Complex intracranial aneurysms: a DELPHI study to define associated characteristics.

PURPOSE: Intracranial aneurysms present significant health risks, as their rupture leads to subarachnoid haemorrhage, which in turn has high morbidity and mortality rates. There are several elements affecting the complexity of an intracranial aneurysm. However, criteria for defining a complex intracranial aneurysm (CIA) in open surgery and endovascular treatment could differ, and actually there is no consensus on the definition of a "complex" aneurysm. This DELPHI study aims to assess consensus on variables defining a CIA. METHODS: An international panel of 50 members, representing various specialties, was recruited to define CIAs through a three-round Delphi process. The panelists participated in surveys with Likert scale responses and open-ended questions. Consensus criteria were established to determine CIA variables, and statistical analysis evaluated consensus and stability. RESULTS: In open surgery, CIAs were defined by fusiform or blister-like shape, dissecting aetiology, giant size (≥ 25 mm), broad neck encasing parent arteries, extensive neck surface, wall calcification, intraluminal thrombus, collateral branch from the sac, location (AICA, SCA, basilar), vasospasm context, and planned bypass (EC-IC or IC-IC). For endovascular treatment, CIAs included giant size, very wide neck (dome/neck ratio ≤ 1:1), and collateral branch from the sac. CONCLUSIONS: The definition of aneurysm complexity varies by treatment modality. Since elements related to complexity differ between open surgery and endovascular treatment, these consensus criteria of CIAs could even guide in selecting the best treatment approach.

Embolization techniques of spontaneous direct carotid-cavernous fistulae: a single-center experience.

PURPOSE: Spontaneous direct carotid-cavernous fistula (CCF) are usually caused by a ruptured carotid cavernous aneurysm. We studied treatment of spontaneous direct CCFs in a single-center cohort of a high-volume tertiary referral center, reporting anatomical details, technical approaches of treatment, and outcomes. METHODS: Adult patients with a spontaneous direct CCF treated between 2010-2022 with follow-up MRI and/or DSA imaging available were retrospectively analyzed. We studied age, sex, clinical presentation, angiographic findings, treatment techniques, outcomes, and complications. RESULTS: Out of 80 patients with CCFs, twelve patients were treated for a non-traumatic direct CCF (15%) in 13 sessions. Median age was 65 years. Two patients had an underlying connective tissue disorder. In 10 cases, the direct CCF was caused by a ruptured cavernous carotid aneurysm. The direct CCFs were treated by endovascular transarterial embolization (10 cases), transvenous embolization (1 case), or surgery (1 case). Selective closure of the shunt was possible in 10 patients. Two patients were treated with parent vessel occlusion (PVO; one endovascular; one surgical, with bypass). Complications occurred in 2 / 12 patients (17%), with permanent morbidity in two patients (17%): trigeminal neuralgia after PVO and new infarct after surgical PVO and bypass. Selective closure of CCF resulted in no morbidity. There was no mortality in our series. CONCLUSION: Spontaneous direct CCFs are caused by rupture of a cavernous carotid aneurysm in most cases. Selective closure of the shunt, usually feasible transarterially with coils, achieves good results. Reconstructive endovascular techniques are preferred to minimize treatment related neurological complications.

Clinical uncertainty in large vessel occlusion ischemic stroke: does automated perfusion imaging make a difference? An intra-rater and inter-rater agreement study.

BACKGROUND: Limited research exists regarding the impact of neuroimaging on endovascular thrombectomy (EVT) decisions for late-window cases of large vessel occlusion (LVO) stroke. OBJECTIVE: T0 assess whether perfusion CT imaging: (1) alters the proportion of recommendations for EVT, and (2) enhances the reliability of EVT decision-making compared with non-contrast CT and CT angiography. METHODS: We conducted a survey using 30 patients drawn from an institutional database of 3144 acute stroke cases. These were presented to 29 Canadian physicians with and without perfusion imaging. We used non-overlapping 95% confidence intervals and difference in agreement classification as criteria to suggest a difference between the Gwet AC1 statistics (κG). RESULTS: The percentage of EVT recommendations differed by 1.1% with or without perfusion imaging. Individual decisions changed in 21.4% of cases (11.3% against EVT and 10.1% in favor). Inter-rater agreement (κG) among the 29 raters was similar between non-perfusion and perfusion CT neuroimaging (κG=0.487; 95% CI 0.327 to 0.647 and κG=0.552; 95% CI 0.430 to 0.675). The 95% CIs overlapped with moderate agreement in both. Intra-rater agreement exhibited overlapping 95% CIs for all 28 raters. κG was either substantial or excellent (0.81-1) for 71.4% (20/28) of raters in both groups. CONCLUSIONS: Despite the minimal difference in overall EVT recommendations with either neuroimaging protocol one in five decisions changed with perfusion imaging. Regarding agreement we found that the use of automated CT perfusion images does not significantly impact the reliability of EVT decisions for patients with late-window LVO.

