Stenting and Angioplasty in Neurothrombectomy: Matched Analysis of Rescue Intracranial Stenting Versus Failed Thrombectomy.

BACKGROUND: Successful reperfusion is one of the strongest predictors of functional outcomes after mechanical thrombectomy (MT). Despite continuous advancements in MT technology and techniques, reperfusion failure still occurs in ≈15% to 30% of patients with large vessel occlusion strokes undergoing MT. We aim to evaluate the safety and efficacy of rescue intracranial stenting for large vessel occlusion stroke after failed MT. METHODS: The SAINT (Stenting and Angioplasty in Neurothrombectomy) Study is a retrospective analysis of prospectively collected data from 14 comprehensive stroke centers through January 2015 to December 2020. Patients were included if they had anterior circulation large vessel occlusion stroke due to intracranial internal carotid artery and middle cerebral artery-M1/M2 segments and failed MT. The cohort was divided into 2 groups: rescue intracranial stenting and failed recanalization (modified Thrombolysis in Cerebral Ischemia score 0-1). Propensity score matching was used to balance the 2 groups. The primary outcome was the shift in the degree of disability as measured by the modified Rankin Scale at 90 days. Secondary outcomes included functional independence (90-day modified Rankin Scale score 0-2). Safety measures included symptomatic intracranial hemorrhage and 90-day mortality. RESULTS: A total of 499 patients were included in the analysis. Compared with the failed reperfusion group, rescue intracranial stenting had a favorable shift in the overall modified Rankin Scale score distribution (acOR, 2.31 [95% CI, 1.61-3.32]; P<0.001), higher rates of functional independence (35.1% versus 7%; adjusted odds ratio [aOR], 6.33 [95% CI, 3.14-12.76]; P<0.001), and lower mortality (28% versus 46.5%; aOR, 0.55 [95% CI, 0.31-0.96]; P=0.04) at 90 days. Rates of symptomatic intracerebral hemorrhage were comparable across both groups (7.1% versus 10.2%; aOR, 0.99 [95% CI, 0.42-2.34]; P=0.98). The matched cohort analysis demonstrated similar results. Specifically, rescue intracranial stenting (n=107) had a favorable shift in the overall modified Rankin Scale score distribution (acOR, 3.74 [95% CI, 2.16-6.57]; P<0.001), higher rates of functional independence (34.6% versus 6.5%; aOR, 10.91 [95% CI, 4.11-28.92]; P<0.001), and lower mortality (29.9% versus 43%; aOR, 0.49 [95% CI, 0.25-0.94]; P=0.03) at 90 days with similar rates of symptomatic intracerebral hemorrhage (7.5% versus 11.2%; aOR, 0.87 [95% CI, 0.31-2.42]; P=0.79) compared with patients who failed to reperfuse (n=107). There was no heterogeneity of treatment effect across the prespecified subgroups for improvement in functional outcomes. CONCLUSIONS: Acute intracranial stenting appears to be a safe and effective rescue strategy in patients with large vessel occlusion stroke who failed MT. Randomized multicenter trials are warranted.

Neuroendovascular Treatment of Acute Stroke During COVID-19: A Guide From the Frontlines.

Since the initial reports surfaced of a novel coronavirus causing illness and loss of life in Wuhan, China, COVID-19 has rapidly spread across the globe, infecting millions and leaving hundreds and thousands dead. As hospitals cope with the influx of patients with COVID-19, new challenges have arisen as health-care systems care for patients with COVID-19 while still providing essential emergency care for patients with acute strokes and acute myocardial infarction. Adding to this complex scenario are new reports that patients with COVID-19 are at increased risk of thromboembolic complications including strokes. In this article, we detail our experience caring for acute stroke patients and provide some insight into neurointerventional workflow modifications that have helped us adapt to the COVID-19 era.

Neurointerventional Radiology for the Aspiring Radiology Resident: Current State of the Field and Future Directions.

