A propensity score-matched comparative study of balloon guide catheters versus conventional guide catheters for concurrent mechanical thrombectomy with carotid stenting in tandem strokes: comparison of first pass effect, symptomatic intracranial hemorrhage, and 90-day functional outcomes.

BACKGROUND: Extensive clot burden in tandem strokes accounts for poor mechanical thrombectomy (MT) outcomes. Several studies have shown the benefit of balloon guide catheters (BGCs) in MT and carotid artery stenting. OBJECTIVE: In view of this potential benefit, to investigate the safety and effectiveness of proximal flow arrest using a BGC during concurrent MT and carotid revascularization for tandem stroke treatment in a comparative, propensity score-matched (PSM) study. METHODS: Patients with a tandem stroke identified from our endovascular database were dichotomized into groups treated with BGCs versus conventional guide catheters. One-to-one PSM adjustment for baseline demographics and treatment selection bias using nearest-neighbor matching was performed. Patient demographics, presentation characteristics, and procedural details were recorded. Outcomes assessed were final modified Thrombolysis in Cerebral Infarction (mTICI) grade, periprocedural symptomatic intracranial hemorrhage (sICH) rate, in-hospital mortality, and 90-day modified Rankin Scale (mRS) score. Mann-Whitney U test and multivariate logistic regression were performed to compare procedural parameters and clinical outcomes. RESULTS: Concurrent carotid revascularization (stenting with/without angioplasty) and MT was performed in 125 cases (BGC: 85; no BGC: 40). After PSM (40 patients/group), the BGC group had a significantly shorter procedure duration (77.9 vs 61.5 min; OR=0.996; P=0.006), lower discharge National Institutes of Health Stroke Scale score (8.0 vs 11.0; OR=0.987; P=0.042), and higher odds of 90-day mRS 0-2 score (52.3% vs 27.5%; OR=0.34; P=0.040). On multivariate regression, the BGC group had a significantly higher first pass effect rate (mTICI 2b or 3)(OR=1.115, 95% CI 1.015 to 1.432; P=0.013) and lower periprocedural sICH rate (OR=0.615, 95% CI 0.406 to 0.932; P=0.025). No difference in in-hospital mortality was observed (OR=1.591, 95% CI 0.976 to 2.593; P=0.067). CONCLUSION: BGCs used for concurrent MT-carotid revascularization with flow arrest were safe and resulted in superior clinical and angiographic outcomes in patients with a tandem stroke.

Preradiosurgical Embolization of Arteriovenous Malformations Reduces Target Volume - The Main Determinant for Complete Obliteration.

BACKGROUND: Embolization and stereotactic radiosurgery (SRS) have increasingly been used to treat complex arteriovenous malformations (AVMs). We studied outcomes of AVM patients treated through a multidisciplinary approach, examined the effect of embolization on SRS success, and analyzed predictors of treatment failure. METHODS: We retrospectively reviewed a prospectively maintained database of patients with AVMs treated with Gamma Knife (Leksell) SRS over an 11-year period. Patients with incomplete medical records and follow-up <2 years were excluded. Demographics, clinical presentation, previous rupture history, angiographic nidus size, Spetzler-Martin (S-M) grade, adjunctive endovascular embolization and microsurgical resection, radiologic evidence of obliteration and hemorrhage, and clinical outcomes (modified Rankin Scale [mRS] scores) were recorded. Radiosurgery-related details including nidus volume and number of sessions and radiosurgery-, embolization-, and resection-associated complications were also recorded. RESULTS: Eighty-three patients (mean age, 41.0 ± 21.3 years) were included. Mean reduction in AVM nidus target volume with endovascular embolization was 66.0 ± 19.7%. S-M grade reduction was achieved in 51.6% cases. Total obliteration after SRS was achieved in 56 AVMs (67.5%) after 2 years, and in 38 (86.4%) after 4 years. Two (2.4%) patients had rehemorrhage after SRS. Overall complication rate was 3.6%. Median angiographic follow-up was 55.5 months. Favorable outcomes (mRS = 0-2) were seen in 77.1%. SRS target volume was an independent predictor of treatment failure regardless of pre-SRS embolization. CONCLUSIONS: High AVM obliteration rates were achieved with judicious use of radiosurgery alone or with embolization. Embolization reduced target nidus volume by an average of 66%. SRS target volume was an independent predictor of treatment failure.