Carotid stenting for symptomatic carotid artery web: Multicenter experience.

OBJECTIVE: Carotid artery webs are an underappreciated cause of recurrent ischemic stroke, and may represent a significant portion of cryptogenic stroke. Evidence-based guidelines for the management of symptomatic carotid webs do not exist. The goal of this study is to audit our local experience for patients with symptomatic carotid artery webs undergoing carotid stenting as a treatment option, along with describing the hypothesized dynamic physiology of carotid webs. METHODS: All patients undergoing stenting for symptomatic carotid artery web at two comprehensive regional stroke centers with high endovascular thrombectomy volume from January 1, 2012 to March 1, 2021 were included. The modified Rankin Scale (mRS) score was used to define functional outcome at 3 months after stenting. RESULTS: Fourteen consecutive patients with symptomatic carotid artery webs underwent stenting. Twelve patients were female (86%), with a median age of 54 (IQR, 48-64) years across all patients. Stroke was the qualifying event in 12 (86%) patients and TIA in 2. Eleven patients (11/14, 79%) achieved a mRS score of 0-2 at 90 days, 2 (14%) were mRS 3-5, and one patient was lost to follow-up. The median follow-up was 12 months (IQR, 10-12). There was no recurrent stroke or TIA like symptoms in any patients. CONCLUSIONS: Carotid stenting appears to be safe at preventing recurrent stroke/TIA with a median follow-up of 12 months in this retrospective multicenter observational study.

Transarterial Embolization of Dural Arteriovenous Fistulas: Conventional, Pressure Cooker, and Microballoon Catheter Embolization Techniques.

BACKGROUND AND OBJECTIVES: Dural fistulas are abnormal connections between dural arteries and intracranial veins treated mainly endovascularly in most settings. The aim was to examine a single-institution experience of microballoon catheter transarterial embolization (TAE) of dural arteriovenous fistulas (dAVFs) and compare it with other TAE techniques. METHODS: We retrospectively identified all dAVFs treated at our institution between 2017 and 2022 with microballoon, conventional, and pressure cooker TAE. We studied occlusion and retreatment rates, treatment-related complications, and radiation doses. RESULTS: During the study period, 66 patients underwent 75 TAE procedures to treat 68 dAVFs: 47 conventional TAE, 14 pressure cooker TAE, and 14 microballoon TAE. Median age of the study population was 63 years with 32% females. The most common dAVF location was the transverse sinus and 20% of dAVFs presented with hemorrhage. At 3-month follow-up, stable complete occlusion of the dAVF was seen in 72% (n = 34) after conventional TAE, 79% (n = 11) after pressure cooker TAE, and 86% (n = 12) after microballoon TAE. Retreatment was required in 19% (n = 9) after conventional TAE, 7% (n = 1) after pressure cooker TAE, and 7% (n = 1) after microballoon TAE. Treatment-related complications occurred in 17% (n =) after conventional TAE, 29% (n = 4) after pressure cooker TAE, and 7% (n = 1) after microballoon TAE. CONCLUSION: In our experience, microballoon TAE of dAVFs resulted in better initial and 3-month angiographic outcomes and required less retreatment than conventional TAE. Microballoon TAE also resulted in fewer treatment-related complications than other techniques. In our experience, microballoon TAE is a reliable and safe endovascular technique to treat dAVFs.

Utilisation of the Scepter Mini dual-lumen balloon - An illustrative series.