OBJECTIVE: The purposes of this study were to document recent trends in stroke intervention at a tertiary-care facility with a comprehensive stroke center and to analyze current procedure volumes and the employment of specialty providers in neurointerventional radiology (NIR). MATERIALS AND METHODS: Institutional trends in the volume of mechanical thrombectomy were analyzed on the basis of the number of patients who underwent mechanical thrombectomy from 2013 to 2017. To evaluate the current status of mechanical thrombectomy volumes in the United States, the number of patients in the Medicare fee-for-service database who underwent mechanical thrombectomy in 2016 was assessed. The specialty backgrounds of the various providers who performed mechanical thrombectomy were analyzed. Procedure volumes for intracranial stenting, embolization, and vertebral augmentation procedures were assessed. RESULTS: From 2013 to 2017, the total numbers of mechanical thrombectomy procedures for acute ischemic stroke were 19 in 2013 and 111 in 2017. The total volume of mechanical thrombectomy procedures in the Medicare fee-for-service population in 2016 was 7479. For intracranial endovascular procedures, 20,850 were performed in the U.S. Medicare population in 2015 and 22,511 in 2016. Radiologists performed 45% of procedures in 2016; neurosurgeons, 41%; and neurologists, 11%. When the total numbers of percutaneous brain and spine procedures were combined, radiologists performed 41%; neurosurgeons, 23%; and neurologists, 3%. In 2016, there were a total of 220 active NIR staff at the NIR programs with rotating residents or fellows. In these programs, 49% of staff members were neuroradiologists, 41% were neurosurgeons, and 10% were neurologists. Of the 72 NIR departments with confirmed rotating fellows or residents, 14 had only neuroradiologists on staff, six had only neurosurgeons, and one had only neurologists. CONCLUSION: Increasing radiology resident interest and participation in NIR should ensure a steady influx of radiologists into the field, continuing the strong tradition of radiology participation, leadership, and innovation in NIR.

Transcranial Optical Monitoring of Cerebral Hemodynamics in Acute Stroke Patients during Mechanical Thrombectomy.

INTRODUCTION: Mechanical thrombectomy is revolutionizing treatment of acute stroke due to large vessel occlusion (LVO). Unfortunately, use of the modified Thrombolysis in Cerebral Infarction score (mTICI) to characterize recanalization of the cerebral vasculature does not address microvascular perfusion of the distal parenchyma, nor provide more than a vascular "snapshot." Thus, little is known about tissue-level hemodynamic consequences of LVO recanalization. Diffuse correlation spectroscopy (DCS) and diffuse optical spectroscopy (DOS) are promising methods for continuous, noninvasive, contrast-free transcranial monitoring of cerebral microvasculature. METHODS: Here, we use a combined DCS/DOS system to monitor frontal lobe hemodynamic changes during endovascular treatment of 2 patients with ischemic stroke due to internal carotid artery (ICA) occlusions. RESULTS AND DISCUSSION: The monitoring instrument identified a recanalization-induced increase in ipsilateral cerebral blood flow (CBF) with little or no concurrent change in contralateral CBF and extracerebral blood flow. The results suggest that diffuse optical monitoring is sensitive to intracerebral hemodynamics in patients with ICA occlusion and can measure microvascular responses to mechanical thrombectomy.

"Scout No Scan" Technique Reduces Patient Radiation Exposure During CT-Guided Spine Biopsy.

OBJECTIVE: The objective of this article is to report our experience with a technique for CT-guided spine biopsies that we refer to as the "scout no scan" technique. CONCLUSION: The scout no scan technique can significantly lower radiation exposure while maintaining high diagnostic yields for CT-guided spinal biopsies.

C-Arm Fluoroscope Angle Settings for Fluoroscopically Guided Lumbar Transforaminal Epidural Injections.