Percutaneous transluminal angioplasty or stenting of petrous and cavernous internal carotid artery stenosis - a systematic review.

Percutaneous transluminal angioplasty (PTA) and stenting have been used for the treatment of internal carotid artery (ICA) stenosis over the past two decades. A systematic review was performed to understand the efficacy of PTA and/or stenting for petrous and cavernous ICA stenosis. In total, 151 patients (mean age 64.9) met criteria for analysis, 117 (77.5%%) were male and 34 (22.5%) were female. Of the 151 patients, 35 of them (23.2%) had PTA, and 116 (76.8%) had endovascular stenting. Twenty-two patients had periprocedural complications. There was no significant difference in the complication rates between the PTA (14.3%) and stent (14.7%) groups. Distal embolism was the most common periprocedural complication. Average clinical follow up for 146 patients was 27.3 months. Eleven patients (7.5%) out of 146 had retreatment. The treatment of petrous and cavernous ICA with PTA and stenting has relatively significant procedure related complication rates and adequate long-term patency.

Stenting for Venous Sinus Stenosis in Patients With Idiopathic Intracranial Hypertension: An Updated Systematic Review and Meta-Analysis of the Literature.

BACKGROUND AND OBJECTIVES: Although venous sinus stenting (VSS) improves cerebrospinal fluid reabsorption and decreases intracranial pressure in patients with idiopathic intracranial hypertension (IIH), the underlying pathophysiology of IIH is not well understood. We present a review and meta-analysis of the literature on VSS for IIH treatment, focusing on the rates of restenosis and symptom recurrence. METHODS: We performed a systematic review of PubMed and Embase databases between January 1, 2011, and December 31, 2021. Articles including ≥5 patients with IIH and venous sinus stenosis treated with VSS and post-treatment rates of restenosis (de novo stenosis at a different anatomic location along the dural sinuses or restenosis within or adjacent to the stent) were selected. Demographic, procedural, and outcomes data were collected and analyzed. Mean values for variables collected were pooled, and a mean value was calculated with a 95% CI. RESULTS: Twenty-four articles were included, comprising 694 patients and 781 VSS cases. The mean age was 33.9 (CI, 31.5-36.2) years. The mean body mass index was 35.3 (CI, 32.9-37.7) kg/m 2 . Before VSS, 98.8% (CI, 96.8%-100.0%) of patients experienced headaches, 87.7% (CI, 80.6%-95.5%) had visual acuity issues, 78.7% (CI, 69.9%-88.5%) had papilledema, 58.3% (CI, 46.0%-73.9%) had tinnitus, and 98.8% (96.4%-100.0%) had symptoms refractory to previous therapies. After VSS, 77.7% (CI, 71.1%-84.95%) experienced symptom improvement and 22.3% (CI, 15.1%-29.0%) had persistent or worsened symptoms. Pooled restenosis rate was 17.7% (CI, 14.9%-20.9%). CONCLUSION: VSS is effective in alleviating IIH signs and symptoms, but the associated high rates of restenosis and persistent symptoms highlight the need for further investigation of this procedure and other adjunctive treatments for IIH.

Non-dermatologic isolated intracranial necrobiotic xanthogranuloma.

Necrobiotic xanthogranuloma is a condition that was first identified in 1980 based on its characteristic histological identity, and it has been known since then as a dermatologic manifestation of an underlying systemic dysproteinemia. Intracranial manifestation is a rare presentation of this condition and has been reported only once in its more than 40 years of existence. Herein and to our knowledge, we report the second observation of an intracranial manifestation and, surprisingly, the first case without the expected dermatologic and systemic dysproteinemia associations. This case identifies an existing knowledge gap in our understanding of necrobiotic xanthogranuloma and emphasises the need for further research into understanding the presentation, comorbidities and management of this condition.