BACKGROUND: Dual-lumen balloon microcatheters can aid in the safety and efficacy of endovascular embolisation of cerebrospinal vascular malformations. The Scepter Mini dual-lumen balloon is a novel device with a smaller profile than previous balloon microcatheters, opening up new indications not only in the treatment of cerebrospinal malformations but in various other neurovascular therapeutic and diagnostic scenarios. METHODS: Following institutional ethics review board approval, a retrospective review of our prospectively maintained database of cases employing the Scepter Mini dual-lumen microballoon catheter was conducted. Five cases in particular were highlighted, demonstrating utilisation of this device, which may be of interest to the Neurointerventionalist. Patient demographics, procedure details, complications and clinical outcome data were reviewed. RESULTS: Five cases employing the Scepter Mini dual-lumen microballoon catheter are presented; trans-arterial embolisation of cerebral AVM, pre-operative tumour embolisation, diagnostic angiography, trans-venous embolisation of cerebral AVM and trans-arterial embolisation of DAVF. No intraprocedural complications were recorded, one patient had a delayed haemorrhage. CONCLUSION: Potential utilisation of the Scepter Mini lies not only in the trans-arterial embolisation of cerebrospinal vascular malformations, but in a range of other diagnostic and therapeutic indications as demonstrated.

Use of the neuroform atlas for stenting of intracranial atherosclerotic disease: Clinical and angiographic outcomes.

BACKGROUND: Intracranial atherosclerotic disease (ICAD) is a potential cause of ischemic stroke. Treatment of ICAD can include intracranial stenting. There are specifically designed stents for this use-case; however, less is known about the off-label use of the Neuroform Atlas stent. In this study, we describe the outcomes of the Neuroform Atlas stent for treatment of ICAD. METHODS: Adult patients with symptomatic ICAD failing best medical treatment undergoing elective intracranial stenting using the Neuroform Atlas stent between November 2018 and March 2021 were included. Patient demographics, procedure-related details and clinical and imaging outcomes were analyzed. RESULTS: Eighteen patients met the inclusion criteria, with a mean follow-up duration of 9.6 ± 6.8 (standard deviation) months. There were two procedure-related mortalities (one massive intracranial hemorrhage and one groin site complication with sepsis). Fifteen patients were alive at the 6-month follow-up, all with satisfactory stent patency on follow-up imaging without any new ischemic events. Modified Rankin Scale at latest follow-up was 1.9 (interquartile range 5). CONCLUSION: In this single-center consecutive series, intracranial stenting with the Neuroform Atlas stent was a safe and effective treatment for symptomatic ICAD patients failing best medical management.

World federation of interventional and therapeutic neuroradiology (WFITN) federation assembly neurointerventional surgery safety checklist.

Over the last 10 years, there has been a rise in neurointerventional case complexity, device variety and physician distractions. Even among experienced physicians, this trend challenges our memory and concentration, making it more difficult to remember safety principles and their implications. Checklists are regarded by some as a redundant exercise that wastes time, or as an attack on physician autonomy. However, given the increasing case and disease complexity along with the number of distractions, it is even more important now to have a compelling reminder of safety principles that preserve habits that are susceptible to being overlooked because they seem mundane. Most hospitals have mandated a pre-procedure neurointerventional time-out checklist, but often it ends up being done in a cursory fashion for the primary purpose of 'checking off boxes'. There may be value in iterating the checklist to further emphasize safety and communication. The Federation Assembly of the World Federation of Interventional and Therapeutic Neuroradiology (WFITN) decided to construct a checklist for neurointerventional cases based on a review of the literature and insights from an expert panel.

Diversity among endovascular neurointerventionalists in Canada results of a national survey 2022.

