Anesthesia modality in endovascular treatment for distal medium vessel occlusion stroke: intention-to-treat propensity score-matched analysis.

BACKGROUND: The optimal anesthesia modality during endovascular treatment (EVT) for distal medium vessel occlusion (DMVO) stroke is uncertain. We aimed to evaluate the association of the anesthesia modality with procedural and clinical outcomes following EVT for DMVO stroke. METHODS: This is a multicenter retrospective analysis of a prospectively collected database. Patients were included if they had DMVO involving the middle cerebral artery-M3/4, anterior cerebral artery-A2/3, or posterior cerebral artery-P1/P2-3, and underwent EVT. The cohort was divided into two groups, general anesthesia (GA) and non-general anesthesia (non-GA), and compared based on the intention-to-treat principle as primary analysis. We used propensity scores to balance the two groups. The primary outcome was the shift in the degree of disability as measured by the 90-day modified Rankin Scale (mRS). Secondary outcomes included successful reperfusion, as well as excellent (mRS 0-1) and good (mRS 0-2) clinical outcomes at 90 days. Safety measures included procedural complications, symptomatic intracerebral hemorrhage (sICH), and 90-day mortality. RESULTS: Among 366 DMVO thrombectomies, 61 matched pairs were eligible for analysis. Median age and National Institutes of Health Stroke Scale score as well as other baseline demographic and clinical characteristics were balanced between both groups. The GA group had no difference in the overall degree of disability (common OR 1.19, 95% CI 0.52 to 2.86, P=0.67) compared with the non-GA arm. Likewise, the GA group had comparable rates of successful reperfusion (OR 2.38, 95% CI 0.80 to 7.07, P=0.12), good/excellent clinical outcomes (OR 1.14, 95% CI 0.44 to 2.96, P=0.79/(OR 0.65, 95% CI 0.24 to 1.81, P=0.41), procedural complications (OR 1.00, 95% CI 0.19 to 5.16, P>0.99), sICH (OR 3.24, 95% CI 0.83 to 12.68, P=0.09), and 90-day mortality (OR 1.43, 95% CI 0.48 to 4.27, P=0.52) compared with the non-GA group. CONCLUSIONS: In patients with DMVO, our study showed that GA and non-GA groups had similar procedural and clinical outcomes, as well as safety measures. Further larger controlled studies are warranted.

Safety and effectiveness assessment of the surpass evolve (SEASE): a post-market international multicenter study.

BACKGROUND: Flow diverters are the first-line treatment for specific intracranial aneurysms (iA). Surpass Evolve (SE) is a new-generation 64-wire flow diverter with a high braid angle. Current literature on the SE is limited. We aimed to report the first international real-world experience evaluating the safety and effectiveness of the SE. METHODS: The Safety and Effectiveness Assessment of the Surpass Evolve (SEASE) was a multicenter retrospective international post-marketing cohort study including consecutive patients treated with SE for iAs between 2020 and 2022. Demographic, clinical, and angiographic data were collected. Primary effectiveness was independent core lab adjudicated complete occlusion rates (Raymond-Roy Class 1) at last follow-up. Primary safety were major ischemic/hemorrhagic events and mortality. RESULTS: In total, 305 patients with 332 aneurysms underwent SE implantation. The patients had a median age of 59 [50-67] years, and 256 (83.9%) were female. The baseline modified Rankin scale score was 0-2 in 291 patients (96.7%). Most aneurysms were unruptured (285, 93.4%) and saccular (309, 93.1%). Previous treatment was present in 76 (22.9%) patients. The median aneurysm size was 5.1 [3.4-9.0] mm, and the median neck width was 3.6 [2.7-5.1] mm. Most aneurysms were in the internal carotid artery C6 ophthalmic segment (126, 38.0%), followed by the communicating segment (58, 17.5%). At median 10.2 [6.4-12.9] months follow-up, 233 (73.0%) aneurysms achieved complete occlusion. After adjusting for confounders, complete occlusion remained consistent. Major stroke and procedure-related mortality were reported in 6 (2%) and 2 (0.7%) cases, respectively. CONCLUSION: These results demonstrate that SE has a consistently high effectiveness and favorable safety for the treatment of iAs.