BACKGROUND DATA: Minimizing fluoroscopy time in spine interventions is critical for time of procedure as well as radiation safety of the patient and medical personnel. Specific fluoroscopy angle settings for fluoroscopically guided L4-S1 transforaminal epidural injections (TFEIs) have not been described. OBJECTIVES: To describe the most common encountered settings for the C-arm fluoroscope angles for fluoroscopically guided L4-S1 (TFEI). METHODS: Each subject was placed in prone position on a flat fluoroscopy table without utilizing any device to alter innate lumbar spine curvature. The data from 246 consecutive patients at their first encounter in the fluoroscopy suite for a single level subpedicular lumbosacral TFEI was retrospectively analyzed. Most procedures occurred at the L4-5, L5-S1, and S1 levels (227 subjects). The C-arm angles including the oblique, cephalad/caudal were recorded for each subject upon observing final needle positioning for successful completion of the procedure according to ISIS Guidelines. RESULTS: For the L4-5 level, 71% of cases had oblique angle of 30°±5° and 94% of cases had neutral cephalad/caudal tilt (0°±5°) observed. For the L5-S1, 72% of cases had oblique angle of 30°±5° and 62% of cases had cephalad tilt angle of 15°±5° observed. For the S1 level, 73% of cases had oblique angle of 5°±5° and 69% of cases had cephalad tilt angle of 15°±5° observed. DISCUSSION/CONCLUSION: This retrospective descriptive study suggests fluoroscope angles for L4-S1 TFEI as a starting point before fine tuning views accounting for individual anatomy. Angles suggested for each level (oblique/cephalad tilt angles) are as follows: L4-5 (30/0°), L5-S1 (30/15°), and S1 (5/15°). Prospective studies using these guidelines would need to be undertaken to prove reproducibility between interventionalists, time efficiency, and radiation exposure reduction.

Mechanical embolectomy for ischemic stroke in a pediatric ventricular assist device patient.

The reported incidence of cerebral embolic or hemorrhagic complications related to mechanical circulatory support in children is high, even while subjects are managed with aggressive antithrombotic therapy. The safety and utility of endovascular treatment for stroke in the pediatric VAD population has not been established in the published literature. We describe a nine-yr-old patient on BiVAD support who experienced threatened AIS on two separate occasions. He was treated successfully via mechanical embolectomy on both occasions and survived to transplantation with minimal neurologic deficits.

The Impact of Preprocedural Platelet Function Testing on Periprocedural Complication Rates Associated With Pipeline Flow Diversion: An International Multicenter Study.

BACKGROUND AND OBJECTIVES: Dual antiplatelet therapy (DAPT) is necessary to minimize the risk of periprocedural thromboembolic complications associated with aneurysm embolization using pipeline embolization device (PED). We aimed to assess the impact of platelet function testing (PFT) on reducing periprocedural thromboembolic complications associated with PED flow diversion in patients receiving aspirin and clopidogrel. METHODS: Patients with unruptured intracranial aneurysms requiring PED flow diversion were identified from 13 centers for retrospective evaluation. Clinical variables including the results of PFT before treatment, periprocedural DAPT regimen, and intracranial complications occurring within 72 h of embolization were identified. Complication rates were compared between PFT and non-PFT groups. Differences between groups were tested for statistical significance using the Wilcoxon rank sum, Fisher exact, or χ 2 tests. A P -value <.05 was statistically significant. RESULTS: 580 patients underwent PED embolization with 262 patients dichotomized to the PFT group and 318 patients to the non-PFT group. 13.7% of PFT group patients were clopidogrel nonresponders requiring changes in their pre-embolization DAPT regimen. Five percentage of PFT group [2.8%, 8.5%] patients experienced thromboembolic complications vs 1.6% of patients in the non-PFT group [0.6%, 3.8%] ( P = .019). Two (15.4%) PFT group patients with thromboembolic complications experienced permanent neurological disability vs 4 (80%) non-PFT group patients. 3.7% of PFT group patients [1.5%, 8.2%] and 3.5% [1.8%, 6.3%] of non-PFT group patients experienced hemorrhagic intracranial complications ( P > .9). CONCLUSION: Preprocedural PFT before PED treatment of intracranial aneurysms in patients premedicated with an aspirin and clopidogrel DAPT regimen may not be necessary to significantly reduce the risk of procedure-related intracranial complications.

Case report of a giant cell tumor of the carotid sheath.

Giant cell tumor of the soft tissue (GCTST) is a neoplasm with low malignant potential and typically affects the trunk and extremities. Herein, we present a case of a palpable right neck mass diagnosed as a GCTST of the carotid sheath in a 38-year-old woman. A review of the imaging characteristics as well as of the differential diagnoses of primary neoplasms of the carotid space is presented.