AIM: Neurointervention (NIR) is a relatively new developing filed of medicine. Diversity and inclusion in various medical fields has made a significant progress. However, many surgical and interventional fields are still lagging in this respect. The aim of this study was to evaluate the degree of diversity and inclusion amongst neurointerventionalists in Canada. MATERIALS AND METHODS: A survey was completed in June 2022 by each neurointerventional division in Canada. The survey included questions regarding demographics, inclusivity, diversity, social and personal parameters. The collected data was analysed using semi-quantitative analysis. RESULTS: As of 2022, 85 physicians were actively practicing NIR in Canada. 52% were neuroradiologists, 38% neurosurgeons and 9% neurologists. 41% were immigrants to Canada (from 19 countries), for 35% English or French were not first language, 35% were visible minority. Women comprised only 21% of the practitioners, with comparable proportion of women in leadership positions. Most practitioners were in the 30-49 age group. 2.4% practitioners identified as LGBTQ. There was no gender difference in terms of life to work balance, with majority of practitioners being engaged in long term relationships and having children. CONCLUSIONS: Our study shows encouraging results in terms of diversity and inclusion amongst Canadian neurointerventionalists regarding the representation of various specialty backgrounds, immigrants, and visible minorities. NIR centers are distributed according to population density and better coverage is needed in smaller communities and remote/isolated areas. Both women and men Canadian neurointerventionalists seem to have a favourable life-work balance. Gaps still exist regarding inclusion of first nations and women which are under-represented among Canadian Neurointerventionalists. Women however are proportionally serving in leadership positions.

Gender disparities in industry compensation and research payments among neurointerventional surgeons in the USA.

BACKGROUND: The purpose of this study is to examine the presence of gender disparity represented by industry payments and research funding within the field of interventional neuroradiology. METHODS: Payment information was collected using the Centers for Medicare and Medicaid Services Open Payment database for the year 2019. Kruskal-Wallis tests were used to analyze differences in annual compensation based on sex in $US, while controlling for geographic factors, academic rank, and h-index. A sample t-test was performed to look at gender differences in h-indexes. RESULTS: The study cohort was comprised of 893 interventional neuroradiologists, 73 (8.2%) of which were female. Of the $48889.20 in mean annual payments reported in the database, $5847.13 (11.2%) went to female interventional neuroradiologists (P<0.05). The significant difference in compensation between male and female neuroradiologists was evident after controlling for state-level variance and academic position. There was a statistically significant difference in total reimbursement (P<0.001), research (P<0.001), consulting (P<0.04), food and beverage (P<0.02), and compensation for services other than consulting between males and females (P<0.02). A statistically significant difference was found for h-index based on gender (males=16.7, females=10.1; P<0.001). CONCLUSIONS: Our findings indicate that in the field of interventional neuroradiology, females receive less research funding and private industry compensation, have lower h-indexes, and are less likely to occupy the highest academic positions. The difference in funding did not differ when accounting for geographic state of practice and academic rank. Future studies should work to identify potential contributory factors of these trends.

Thoracolumbar spinal dural arteriovenous fistulae present with longer arteriovenous transit compared to cranial and cervical dural fistulae.

BACKGROUND: Thoraco-lumbar spinal dural arteriovenous fistulae represent a rare subset of central nervous system vascular malformations. One of the unique features of spinal dural arteriovenous fistulae is their extremely low propensity to cause hemorrhage (either parenchymal or subarachnoid), with a distinct clinical presentation of myelopathy secondary to spinal venous congestion. The exact mechanism for this unique presentation is still unclear. METHODS: Following institutional review board approval, we retrospectively analyzed our prospectively maintained database of spinal dural arteriovenous fistulae and cranial (cr) DAVF cases presenting between 2008 and 2021. For all cases, angiograms were reviewed and arteriovenous transit times were calculated. Patient demographics, angiographic features, and clinical and radiological outcomes were assessed. RESULTS: In total, 66 patients presenting with confirmed thoracolumbar spinal dural arteriovenous fistulaes were identified and compared to patients presenting with cervical spinal dural arteriovenous fistulaes (n = 10), ruptured crDAVFs (n = 32) and unruptured crDAVFs (n = 20). Mean age in the target group was 66 ± 13 versus 57-62 in the other groups, p < 0.05 on one-way analysis of variance; with 80% males versus 50%-65% in other groups. Mean arteriovenous transit time in the thoracolumbar group measured 1.98 s ± 0.96 versus 0.25-0.5 s range in other groups (p < 0.0001 on one-way analysis of variance). CONCLUSION: Prolonged arteriovenous transit times may represent a distinct feature of thoracolumbar spinal dural arteriovenous fistulaes. This may, amongst other factors, play a role in the observed lesser likelihood of hemorrhagic complications compared to other dural arteriovenous shunts.

Motion artifact correction for cone beam CT stroke imaging: a prospective series.