Diffusion-weighted imaging lesions after intracranial aneurysm treatment with Pipeline Flex and Pipeline Flex with Shield technology: a retrospective cohort analysis.

BACKGROUND: The Pipeline Flex embolization device with Shield technology (PED Shield) is the first flow diverter for brain aneurysm treatment approved in the United States using surface-modified technology. The effect of PED Shield on decreasing perioperative diffusion-weighted imaging positive (DWI+) hits, as a marker for in-human decrease thrombogenicity, is unclear. OBJECTIVE: To determine if the number of periprocedural DWI+ lesions differs between patients with an aneurysm treated with PED Flex and PED Shield. METHODS: This retrospective study compares the outcomes of consecutive patients with an aneurysm treated with PED Flex and PED Shield. The primary outcome of interest was the occurrence of DWI+ lesions. We also assessed potential predictors of DWI+ lesions and compared the outcomes between on-label and off-label treatment indications. RESULTS: 89 patients were included, 48 (54%) treated with PED Flex and 41 (46%) with PED Shield. After matching, the incidence of DWI+ lesions was 61% and 62% for the PED Flex and PED Shield groups, respectively. Results were consistent across each model with no significant differences in DWI+ lesions between treatment groups, and effect sizes ranging from OR=1.08 (95% CI 0.41 to 2.89) after propensity score matching to OR=1.84 (95% CI 0.65 to 5.47) after multivariable regression. Multivariable models demonstrated reduced DWI+ lesions with balloon-assisted therapies and posterior circulation treatment, while a significant linear relationship was encountered with fluoroscopy time. CONCLUSION: There was no significant difference in the incidence of perioperative DWI+ lesions between patients with an aneurysm treated with PED Flex and PED Shield. Larger cohorts are likely needed to demonstrate differences between the devices.

Direct Versus Indirect Revascularization for Moyamoya: a Large Multicenter Study.

BACKGROUND: Moyamoya is a chronic occlusive cerebrovascular disease of unknown etiology causing neovascularization of the lenticulostriate collaterals at the base of the brain. Although revascularization surgery is the most effective treatment for moyamoya, there is still no consensus on the best surgical treatment modality as different studies provide different outcomes. OBJECTIVE: In this large case series, we compare the outcomes of direct (DR) and indirect revascularisation (IR) and compare our results to the literature in order to reflect on the best revascularization modality for moyamoya. METHODS: We conducted a multicenter retrospective study in accordance with the Strengthening the Reporting of Observational studies in Epidemiology guidelines of moyamoya affected hemispheres treated with DR and IR surgeries across 13 academic institutions predominantly in North America. All patients who underwent surgical revascularization of their moyamoya-affected hemispheres were included in the study. The primary outcome of the study was the rate of symptomatic strokes. RESULTS: The rates of symptomatic strokes across 515 disease-affected hemispheres were comparable between the two cohorts (11.6% in the DR cohort vs 9.6% in the IR cohort, OR 1.238 (95% CI 0.651 to 2.354), p=0.514). The rate of total perioperative strokes was slightly higher in the DR cohort (6.1% for DR vs 2.0% for IR, OR 3.129 (95% CI 0.991 to 9.875), p=0.052). The rate of total follow-up strokes was slightly higher in the IR cohort (8.1% vs 6.6%, OR 0.799 (95% CI 0.374 to 1.709) p=0.563). CONCLUSION: Since both modalities showed comparable rates of overall total strokes, both modalities of revascularization can be performed depending on the patient's risk assessment.

Tenzing 7 delivery catheter with or without a leading microwire for single pass aspiration thrombectomy: A multicenter experience.