Use of Novel Automated Active Irrigation With Drainage Versus Passive Drainage Alone for Chronic Subdural Hematoma-A Propensity Score-Matched Comparative Study With Volumetric Analysis.

BACKGROUND: Passive drainage post-surgical evacuation of symptomatic chronic subdural hematoma (cSDH) is currently standard of care. High rates of infection, drain occlusion, and recurrence are associated complications. OBJECTIVE: To explore the use of a novel double-lumen active automated irrigation and aspiration system, IRRAflow (IRRAS), for patients with cSDH and compared procedural and clinical outcomes against passive drainage alone with propensity score matching (PSM) and volumetric analysis. METHODS: A prospectively maintained database was retrospectively searched for consecutive patients presenting with cSDH. One-to-one PSM of covariates (including baseline comorbidities and presentation hematoma volume) in active and passive irrigation groups was performed to adjust for treatment selection bias. Rates of hematoma clearance, catheter-related occlusion, and infection; number of revisions; and length of hospital stay were recorded. RESULTS: This study included 55 patients: active continuous irrigation-drainage-21 (21 post-PSM) and passive drainage-34 (21 post-PSM). For PSM groups, a significantly higher rate of hematoma clearance was obtained in the active irrigation-drainage group (0.5 ± 0.4 vs 0.4 ± 0.5 mL/day) and in the passive drainage group; odds ratio (OR) = 1.291 (CI: 1.062-1.570, P = .002) and a significantly lower rate of catheter-related infections (OR = 0.051; CI: 0.004-0.697, P = .039). A nonsignificantly lower hematoma expansion rate at discharge was noted in the active irrigation-drainage group (4.8% vs 23.8%; OR = 0.127; P = .186). No statistical difference in all-cause in-hospital mortality or discharge Glasgow Coma Scale score was observed between groups. CONCLUSION: Active and automated continuous irrigation plus drainage after cSDH surgical evacuation resulted in faster hematoma clearance and led to favorable clinical outcomes and low complication and revision rates compared with passive irrigation.

Salvage of Intraoperative Rupture of a Wide-Necked Middle Cerebral Artery Bifurcation Aneurysm: The Felt-Fenestrated Clipping Technique.

BACKGROUND: Intraoperative aneurysm rupture during microsurgical clipping can be managed with different salvage techniques. In an aneurysm with a very wide neck that is located at a bifurcation, repairing an iatrogenic tear can be challenging and carry the risk of branch occlusion and infarction. OBJECTIVE: To describe a variation of the cotton-clipping technique modified to better fit the bifurcation anatomy, which we call "felt-fenestrated clipping." METHODS: An illustrative case of intraoperative rupture of a wide-necked middle cerebral artery bifurcation aneurysm is presented. Radiological imaging, operative video, and technique illustration were obtained and prepared for this report. RESULTS: A middle-aged woman underwent microsurgical clipping of a wide-necked middle cerebral artery bifurcation aneurysm. A right-angle clip became dislodged from the clip applier and snapped across the aneurysm causing a small rupture at the base. This was later determined to be the result of improper placement of a standard clip onto a mini-clip applier. After a few salvage attempts, a small piece of Teflon felt was placed over the rupture site and held in place using a straight, fenestrated clip. Then, the right-angle clip was applied over the true neck of the aneurysm and the edge of the rupture site, covering the Teflon felt to obtain true hemostasis. CONCLUSION: We demonstrate a technically successful felt-fenestrated clipping technique for treatment of an intraoperative rupture not amenable to other salvage options. This technique is useful to achieve hemostasis while preserving branches in wide-necked bifurcation aneurysms.

Carotid Artery Stenting Using the Walrus Balloon Guide Catheter With Flow Reversal for Proximal Embolic Protection: Technical Description and Single-Center Case Series.