BACKGROUND: Imaging assessment for acute ischemic stroke (AIS) patients in the angiosuite using cone beam CT (CBCT) has created increased interest since endovascular treatment became the first line therapy for proximal vessel occlusions. One of the main challenges of CBCT imaging in AIS patients is degraded image quality due to motion artifacts. This study aims to evaluate the prevalence of motion artifacts in CBCT stroke imaging and the effectiveness of a novel motion artifact correction algorithm for image quality improvement. METHODS: Patients presenting with acute stroke symptoms and considered for endovascular treatment were included in the study. CBCT scans were performed using the angiosuite X-ray system. All CBCT scans were post-processed using a motion artifact correction algorithm. Motion artifacts were scored before and after processing using a 4-point scale. RESULTS: We prospectively included 310 CBCT scans from acute stroke patients. 51% (n=159/310) of scans had motion artifacts, with 24% being moderate to severe. The post-processing algorithm improved motion artifacts in 91% of scans with motion (n=144/159), restoring clinical diagnostic capability in 34%. Overall, 76% of the scans were sufficient for clinical decision-making before correction, which improved to 93% (n=289/310) after post-processing with our algorithm. CONCLUSIONS: Our results demonstrate that CBCT motion artifacts are significantly reduced using a novel post-processing algorithm, which improved brain CBCT image quality and diagnostic assessment for stroke. This is an important step on the road towards a direct-to-angio approach for endovascular thrombectomy (EVT) treatment.

The butterfly effect: improving brain cone-beam CT image artifacts for stroke assessment using a novel dual-axis trajectory.

BACKGROUND: Cone-beam computed tomography (CBCT) imaging of the brain can be performed in the angiography suite to support various neurovascular procedures. Relying on CBCT brain imaging solely, however, still lacks full diagnostic confidence due to the inferior image quality compared with CT and various imaging artifacts that persist even with modern CBCT. OBJECTIVE: To perform a detailed evaluation of image artifact improvement using a new CBCT protocol which implements a novel dual-axis 'butterfly' trajectory. METHODS: Our study included 94 scans from 47 patients who received CBCT imaging for assessment of either ischemia or hemorrhage during a neurovascular procedure. Both a traditional uni-axis 'circular' and novel dual-axis 'butterfly' protocol were performed on each patient (same-patient control). Each brain scan was divided into six regions and scored out of 3 based on six artifacts originating from various physics-based and patient-based sources. RESULTS: The dual-axis trajectory produces CBCT images with significantly fewer image artifacts than the traditional circular scan (whole brain average artifact score, AS: 0.20 vs 0.33), with the greatest improvement in bone beam hardening (AS: 0.13 vs 0.78) and cone-beam artifacts (AS: 0.04 vs 0.55). CONCLUSIONS: Recent developments in CBCT imaging protocols have significantly improved image artifacts, which has improved diagnostic confidence for stroke and supports a direct-to-angiography suite transfer approach for patients with acute ischemic stroke.

Development of a management protocol for internal carotid artery injury during endoscopic surgery: a modified Delphi method and single-center multidisciplinary working group.

BACKGROUND: Intra-operative internal carotid artery (ICA) injury during transnasal endoscopic surgery is a potentially catastrophic event. Such an injury is life-threatening in the immediate setting, with a reported peri-operative mortality rate of 10%. Nasal packing, muscle patches, direct vessel closure, and endovascular techniques have been described as useful strategies for managing ICA bleeds. The objective of this study was to develop a formalized management protocol for intra-operative ICA injury through engagement with a multi-disciplinary panel. METHODS: A modified Delphi method including literature review, iterative rounds of stakeholder feedback, and expert panel discussions was used to develop a management protocol for ICA injury during transnasal endoscopic surgery. The 10-person multi-disciplinary panel included otolaryngologists, neurosurgeons, interventional neuroradiologists, anesthesiologists, and operating room nursing staff. RESULTS: After three rounds of stakeholder engagement with the expert panel, consensus was reached on important elements to include within the protocol. The protocol was divided in three categories: Alert, Control, and Transfer. 'Alert' focusses on early communication with anesthesia and nursing staff. 'Control' focusses on techniques to expose the injury and obtain hemostasis or adequate tamponade. Lastly, 'Transfer' describes the process of contacting neuro-interventional radiology and safely transferring the patient. A one-page handout of the protocol was developed for placement in operating theatres. CONCLUSION: Due to the life-threatening nature of ICA injury, it is imperative that endoscopic sinus and skull base surgeons are prepared to manage this complication. Using a modified Delphi method with a multidisciplinary expert panel, a protocol for management of intra-operative ICA injury was developed.