INTRODUCTION: Aspiration mechanical thrombectomy traditionally includes use of an inner microcatheter and leading microwire to navigate an aspiration catheter (AC) to the site of occlusion. Early clinical experience suggests that a leading microwire is often not needed with the Tenzing 7 (T7, Route 92 Medical, San Mateo, CA), a soft tapered tip ledge-reducing delivery catheter. This multicenter experience aims to describe AC delivery success in single-pass thrombectomy using T7 with and without a leading microwire. METHODS: A retrospective review was conducted of consecutive patients who underwent single-pass thrombectomy with T7 at six institutions between 2020 and 2022. We examined the percentage of successful AC delivery, puncture-to-revascularization time, and procedural complication rate. RESULTS: A leading microwire with T7 was used in 19/89 (21%) of patients, and it was not used with T7 in 70/89 (79%) of patients. Successful AC delivery was similar with and without microwires (97% vs. 90%, p = 0.15). Median puncture-to-revascularization times were similar (17 min microwire vs. 16 min no-microwire, p = 0.12). No complications were associated with microwire use; one (1.4%) patient had a T7-related vasospasm resolved with verapamil during thrombectomy without a leading microwire. Differences in complication rates were not statistically significant (p = 0.46). CONCLUSION: In our real-world clinical experience, leading microwire use was infrequently necessary with the T7 delivery catheter. Successful AC delivery and complication rates were similar with and without microwire use in single-pass T7 thrombectomies. Initial pass with T7 may be performed without use of leading microwire, reserving microwire use for refractory cases or known difficult-to-navigate vasculature.

Anterior circulation location-specific results for stent-assisted coiling - carotid versus distal aneurysms: 1-year outcomes from the Neuroform Atlas Stent Pivotal Trial.

BACKGROUND: The Neuroform Atlas Stent System is an established treatment modality for unruptured anterior and posterior circulation intracranial aneurysms. Location-specific results are needed to guide treatment decision-making. However, it is unclear whether there are differences in safety and efficacy outcomes between carotid and more distal anterior circulation aneurysms. METHODS: The ATLAS IDE trial was a prospective, multicenter, single-arm, open-label interventional study that evaluated the safety and efficacy of the Neuroform Atlas Stent System. We compared differences in efficacy and safety outcomes of proximal internal carotid artery (ICA) versus distal and bifurcation anterior circulation aneurysms. RESULTS: Of 182 cases, there were 70 aneurysms in the ICA and 112 in the distal anterior circulation (including ICA terminus/bifurcation). There were no significant differences in the primary efficacy endpoint (85.5% vs 83.9%, p=0.78) and complete aneurysm occlusion rates (88.7% vs 87.9%, p=0.78) between proximal ICA aneurysms and distal aneurysms, respectively. Complications were more often encountered in distal and bifurcation aneurysms, but the overall rate of major safety events was low and comparable between the two groups (1.4% vs 6.3%, p=0.14). Recanalization and retreatment rates were also similar between the groups. CONCLUSION: The results of this study suggest that the Neuroform Atlas Stent System is a safe and efficacious treatment modality for unruptured anterior circulation intracranial aneurysms, regardless of aneurysm location. TRIAL REGISTRATION NUMBER: NCT02340585.

Standalone middle meningeal artery embolization versus middle meningeal artery embolization with concurrent surgical evacuation for chronic subdural hematomas: a multicenter propensity score matched analysis of clinical and radiographic outcomes.

