniotomy was performed, which allowed endoport cannulation of the hematoma from a lateral subfrontal cortical entry point. Endoport-assisted hematoma evacuation resulted in nearly 90% volume reduction and improvement of the patient's functional status at clinical follow-up. We found that minimally invasive endoport technology can be employed in conjunction with conventional neurosurgical skull base principles to achieve safe and effective evacuation of large lobar hematomas in carefully selected patients.

ACR Appropriateness Criteria® Cranial Neuropathy.

Evaluation of cranial neuropathy can be complex given the different pathway of each cranial nerve as well as the associated anatomic landmarks. Radiological evaluation requires imaging of the entire course of the nerve from its nucleus to the end organ. MRI is the modality of choice with CT playing a complementary role, particularly in the evaluation of the bone anatomy. Since neoplastic and inflammatory lesions are prevalent on the differential diagnosis, contrast enhanced studies are preferred when possible. The American College of Radiology Appropriateness Criteria are evidencebased guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Dilated Virchow-Robin Spaces Mimicking a Brainstem Arteriovenous Malformation.

Virchow-Robin spaces (VRS) are ubiquitous and commonly observed as the resolution of magnetic resonance imaging (MRI) continues to improve. The function of VRS and the etiology of their dilation is still a subject of research. Diagnosing dilated VRS (dVRS) can be challenging because they may appear similar to other pathologies such as cystic neoplasms, infectious cysts, and even arteriovenous malformations (AVMs) on certain MRI pulse sequences. We reported a unique case of brainstem dVRS mimicking an AVM. Furthermore, the extensive pontine involvement of our patient's lesion is rarely described in neurosurgical literature. Understanding the imaging characteristics of dVRS is critical to accurately diagnose these lesions and avoid unnecessary tests and procedures.

Patency of the vein of Labbé after venous stenting of the transverse and sigmoid sinuses.

BACKGROUND: Venous sinus stenting is an emerging treatment for patients with idiopathic intracranial hypertension and evidence of venous stenosis. Stents placed across the transverse and sigmoid sinuses often cover the vein of Labbé (VOL), a major anastomotic vein draining the cerebral hemisphere. The patency of the VOL after stenting and its clinical implications are poorly understood. METHODS: A retrospective analysis was performed of a prospectively collected database of patients undergoing venous sinus stenting. Pre- and post-stent angiography were compared to assess changes in VOL patency, clinical and radiographic outcomes. RESULTS: The study cohort comprised 56 patients. The stent covered the VOL in 92.9% of cases. Thirty-two cases with VOL coverage had evaluable angiograms immediately after stent placement. Among these, VOL filled normally in 75.0%, exhibited diminished caliber with normal transit time in 3.1%, filled sluggishly in 18.8%, and was occluded in 3.1%. Follow-up was assessed in patients with at least 3 months' angiographic follow-up (46 patients, mean 7.2 months). Of these, normal filling was seen in 71.7%, diminished caliber in 26.1%, and sluggish filling in 2.2% of cases. Neither stent coverage of the VOL nor its patency immediately after stenting or at follow-up correlated with stent-adjacent stenosis. There were no neurological sequelae from coverage of the VOL or alteration of its drainage pattern. CONCLUSIONS: In the majority of venous stenting cases involving the transverse and sigmoid sinuses, the VOL remains widely patent. Complete VOL occlusion rarely occurs after stenting and may not result in clinical sequelae. Stent coverage of the VOL should not deter the therapeutic use of venous sinus stenting.

Clinical Features, Management Considerations and Outcomes in Case Series of Patients with Parasellar Intracranial Aneurysms Undergoing Anterior Skull Base Surgery.

BACKGROUND: The coincidence of parasellar aneurysms (IAs) and anterior skull base (ASB) lesions, while rare, presents a management challenge. IAs embedded within, or adjacent to, ASB lesions are at risk in the perioperative period and may have unique presentations, natural histories, and outcomes. The objective of this study was to outline management options and nuances in patients with coexisting IAs and ASB lesions. METHODS: We retrospectively evaluated all patients who presented for management of IAs and ASB lesions from January 2006 to January 2014. Medical charts and imaging were reviewed for patient, tumor and IA characteristics, pathology, operative findings, complications, and outcomes. RESULTS: Of 13 patients included in the study, 11 had histologically proven or presumed pituitary macroadenomas. The majority of cases presented with visual and endocrine deficits, and the median maximal tumor diameter was 3.1 cm. There were 17 IAs, all located in the parasellar area. Endovascular treatment of the IA was performed before tumor resection in 2 cases. Transsphenoidal resection was performed before IA occlusion in 1 case, and intraoperative vascular injury occurred in 2 cases. The median follow-up was 36 months. CONCLUSIONS: Management decisions for patients with coincident IA and ASB lesions require careful, individualized treatment plans. Coil embolization is well tolerated and does not delay surgery, except in cases requiring stent placement. Inadvertent intraoperative rupture of an adjacent IA during anterior skull base surgery may be treated with emergent coil embolization, flow diversion, or carotid sacrifice, but adequate preoperative planning can reduce this risk.