Recognition of the variant type of spinal dural arteriovenous fistula: a rare but important consideration.

OBJECTIVE: Spinal dural arteriovenous fistulas (SDAVFs) typically represent abnormal shunts between a radiculomeningeal artery and radicular vein, with the point of fistulization classically directly underneath the pedicle of the vertebral body, at the dural sleeve of the nerve root. However, SDAVFs can also develop in atypical locations or have more than one arterial feeder, which is a variant of SDAVF. The aim of this study was to describe the incidence and multidisciplinary treatment of variant SDAVFs in a single-center case series. METHODS: Following institutional review board approval, the authors retrospectively analyzed their prospectively maintained database of patients with SDAVFs who presented between 2008 and 2020. For all patients, spinal digital subtraction angiograms were reviewed and variant SDAVFs were identified. Variant types of SDAVFs were defined as cases in which the fistulous point was not located underneath the pedicle. Patient demographics, angiographic features, clinical outcomes, and treatment modalities were assessed. RESULTS: Of 59 patients with SDAVFs treated at the authors' institution, 4 patients (6.8%) were identified as having a variant location of the shunt zone, pinpointed on the dura mater at the intervertebral level, further posteriorly within the spinal canal. In 3 cases (75%), a so-called bimetameric arterial supply was demonstrated. CONCLUSIONS: Recognition of the variant type of SDAVF is crucial for management, as correct localization of the fistulous point and bimetameric supply are critical for successful surgical disconnection, preventing delay in achieving definitive treatment.

Feasibility of robot-assisted neuroendovascular procedures.

OBJECTIVE: Geographic factors prevent equitable access to urgent advanced neuroendovascular treatments. Robotic technologies may enable remote endovascular procedures in the future. The authors performed a translational, benchtop-to-clinical study to evaluate the in vitro and clinical feasibility of the CorPath GRX Robotic System for robot-assisted endovascular neurointerventional procedures. METHODS: A series of bench studies was conducted using patient-specific 3D-printed models to test the system's compatibility with standard neurointerventional devices, including microcatheters, microwires, coils, intrasaccular devices, and stents. Optimal baseline setups for various procedures were determined. The models were further used to rehearse clinical cases. Subsequent to these investigations, a prospective series of 6 patients was treated using robotic assistance for complex, wide-necked intracranial saccular aneurysms between November 2019 and February 2020. The technical success, incidence of periprocedural complications, and need for conversion to manual procedures were evaluated. RESULTS: The ideal robotic setup for treatment of both anterior and posterior circulation aneurysms was determined to consist of an 80-cm guide catheter with a 115-cm-long intermediate catheter, a microcatheter between 150 and 170 cm in length, and a microwire with a minimum length of 300 cm. All coils, intrasaccular devices, and stents tested were compatible with the system and could be advanced or retracted safely and placed accurately. All 6 clinical procedures were technically successful, with all intracranial steps being performed robotically with no conversions to manual intervention or failures of the robotic system. There were no procedure-related complications or adverse clinical outcomes. CONCLUSIONS: This study demonstrates the feasibility of robot-assisted neurointerventional procedures. The authors' results represent an important step toward enabling remote neuroendovascular care and geographic equalization of advanced endovascular treatments through so-called telestroke intervention.

Women in neurointervention, a gender gap? Results of a prospective online survey.