Middle meningeal artery embolization in the management of chronic subdural hematoma in medically complex pediatric neurosurgical patients: technical note.

Middle meningeal artery (MMA) embolization has gained acceptance as a treatment for chronic subdural hematoma (cSDH) in adult patients but has not been well described in pediatric patients. Standard cSDH treatment has historically consisted of burr hole drainage with or without subdural drain placement. However, due to the high rate of recurrence and frequency of comorbidities within this population, as both pediatric and adult patients with cSDH frequently have concurrent cardiac disease and a need for anticoagulant therapies, MMA embolization has increasingly demonstrated its value as both an adjunctive and primary treatment. In this report, the authors present 3 cases of successful MMA embolization in medically complex children at a single institution. MMA embolization was used as a primary treatment modality and as an adjunctive therapy in the acute setting following surgical hematoma evacuation. Two patients were receiving anticoagulation treatment requiring reversal. Technical considerations specific to the pediatric population as well as those common to both the pediatric and adult populations are addressed. Further work is needed to define the optimal indications and outcomes for MMA embolization in children with cSDH.

Target Ultra and Nano coils in the endovascular treatment of small intracranial aneurysms (ULTRA Registry).

OBJECTIVE: The ULTRA Registry is a national multicenter prospective study designed to assess aneurysm occlusion rates and safety profiles of the Target Ultra and Nano coils in the treatment of small intracranial aneurysms (IAs). METHODS: Patients with small (≤ 5 mm) ruptured and unruptured IAs were treated exclusively with Target Ultra and Nano coils. The primary endpoints were the initial rate of complete or near-complete aneurysm occlusion, aneurysm recurrence, and need for retreatment. Secondary endpoints were device- and procedure-related adverse events, hemorrhage from the coiled aneurysm at any time during follow-up, and clinical outcomes. RESULTS: The ULTRA Registry included 100 patients with a mean ± SD age of 56 ± 11.6 years, of whom 75 were women and 48 presented after aneurysm rupture. The mean aneurysm size was (3.5 ± 0.9) × (2.8 ± 0.9) × (3.0 ± 1.0) mm, and the mean packing density was 34.4% ± 16.7%. Posttreatment complete or near-complete occlusion reported by an independent imaging core laboratory was seen in 92% of patients at baseline and in 87%, 87%, and 83% of patients at first, second, and final follow-up, respectively. At first, second, and final follow-up, 10%, 11%, and 15%, respectively, of patients were deemed to require retreatment. There were three procedural-related ischemic strokes and one intracranial hemorrhage from wire perforation of a parent artery not involved by the aneurysm. There were no coil-related adverse events, including no intraoperative aneurysm ruptures and no known aneurysm ruptures after coiling. CONCLUSIONS: This assessment of aneurysm occlusion rates and safety profiles in ULTRA Registry study participants demonstrates excellent safety and efficacy profiles for Target Ultra and Nano coils in the treatment of small IAs.

The impact of Verapamil for radial access in diagnostic cerebrovascular angiograms: A retrospective case-control study.

INTRODUCTION: Different combinations of medications are utilized during wrist access for radial artery (RA) or ulnar artery (UA) catheterization in neuroendovascular procedures to preclude vasospasm. These "cocktails" commonly include the calcium channel blocker Verapamil, without established benefit. We analyze outcomes in patients with and without Verapamil in their "cocktail" by using a case-control cohort of our single-center experience. METHODS: A prospective log of consecutive patients who underwent diagnostic cerebral angiograms using RA/UA access was retrospectively reviewed, and patients were grouped into Verapamil and non-Verapamil cohorts. The primary outcomes assessed were the presence of forearm skin rashes (hives) and RA/UA spasms. Our initial management included Verapamil (5 mg) in the cocktail, but Verapamil was removed after we noticed the development of hives in multiple patients immediately following its injection. RESULTS: A total of 221 patients underwent 241 RA/UA diagnostic cerebral angiograms and were included in our analysis. One hundred and forty-nine patients (61.8%) underwent catheterization with Verapamil and 92 (38.2%) were catheterized without it. Four of the 149 patients in the Verapamil group (2.7%) developed hives during the procedure and were treated with Benadryl (25 mg). Of the 92 patients who did not receive Verapamil, there were zero (0%) cases of hives and one (1.1%) case of vasospasm. CONCLUSION: Verapamil in the "cocktail" for wrist access diagnostic cerebral angiograms was associated with periprocedural hives, but not associated with a significant reduction in spasm compared to the non-Verapamil group. Our findings suggest that the administration of prophylactic Verapamil for these procedures may not be necessary.