BACKGROUND: The use of modern transfemoral balloon guide catheters (BGC) for flow reversal during carotid artery stenting is scarcely described in the literature but represents a promising and efficient technique for embolic protection. OBJECTIVE: To describe a flow-reversal technique using the Walrus BGC (Q'Apel Medical Inc.) and report our center's experience. METHODS: We performed a retrospective analysis of data for consecutive patients aged 18 years or older who underwent elective carotid artery stenting with the use of flow reversal through the Walrus BGC between July 2020 and September 2021. Patient characteristics, procedural details, and clinical follow-up were evaluated. RESULTS: One hundred and five patients were included. Mean age was 69.8 ± 9.4 years, and 36 (34.3%) were women. The most common comorbidities were hyperlipidemia (76.2%) and hypertension (57.1%). Fifty-nine (56.2%) patients were symptomatic. Ninety-nine (94.3%) patients had stenosis ≥70%. Contralateral stenosis ≥50% was present in 44 patients (41.9%). Distal filters were used after flow reversal was established in 90 patients (85.7%). Angioplasty was performed in 85 patients (80.9%). Stenting was successful in 100% of cases. No periprocedural transient ischemic attacks (TIAs) or strokes occurred. Stroke occurred in 2 patients (1.9%) during the 30-day follow-up period, resulting in 1 (0.9%) death. CONCLUSION: In our experience, this technique was safe, feasible, and efficient, with 100% technical success and no periprocedural thromboembolic complications. More extensive studies are needed to establish the role of proximal protection with flow reversal using modern BGCs.

Stroke thrombectomy volume, rather than stroke center accreditation status of hospitals, is associated with mortality and discharge disposition.

BACKGROUND: Few studies have explored the association between stroke thrombectomy (ST) volume and hospital accreditation with clinical outcomes. OBJECTIVE: To assess the association of ST case volume and accreditation status with in-hospital mortality and home discharge disposition using the national Medicare Provider Analysis and Review (MEDPAR) database. METHODS: Rates of hospital mortality, home discharge disposition, and hospital stay were compared between accredited and non-accredited hospitals using 2017-2018 MEDPAR data. The association of annual ST case volume with mortality and home disposition was determined using Pearson's correlation. Median rate of mortality and number of ST cases at hospitals within the central quartiles were estimated. RESULTS: A total of 29 355 cases were performed over 2 years at 847 US centers. Of these, 354 were accredited. There were no significant differences between accredited and non-accredited centers for hospital mortality (14.8% vs 14.5%, p=0.34) and home discharge (12.1% vs 12.0%, p=0.78). A significant positive correlation was observed between thrombectomy volume and home discharge (r=0.88; 95% CI 0.58 to 0.97, p=0.001). A significant negative relationship was found between thrombectomy volume and mortality (r=-0.86; 95% CI -0.97 to -0.49, p=0.002). Within the central quartiles, the median number of ST cases at hospitals with mortality was 24/year, and the median number of ST cases at hospitals with home discharge rate was 23/year. CONCLUSION: A higher volume of ST cases was associated with lower mortality and higher home discharge rate. No significant differences in mortality and discharge disposition were found between accredited and non-accredited hospitals.

Management of saccular superior cerebellar artery aneurysms: The Buffalo experience case series and systematic review.