BACKGROUND AND PURPOSE: Women's representation in medicine has increased over time yet the proportion of women practicing neurointervention remains low. We conducted an anonymous online survey through which we could explore the gender gap in neurointervention, identify potential issues, difficulties, or obstacles women might face, and evaluate if men encounter similar issues. METHODS: An online questionnaire was designed in SurveyMonkey®. Invitation to participate was emailed through national and international neurointerventional societies as well as directly through private mailing lists to men and women working in neurointervention. Responses were collected from 10 May 2019 to 10 September 2019. RESULTS: There were 295 complete responses, 173 (59%) male and 122 (41%) female. Most respondents (83%) fell within age categories 35-60 years, with representation from 40 countries across five continents. In all 95% were working full time, 73% had worked as a neurointerventionalist for >6 years, 77% worked in University-affiliated teaching institutions. Almost half of the respondents indicated no female neurointerventionalist worked in their center. Female respondents were younger and age-adjusted analysis was undertaken. Significantly fewer females than males were married and had children. Significantly fewer females held supervisory roles, held academic titles, and significantly less had a mentor. Females were less satisfied in their careers. More females felt they receive less recognition than colleagues of the opposite sex. Males had a greater proportion of work time dedicated to neurointervention. Similar proportions of both genders experienced bullying in work (40%-47%); however, sexual harassment was more common for females. There were no differences between genders in how they dealt with complications or their effects on mental well-being. CONCLUSION: There are many potential reasons why women are underrepresented in neurointervention, however, the literature suggests this is not unique to our specialty. Multiple long-term strategies will be necessary to address these issues, some of which are discussed in the article.

When Two Is Better than One : The Buddy-wire Technique in Flow-diversion Procedures.

BACKGROUND: Delivery of most flow diverters (FD) requires larger, and thus stiffer microcatheters (0.021-0.027in.) which can pose challenges to intracranial navigation. The concomitant use of two microwires within one microcatheter, also known as the buddy-wire technique, may be helpful for navigation and support in challenging situations. METHODS: We analyzed all flow diverter procedures in our prospectively collected database. We recorded all patient-related, anatomical and procedural information. We performed univariate statistics and technical descriptions. RESULTS: In total, 208 consecutive patients treated with a FD at our institution between July 2014 and August 2020 were retrospectively analyzed. In 17 patients the buddy-wire technique was used (mean age 63 years, range 31-87 years: 16 female). Aneurysms were located at the petrous, cavernous, supraophthalmic internal carotid artery, and a proximal M2 branch in 2, 7, 7 and 1 patient(s), respectively. In all cases a 0.027in. microcatheter was used for device deployment. In 14 patients with a wide-necked aneurysm the buddy-wire provided additional support to advance the microcatheter and mitigated the ledge between the aneurysm neck and the parent artery or a side branch. In two giant cavernous aneurysms treated with telescoping FDs, the buddy-wire was used to re-enter the proximal end of the foreshortened FD. CONCLUSION: The buddy-wire is a useful technique in FD procedures to prevent herniation of the microcatheter into the aneurysm sack, in wide-necked aneurysms to mitigate the ledge effect between the aneurysm neck and the parent artery where the microcatheter tip may get stuck, or to enable re-entry into a foreshortened FD.

Embolization strategies for intracranial dural arteriovenous fistulas with an isolated sinus: a single-center experience in 20 patients.

BACKGROUND: Intracranial dural arteriovenous fistulas (DAVFs) draining into an isolated sinus segment constitute a specific entity within the spectrum of cranial dural AV shunts, with under-reporting of their optimal treatment. OBJECTIVE: To describe the multimodal treatment approach to isolated sinus DAVFs in a large single-center cohort. METHODS: Retrospective analysis of adult patients with an isolated sinus DAVF treated at our institution between 2004 and 2020 was performed. Cases were analyzed for demographics, clinical presentation, angiographic findings, treatment techniques, angiographic and clinical outcomes, and complications. RESULTS: Of 317 patients with DAVFs, 20 (6.3%) with an isolated sinus DAVF underwent treatment. Transarterial embolization was performed through the middle meningeal artery in 9 of 12 procedures, with a success rate of 66.7%. Transarterial glue embolization proved successful in two of five procedures (40%) and Onyx in six of seven procedures (85.7%). Transvenous embolization (TVE) with navigation via the occlusion into the isolated sinus was successful in seven out of nine procedures (77.8%). All three open TVE and one pure open surgical procedure gained complete closure of the fistula. There were two major complications. Complete occlusion of the fistula was eventually obtained in all cases (100%). CONCLUSIONS: Isolated sinus DAVFs are always aggressive and require a multimodal approach to guarantee closure of the shunt. Transarterial treatment with Onyx achieves good results. Transvenous treatment appears equally successful, navigating into the occluded segment across the occlusion or via burr hole as backup.