Microvascular reperfusion during endovascular therapy: the balance of supply and demand.

BACKGROUND: Endovascular therapy (EVT) has revolutionized the treatment of acute stroke, but large vessel recanalization does not always result in tissue-level reperfusion. Cerebral blood flow (CBF) is not routinely monitored during EVT. We aimed to leverage diffuse correlation spectroscopy (DCS), a novel transcranial optical imaging technique, to assess the relationship between microvascular CBF and post-EVT outcomes. METHODS: Frontal lobe CBF was monitored by DCS in 40 patients undergoing EVT. Baseline CBF deficit was calculated as the percentage of CBF impairment on pre-EVT CT perfusion. Microvascular reperfusion was calculated as the percentage increase in DCS-derived CBF that occurred with recanalization. The adequacy of reperfusion was defined by persistent CBF deficit, calculated as: baseline CBF deficit - microvascular reperfusion. A good functional outcome was defined as 90-day modified Rankin Scale score ≤2. RESULTS: Thirty-six of 40 patients achieved successful recanalization, in whom microvascular reperfusion in itself was not associated with infarct volume or functional outcome. However, patients with good functional outcomes had a smaller persistent CBF deficit (median 1% (IQR -11%-16%)) than patients with poor outcomes (median 28% (IQR 2-50%)) (p=0.02). Smaller persistent CBF deficit was also associated with smaller infarct volume (p=0.004). Multivariate models confirmed that persistent CBF deficit was independently associated with infarct volume and functional outcome. CONCLUSIONS: CBF augmentation alone does not predict post-EVT outcomes, but when microvascular reperfusion closely matches the baseline CBF deficit, patients experience favorable clinical and radiographic outcomes. By recognizing inadequate reperfusion, bedside CBF monitoring may provide opportunities to personalize post-EVT care aimed at CBF optimization.

Intraoperative angiography in neurosurgery: temporal trend, access site, and operative indication considerations from a 6-year institutional experience.

BACKGROUND: Historically, the transfemoral approach (TFA) has been the most common access site for cerebral intraoperative angiography (IOA). However, in line with trends in cardiac interventional vascular access preferences, the transradial approach (TRA) and transulnar approach (TUA) have been gaining popularity owing to favorable safety and patient satisfaction outcomes. OBJECTIVE: To compare the efficacy and safety of TRA/TUA and TFA for cerebral and spinal IOA at an institutional level over a 6-year period. METHODS: Between July 2016 and December 2022, 317 angiograms were included in our analysis, comprising 60 TRA, 10 TUA, 243 TFA, and 4 transpopliteal approach cases. Fluoroscopy time, contrast dose, reference air kerma, and dose-area products per target vessel catheterized were primary endpoints. Multivariate regression analyses were conducted to evaluate predictors of elevated contrast dose and radiation exposure and to assess time trends in access site selection. RESULTS: Contrast dose and radiation exposure metrics per vessel catheterized were not significantly different between access site groups when controlling for patient position, operative region, 3D rotational angiography use, and different operators. Access site was not a significant independent predictor of elevated radiation exposure or contrast dose. There was a significant relationship between case number and operative indication over the study period (P<0.001), with a decrease in the proportion of cases for aneurysm treatment offset by increases in total cases for the management of arteriovenous malformation, AVF, and moyamoya disease. CONCLUSIONS: TRA and TUA are safe and effective access site options for neurointerventional procedures that are increasingly used for IOA.

Rescue intracranial stenting for failed posterior circulation thrombectomy: analysis from the Stenting and Angioplasty in NeuroThrombectomy (SAINT) study.