BACKGROUND: Middle meningeal artery embolization (MMAE) has emerged as a promising therapy for chronic subdural hematomas (cSDHs). The efficacy of standalone MMAE compared with MMAE with concurrent surgery is largely unknown. METHODS: cSDH patients who underwent successful MMAE from 14 high volume centers with at least 30 days of follow-up were included. Clinical and radiographic variables were recorded and used to perform propensity score matching (PSM) of patients treated with standalone MMAE or MMAE with concurrent surgery. Multivariable logistic regression models were used for additional covariate adjustments. The primary outcome was recurrence requiring surgical rescue, and the secondary outcome was radiographic failure defined as <50% reduction of cSDH thickness. RESULTS: 722 MMAE procedures in 588 cSDH patients were identified. After PSM, 230 MMAE procedures remained (115 in each group). Median age was 73 years, 22.6% of patients were receiving anticoagulation medication, and 47.9% had no preoperative functional disability. Median midline shift was 4 mm and cSDH thickness was 16 mm, representing modestly sized cSDHs. Standalone MMAE and MMAE with surgery resulted in similar rates of surgical rescue (7.8% vs 13.0%, respectively, P=0.28; adjusted OR (aOR 0.73 (95% CI 0.20 to 2.40), P=0.60) and radiographic failure (15.5% vs 13.7%, respectively, P=0.84; aOR 1.08 (95% CI 0.37 to 2.19), P=0.88) with a median follow-up duration of 105 days. These results were similar across subgroup analyses and follow-up durations. CONCLUSIONS: Standalone MMAE led to similar and durable clinical and radiographic outcomes as MMAE combined with surgery in select patients with moderately sized cSDHs and mild clinical disease.

Safety and Efficacy of Flow Diverters for Treatment of Unruptured Anterior Communicating Artery Aneurysms: Retrospective Multicenter Study.

BACKGROUND: The anterior communicating artery (AComm) region is the most common site of intracranial aneurysms, with increased rupture risk compared with other locations. Overall, flow diverters present as a safe and efficacious treatment for intracranial aneurysms, but there is paucity of data for their use in the treatment of unruptured AComm aneurysms. We present the largest multicentric analysis evaluating the outcomes of flow diverters in AComm aneurysm treatment. METHODS: Databases from 10 centers were retrospectively reviewed for unruptured AComm aneurysms treated with flow diverters. Demographics, clinical presentation, radiographic characteristics, procedural complications, and outcomes were assessed. RESULTS: A total of 144 patients harboring 147 AComm aneurysms were treated between January 2012 and December 2021. Seventy-four were women (51.4%) and median age was 60 (IQR 50-67) years. All were unruptured AComm aneurysms. Half of the cohort had similar anterior cerebral artery sizes (51.4%). The most common morphology was saccular (94.6%), with a branch involvement in 32.7% of cases. Median vessel diameter was 2.4 mm, and the Pipeline Flex was the most prevalent device (32.7%). Median follow-up time was 17 months, with complete occlusion in 86.4% at the last follow-up. Functional independence (modified Rankin Scale score 0-2) was reported in 95.1%. Intraprocedural complications occurred in 5.6%, and postoperative complications were noted in 9.7% of cases. Combined major complication and mortality rate was 2.1%. CONCLUSIONS: Our study suggests that flow diverters are a useful treatment for AComm aneurysms. Mid-term results indicated favorable aneurysm occlusion with a good safety profile. Additional prospective studies with longer follow-up periods and independent adjudication are warranted to better assess these results.

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.

Early Termination versus Standard Regimen Duration of Dual Antiplatelet Therapy in Intracranial Aneurysm Patients Treated With Pipeline Embolization Device Flex With Shield Technology: Preliminary Experience of 3 U.S. Centers.

BACKGROUND: Pipeline Flex Embolization Device with Shield Technology (PED-Shield) is a third-generation flow diverter with reduced thromboembolic potential. However, safety profile and dual antiplatelet therapy (DAPT) recommendations with PED-Shield is not well -established. We aim to assess the safety and complication profile with early termination of DAPT with use of PED-Shield. METHODS: Databases of 3 high-volume cerebrovascular centers were retrospectively reviewed. We identified patients with unruptured and ruptured intracranial aneurysms treated with PED-Shield. Patient demographics, aneurysm characteristics, complications, and angiographic outcomes were extracted. All patients who had early termination of DAPT, defined as <180 days, as well as standard duration were included. RESULTS: A total of 37 patients, totaling 37 aneurysms, had early termination of DAPT and 24 patients with 24 aneurysms received standard duration (>180 days) of DAPT. There was no difference in pre-procedural DAPT regimens between the groups (P = 0.503). Following DAPT termination, o1ne major thromboembolic complication was observed in the early termination group while no major or minor thromboembolic or hemorrhagic complication was noted in the standard duration group. Time of angiographic follow-up was not statistically different (P = 0.063) between the early termination (343 days, interquartile range [IQR] 114-371 days) and the standard duration (175 days, IQR 111-224.5 days) groups. There were no statistically significant differences in complete aneurysm occlusion (P = 0.857), residual neck (P = 0.582), and aneurysm remnant (P = 0.352) rates between the groups on angiography. CONCLUSIONS: Early termination of DAPT proves safe after PED-Shield treatment of intracranial aneurysms with comparable complete occlusion rates.