BACKGROUND: Results of the management of superior cerebellar artery (SCA) aneurysms are typically reported in combination with those for all posterior circulation aneurysms. We report our experience with the management of SCA aneurysms and a systematic review of the endovascular management of these rare aneurysms. METHODS: Patients with saccular SCA aneurysms that were not associated with arteriovenous malformations and who presented to our institute between 2000 and 2017 were identified. Patient demographics, aneurysm characteristics, interventions, and follow-up data were collected, compared, and analyzed. For the review, data including number of aneurysm treated, outcomes, follow-up, and occlusion rates were collected. RESULTS: Mean age of the 31 identified patients was 57.4 ± 12.3 years; 19.4% were men. Mean aneurysm size was 5.1 ± 2.9 mm. Seven of 21 patients with unruptured aneurysms were managed conservatively. Ten patients (32.3%) presented with ruptured aneurysms (mean aneurysm size, 6.2 ± 3.2 mm). Treatment was successfully completed in 22 patients: 13-primary coiling, 7-stent-assisted coiling, and 2-microsurgical clipping. Complete angiographic aneurysm occlusion after primary treatments was achieved in 19 (86.4%) patients. The total complication rate among treated patients was 4.2% (1 of 24 treated aneurysms). No minor complications occurred. However, in 2 patients, coil embolization was attempted but aborted due to coil protrusion into the parent artery. Clinical and angiographic follow-up data were available for 26 observed or treated patients. Mean follow-up duration was 5.3 ± 4.5 years. Six articles met our review inclusion criteria and demonstrated similar mean treated aneurysm sizes ranging from 4.6-7.7 mm, and follow-up from these articles ranged from 15.3-50 months. CONCLUSIONS: Endovascularly treated patients with ruptured and unruptured SCA aneurysms, of which most were <7 mm, had good clinical outcomes with minimal complications.

Rist Guide Catheter for Endovascular Procedures: Initial Case Series from a Single Center.

BACKGROUND: The transradial approach (TRA) for endovascular procedures has become a frequent practice in neurointervention. Advantages of the TRA include less access-site complications, early ambulation, and less postprocedural pain. The Rist 079 radial access guide catheter (Medtronic) is the first device designed specifically for neurointerventions performed through the TRA. In this study, we report our initial experience with the Rist catheter in a variety of neurointerventional procedures, aiming to evaluate the performance of this device and discuss its limitations. METHODS: A prospectively maintained database was retrospectively searched to identify patients who underwent procedures using the Rist catheter. Information on demographics, procedural details, and complications was recorded. RESULTS: Seventy-eight patients were included in the study, with a mean age of 60.3 years (range, 25-92 years); 45 (57.7%) were men. The interventional or diagnostic procedure was successfully completed in 77 patients (98.7%). The radial artery was the primary access-site choice in 71 patients (91%). The most frequent type of procedures performed were coiling or stent-assisted coiling (16.7%) and angioplasty and stenting (16.7%), followed by middle meningeal artery embolization (14.1%). Crossover to femoral artery access while maintaining use of the Rist was done in 5 cases (6.4%). Reasons for access or procedural failure included anatomical anomaly of the target vessel, unfavorable geometry of the great vessels, and proximal tortuosity of the supra-aortic vessels. CONCLUSION: We demonstrated a high success rate with use of the Rist catheter system for a variety of procedures.

Acute isolated posterior cerebral artery stroke treated with mechanical thrombectomy: A single-center experience and review of the literature.

BACKGROUND: Acute isolated posterior cerebral artery (PCA) occlusions account for 5-10% of all ischemic events. Due to peculiar patient presentation, the potential benefit of mechanical thrombectomy (MT) remains controversial. We evaluated the safety, feasibility, and effectiveness of MT in our patients and compared our results with the literature review conducted. METHODS: Charts were reviewed retrospectively for consecutive patients diagnosed with acute PCA stroke who underwent MT. Demographics, procedural, and follow-up details were noted. For the literature review, a systematic search of PubMed, MEDLINE, and EMBASE databases was conducted for the keywords "posterior cerebral artery" and "thrombectomy" for articles published between January 1, 2010 and June 30, 2021. Estimated rates for recanalization, favorable outcomes (modified Rankin Scale [mRS] score 0-2), symptomatic intracerebral hemorrhage (sICH), and mortality were extracted. RESULTS: Our cohort included 21 patients. Mean age was 71.2 years (standard deviation [SD] ± 10.2). Median National Institutes of Health Stroke Scale (NIHSS) presentation score was 9 (interquartile range [IQR] 5-15), with visual symptoms reported in 12(57.1%) patients. Overall, final modified thrombolysis in cerebral infarction (mTICI) 2b-3 was achieved in 17 patients (80.9%) with first-pass mTICI 2b-3 attained in 8 (38.1%). Postprocedure sICH occurred in 1 (4.8%) patient. Fifteen (71.4%) patients had a 0-2 mRS score at 90 days. Visual symptoms resolved in 10 of 12(83.3%) patients. Mortality occurred in 2 (9.5%) patients. For the systematic review, cohorts from 4 articles plus ours were included, totaling 222 patients. The estimated rate of successful recanalization was 85.25% (95% confidence interval[CI], 73.05%-97.45%), sICH was 3.60% (95% CI, 1.11%-6.09%), and mortality was 10.51% (95% CI, 5.88%-15.15%). CONCLUSION: The results of our series and systematic review indicate MT as a potentially safe and effective treatment modality for acute PCA stroke. These results also indicate that patient selection and assessment may be the key in obtaining favorable outcomes.