BACKGROUNDS: Recent trials have shown improved outcomes after mechanical thrombectomy (MT) for vertebrobasilar occlusion (VBO) stroke. However, there is a paucity of data regarding safety and outcomes of rescue intracranial stenting (RS) after failed MT (FRRS+) for posterior circulation stroke. We sought to compare RS to failed reperfusion without RS (FRRS-). METHODS: This is a retrospective analysis of the Stenting and Angioplasty in NeuroThrombectomy (SAINT) study, a multicenter collaboration involving prospectively collected databases. Patients were included if they had posterior circulation stroke and failed MT. The cohort was divided into two groups: FRRS+ and FRRS- (defined as modified Thrombolysis In Cerebral Infarction (mTICI) score 0-2a). The primary outcome was a shift in the degree of disability as measured by the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included mRS 0-2 and mRS 0-3 at 90 days. Safety measures included rates of symptomatic intracranial hemorrhage (sICH), procedural complications, and 90-day mortality. Sensitivity and subgroup analyses were performed to identify outcomes in a matched cohort and in those with VBO, respectively. RESULTS: A total of 152 failed thrombectomies were included in the analysis. FRRS+ (n=84) was associated with increased likelihood of lower disability (acOR 2.24, 95% CI 1.04 to 4.95, P=0.04), higher rates of mRS 0-2 (26.8% vs 12.5%, aOR 4.43, 95% CI 1.22 to 16.05, P=0.02) and mRS 0-3 (35.4% vs 18.8%, aOR 3.13, 95% CI 1.08 to 9.10, P=0.036), and lower mortality (42.7% vs 59.4%, aOR 0.40, 95% CI 0.17 to 0.97, P=0.04) at 90 days compared with FRRS- (n=68). The rates of sICH and procedural complications were comparable between the groups. Sensitivity and subgroup analyses showed similar results. CONCLUSION: In patients with posterior circulation stroke who had failed MT, RS resulted in better functional outcomes with comparable safety profile to procedure termination.

General anesthesia vs procedural sedation for failed NeuroThrombectomy undergoing rescue stenting: intention to treat analysis.

BACKGROUND: There is little data available to guide optimal anesthesia management during rescue intracranial angioplasty and stenting (ICAS) for failed mechanical thrombectomy (MT). We sought to compare the procedural safety and functional outcomes of patients undergoing rescue ICAS for failed MT under general anesthesia (GA) vs non-general anesthesia (non-GA). METHODS: We searched the data from the Stenting and Angioplasty In Neuro Thrombectomy (SAINT) study. In our review we included patients if they had anterior circulation large vessel occlusion strokes due to intracranial internal carotid artery (ICA) or middle cerebral artery (MCA-M1/M2) segments, failed MT, and underwent rescue ICAS. The cohort was divided into two groups: GA and non-GA. We used propensity score matching to balance the two groups. The primary outcome was the shift in the degree of disability as measured by the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included functional independence (90-day mRS0-2) and successful reperfusion defined as mTICI2B-3. Safety measures included symptomatic intracranial hemorrhage (sICH) and 90-day mortality. RESULTS: Among 253 patients who underwent rescue ICAS, 156 qualified for the matching analysis at a 1:1 ratio. Baseline demographic and clinical characteristics were balanced between both groups. Non-GA patients had comparable outcomes to GA patients both in terms of the overall degree of disability (mRS ordinal shift; adjusted common odds ratio 1.29, 95% CI [0.69 to 2.43], P=0.43) and rates of functional independence (33.3% vs 28.6%, adjusted odds ratio 1.32, 95% CI [0.51 to 3.41], P=0.56) at 90 days. Likewise, there were no significant differences in rates of successful reperfusion, sICH, procedural complications or 90-day mortality among both groups. CONCLUSIONS: Non-GA seems to be a safe and effective anesthesia strategy for patients undergoing rescue ICAS after failed MT. Larger prospective studies are warranted for more concrete evidence.

Sports-related concussion testing.