Evaluation of pure subarachnoid hemorrhage after mechanical thrombectomy in a series of 781 consecutive patients.

INTRODUCTION: Subarachnoid hyperdensity is commonly seen on postoperative computed tomography scans within 24 h after mechanical thrombectomy. The impact on patients' outcomes remains uncertain. We present a real-world experience evaluating periprocedural factors associated with the development of subarachnoid hemorrhage (SAH) and its impact on outcomes of patients with acute stroke undergoing mechanical thrombectomy. METHODS: A single-center, retrospective analysis was performed between January 2016 and August 2021, including all consecutive patients who underwent thrombectomy. Our study aimed to evaluate periprocedural factors associated with subarachnoid hemorrhage within 24 h of the intervention, and the potential impact on patients' outcome. RESULTS: Of 781 patients, 44 patients (5.63%) demonstrated pure SAH within 24 h of the intervention. Patients from the SAH group were more likely to have tandem occlusion (15.9% vs. 5.2%, p = .003), aspiration using reperfusion pump system (81.4% vs. 66.8%, p = .047), intraoperative complications (9.1% vs. 0.9%; p < .001), longer puncture-to-recanalization times (45 min vs 29 min, p = .042) and a higher median number of passes to achieve recanalization (1 vs. 3, p = .002). There was no statistically significant difference in the long-term functional outcome between the groups. CONCLUSION: We suggest that dual-energy computed tomography could better distinguish between blood and pure contrast stagnation. Still, SAH was not associated with an unfavorable outcome in stroke patients undergoing thrombectomy.

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.

Surpass Intracranial Aneurysm Embolization System Pivotal Trial to Treat Large or Giant Wide-Neck Aneurysms - SCENT: 3-year outcomes.

BACKGROUND: To report the 3-year safety and effectiveness of the Surpass Streamline flow diverter in the SCENT trial (Surpass Intracranial Aneurysm Embolization System Pivotal Trial to Treat Large or Giant Wide-Neck Aneurysms). METHODS: The Surpass Streamline flow diverter device was evaluated in a multicenter, prospective, single-arm, non-randomized interventional trial including patients with uncoilable or previously treated but failed aneurysms of the intracranial internal carotid artery. 3-year outcomes were tabulated with descriptive statistics and compared with 1-year outcomes. RESULTS: Of 180 patients in the modified intent-to-treat (mITT) cohort, 36-month clinical and angiographic follow-up was available in 134 and 117 cases, respectively. Effectiveness endpoint of complete aneurysm occlusion without clinically significant stenosis or retreatment was met in 71.8% (79/110, 95% CI 62.4% to 80.0%) of cases. Safety composite endpoint was 12.2% (22/180) over the 3-year period, with two major safety events (ipsilateral ischemic strokes) occurring between 12-36 months. Complete aneurysm occlusion was noted in 77.8% (91/117), and 99.1% (116/117) of the patients demonstrated adequate aneurysm occlusion (complete occlusion or neck residual). There were four cases (2.2%) of aneurysm rupture, all occurring within the first month of the index procedure. Target aneurysm retreatment rate was 2.8% (5/180). CONCLUSION: The present findings support the long-term safety and effectiveness of the Surpass Streamline flow diverter device. TRIAL REGISTRATION: NCT01716117.

Super large-bore ingestion of clot (SLIC) leads to high first pass effect in thrombectomy for large vessel occlusion.

BACKGROUND: Super large-bore aspiration (SLBA) has shown high rates of complete clot ingestion. OBJECTIVE: To report the initial clinical feasibility, safety, and efficacy of this novel SLBA insert combination-super large-bore ingestion of clot (SLIC) technique for stroke. METHODS: We performed a retrospective review of three comprehensive stroke center databases. The SLIC technique entails a triaxial assembly of an 8 Fr 0.106″ Base Camp catheter, 0.088″ catheter extender (HiPoint), and an insert catheter (Tenzing 8) that completely consumes the inner diameter of the 0.088″ SLBA catheter. The HiPoint catheter is delivered over the Tenzing 8 to the face of the embolus, which is withdrawn, while aspirating through the Base Camp and HiPoint catheters as a single assembly. RESULTS: Thirty-three consecutive patients with large vessel occlusion were treated with SLIC. The median age was 70 years (30-91) and 17 were male (51.5%). The median presenting National Institutes of Health Stroke Scale score and Alberta Stroke Program Early CT score was 21 (1-34) and 8 (5-10), respectively. There was 100% success in delivering the 0.088″ catheter to the site of the occlusion. The successful revascularization rate (modified Thrombolysis in Cerebral Infarction (mTICI) score ≥2B) was 100% within a single pass in most cases (82%). Final mTICI ≥2C was achieved in 94.1% of occlusions, with 73.5% mTICI 3 recanalization. The rate of first pass effect in achieving excellent reperfusion (mTICI ≥2C) was 70.5%. There were no adverse events or postprocedural symptomatic hemorrhages. CONCLUSIONS: Our initial experience with the SLIC technique resulted in achieving a first pass effect (mTICI ≥2C) in 70.5%. Navigation of the SLBA catheter extender over the Tenzing insert was successful and safe in this early experience.

Prospective study on embolization of intracranial aneurysms with the pipeline device (PREMIER study): 3-year results with the application of a flow diverter specific occlusion classification.

BACKGROUND: The pipeline embolization device (PED; Medtronic) has presented as a safe and efficacious treatment for small- and medium-sized intracranial aneurysms. Independently adjudicated long-term results of the device in treating these lesions are still indeterminate. We present 3-year results, with additional application of a flow diverter specific occlusion scale. METHODS: PREMIER (prospective study on embolization of intracranial aneurysms with pipeline embolization device) is a prospective, single-arm trial. Inclusion criteria were patients with unruptured wide-necked intracranial aneurysms ≤12 mm. Primary effectiveness (complete aneurysm occlusion) and safety (major neurologic event) endpoints were independently monitored and adjudicated. RESULTS: As per the protocol, of 141 patients treated with a PED, 25 (17.7%) required angiographic follow-up after the first year due to incomplete aneurysm occlusion. According to the Core Radiology Laboratory review, three (12%) of these patients progressed to complete occlusion, with an overall rate of complete aneurysm occlusion at 3 years of 83.3% (115/138). Further angiographic evaluation using the modified Cekirge-Saatci classification demonstrated that complete occlusion, neck residual, or aneurysm size reduction occurred in 97.1%. The overall combined safety endpoint at 3 years was 2.8% (4/141), with only one non-debilitating major event occurring after the first year. There was one case of aneurysm recurrence but no cases of delayed rupture in this series. CONCLUSIONS: The PED device presents as a safe and effective modality in treating small- and medium-sized intracranial aneurysms. The application of a flow diverter specific occlusion classification attested the long-term durability with higher rate of successful aneurysm occlusion and no documented aneurysm rupture. TRIAL REGISTRATION: NCT02186561.

Triple therapy versus dual-antiplatelet therapy for dolichoectatic vertebrobasilar fusiform aneurysms treated with flow diverters.