Due to the recent focus on concussion in sports, a number of tests have been developed to diagnose and manage concussion. While each test measures different brain functions, no single test has been shown to quickly and reliably assess concussion in all cases. In addition, most of the current concussion tests have not been validated by scientific investigation. This review identifies the pros and cons of the most commonly used noninvasive tests for concussion in order to provide a more complete picture of the resources that are available for concussion testing. The potential utility of research tools such as the head impact telemetry system, advanced magnetic resonance imaging protocols, and biomarkers are discussed in the context of the currently employed tools.

Novel endovascular treatment of enlarging facial artery pseudoaneurysm resulting from molar extraction: a case report.

PURPOSE: A novel endovascular therapy to treat a pseudoaneurysm as a complication of molar tooth extraction is described. PATIENTS AND METHODS: A 20-year-old man presented 2 weeks after third molar tooth extraction with an enlarging pulsatile jaw mass, identified as a facial artery pseudoaneurysm. Endovascular embolization with microcoils and a liquid embolic agent, Onyx, was performed. The use of Onyx in this manner is an off-label use. RESULTS: Immediately after treatment, the pulsatile mass resolved and remained obliterated at 2 months of follow-up. CONCLUSIONS: Onyx embolization of facial artery vascular lesions can be safely accomplished while avoiding microvascular complications and provides a satisfactory and durable result.

Computed tomography-guided transforaminal lumbar puncture using local anesthesia and a straight 22-gauge spinal needle for intrathecal nusinersen in adults: Findings in 77 procedures.

BACKGROUND: Intrathecal nusinersen is the first Food and Drug Administration-approved treatment for spinal muscular atrophy. Reliable intrathecal access is critical for initial and maintenance therapy; however, this can be challenging in older patients with spinal muscular atrophy many of whom have had prior lumbar instrumentation and osseous fusion. Transforaminal lumbar punctures have emerged as a technique for intrathecal access that avoids the hazards of cervical punctures. We describe our technique for transforaminal lumbar punctures under computed tomography guidance using local anesthesia and a straight 22-gauge needle. METHODS: Following local institutional review board approval, medical records of all patients undergoing computed tomography-guided transforaminal lumbar puncture for intrathecal nusinersen injection were obtained and analyzed. The rate of technical success and immediate complications were recorded. Any delayed complications noted in a 3-day follow-up phone call and future office visit were also recorded. Data collation and analysis were performed using Excel. RESULTS: A total of 77 transforaminal lumbar punctures were performed with intrathecal administration of nusinersen, for a 100% technical success rate. Local anesthesia was used in 76 cases, with conscious sedation used in one case. General anesthesia was not used in any case. There were no major complications. One patient had a postdural puncture headache that resolved completely after a transforaminal epidural blood patch performed 4 days later. CONCLUSIONS: Intrathecal administration of nusinersen is critical for treatment of patients with spinal muscular atrophy. Our described technique allows for reliable access to the intrathecal space using local anesthesia and a straight 22-gauge spinal needle under computed tomography guidance, and is easily reproducible.

Artery of Davidoff and Schechter: A Large Angiographic Case Series of Dural AV Fistulas.

The artery of Davidoff and Schechter (ADS) is the only meningeal branch of the posterior cerebral artery (PCA), supplying the medial tentorial margin and posterior portions of the falx. Given its small size, it is rarely identified on angiographic studies, unless enlarged in pathologies such as dural arteriovenous fistulas (DAVFs) or vascularized masses. This artery was first described by Wollschlaeger and Wollschlaeger in 1965, and to date, only a few reports have described its significance. The objective of this study is to report our experience with the ADS in dural fistulas from 2 tertiary medical centers and to emphasize the importance of recognizing this artery during angiographic examination of vascular tentorial and posterior fossa lesions. To our knowledge, this report demonstrates the largest angiographic case series published to date, recognizing a total of 7 patients with ADS arising secondary to a posterior fossa or tentorial DAVF and one of the largest reported series of DAVFs supplied by the ADS treated by endovascular and surgical techniques. Our cases validate the importance of prompt identification of the ADS for the diagnosis as well as endovascular treatment of vascular malformations in the posterior fossa and tentorial region.