BACKGROUND: Dolichoectatic vertebrobasilar fusiform aneurysms (DVBFAs) have poor natural history when left untreated and high morbimortality when treated with microsurgery. Flow diversion (FD) with dual-antiplatelet therapy (DAPT) is feasible but carries high risk of perforator occlusion and progression of brainstem compression. Elaborate antithrombotic strategies are needed to preserve perforator patency while vessel remodeling occurs. We compared triple therapy (TT (DAPT plus oral anticoagulation)) and DAPT alone in patients with DVBFAs treated with FD. METHODS: Retrospective comparison of DAPT and TT in patients with DVBFAs treated with FD at eight US centers. RESULTS: The groups (DAPT=13, TT=14) were similar in age, sex, clinical presentation, baseline disability, and aneurysm characteristics. Radial access use was significantly higher in the TT group (71.4% vs 15.3%; P=0.006). Median number of flow diverters and adjunctive coiling use were non-different between groups. Acute ischemic stroke rate during the oral anticoagulation period was lower in the TT group than the DAPT group (7.1% vs 30.8%; P=0.167). Modified Rankin Scale score decline was significantly lower in the TT group (7.1% vs 69.2%; P=0.001). Overall rates of hemorrhagic complications (TT, 28.6% vs DAPT, 7.7%; P=0.162) and complete occlusion (TT, 25% vs DAPT, 54.4%; P=0.213) were non-different between the groups. Rate of moderate-to-severe disability at last follow-up was significantly lower in the TT group (21.4% vs 76.9%; P=0.007). CONCLUSIONS: Patients with DVBFAs treated with FD in the TT group had fewer ischemic strokes, less symptom progression, and overall better outcomes at last follow-up than similar patients in the DAPT group.

Brain aneurysm rupture during mechanical thrombectomy for large vessel occlusion: Technical case series and complication avoidance strategies.

Endovascular therapy became the mainstream treatment for patients with acute stroke due to emergent large vessel occlusion (LVO). With increasing number of interventions, it is not uncommon for incidental vascular pathologies to be found during mechanical thrombectomy. Overall, intracranial aneurysms can occur in up to 4% of the population, but previous studies suggest a slightly higher prevalence of intracranial aneurysms in stroke patients as they may share common risk factors. We report on three patients with acute stroke secondary to LVO undergoing mechanical thrombectomy with brain aneurysms incidentally discovered and discuss the potential implications and technical considerations of performing revascularization in these scenarios. In the first case, a patient treated with stent-retriever and aspiration developed a carotid-cavernous fistula without clinical repercussion. The second case illustrates an internal carotid artery posterior communicating segment aneurysm rupture with a massive subarachnoid hemorrhage. The third case exemplifies an unruptured middle cerebral artery bifurcation aneurysm related to an M2 occlusion managed with a different strategy, avoiding aneurysm rupture. Intraprocedural aneurysm rupture is a potential complication during mechanical thrombectomy, especially when anatomical challenges are present. Interventionalists should be aware of the potential risk and constraints in this setting in order to mitigate adverse events.

Superficial Temporal Artery to the Middle Cerebral Artery Anastomotic Aneurysm Treated With an Endovascular Approach: A Case Report.

BACKGROUND AND IMPORTANCE: Anastomotic aneurysms are widely described in the cardiac literature; however, they have been less frequently reported in the neurological field. Historically, neurosurgeons have been treating anastomotic aneurysms arising from the superficial temporal artery to the middle cerebral artery (STA-MCA) bypass with open surgery. We proposed an endovascular treatment for our patient using the stent-assisted coiling technique, achieving good outcomes. CLINICAL PRESENTATION: A man in his late forties with symptomatic chronic carotid occlusion underwent direct STA-MCA bypass surgery. On follow-up images, an incidental anastomotic aneurysm was discovered. The risks and benefits of treatment or watchful waiting were addressed, and an endovascular approach was the chosen treatment technique. Such complication is widely described in the cardiac literature; however, it has scarce reports in the neurological field. Furthermore, stent-assisted coiling was performed achieving complete occlusion of the aneurysm maintaining good patency of the bypass. CONCLUSION: STA-MCA aneurysm at the site of anastomosis is a potential complication after a direct bypass. Traditional management has been reported using open surgery with clipping or wrapping of the aneurysm. However, we propose endovascular surgery as an alternative approach to such complication, achieving good clinical outcomes.