Venous sinus stenting for the treatment of acute blindness in a patient with idiopathic intracranial hypertension.

We present a case of acute onset of blindness treated with venous sinus stenting in the hyperacute period (24-48 h). The patient had not been diagnosed previously with idiopathic intracranial hypertension and presented at an outside facility with a short history of headache, nausea, vomiting and visual deficits. Initial management included lumbar punctures for pressure relief. Unfortunately, the patient's condition deteriorated and she experienced the rapid onset of blindness. Within 24-48 h of blindness onset, she was transferred to our institution for emergent endovascular stenting of the venous sinuses. The intervention resulted in improvement of symptoms and recovery of visual acuity over a short-term follow-up period.

Not a trifecta: complementary use of carotid artery revascularization techniques in the era of hybrid neurosurgery.

OBJECTIVE: Carotid stenosis is currently treated by carotid endarterectomy (CEA), carotid artery stenting (CAS), or transcarotid artery revascularization (TCAR). This study sought to add to the literature by providing real-world data comparing the safety and effectiveness associated with the performance of these carotid revascularization techniques by dual-trained neurosurgeons. METHODS: The authors performed a retrospective review of carotid stenosis databases at two US centers. Patients treated by CEA, transfemoral CAS, or TCAR for atherosclerotic carotid artery disease were included. Clinical outcomes were compared at 30 days after the procedure. RESULTS: Seven hundred eighty patients were included (583 with CAS, 165 with CEA, and 32 with TCAR). Overall, 486 patients (62.3%) were men, and 393 (50.4%) had left-sided carotid stenosis. Most patients (n = 617, 79.1%) had symptomatic disease. Among the three treatment groups, there were no statistically significant differences with respect to 30-day ischemic events (CAS 3.8%, CEA 1.8%, TCAR 6.3%; p = 0.267) or 30-day mortality rates (CAS 3.6%, CEA 2.4%, TCAR 3.1%; p = 0.857). Male sex had significantly lower odds of 30-day transient ischemic attack (TIA) or stroke in both univariable (p = 0.024) and multivariable (p = 0.023) regression models. Increasing age had significantly higher odds of 30-day mortality on univariable (p = 0.006) and multivariable (p = 0.003) regression. Patients with the occurrence of 30-day TIA or stroke also had significantly higher odds of 30-day mortality on univariable (p < 0.001) and multivariable (p < 0.001) regression. CONCLUSIONS: This real-world experience reflects the current practice of hybrid neurosurgery at two high-volume tertiary care centers and suggests that all three treatment modalities have comparable safety and effectiveness if patients are properly selected.

A Systematic Review of Non-Galenic Pial Arteriovenous Fistulas.

OBJECTIVE: Non-galenic pial arteriovenous fistulas (NGPAVFs) are rare cerebrovascular pathologies accounting for only 1.6%-4.8% of all brain vascular malformations. We performed a comprehensive review of NGPAVF cases reported in the literature to further characterize their clinical patterns of presentation, angiographic features, management, clinical outcomes, and complications. METHODS: We searched PubMed, Google Scholar, and Embase from each database's earliest records to April 2022 for all relevant English language articles. A total of 3280 articles were screened to identify those that met prespecified inclusion criteria. Differences in clinical outcomes between children (≤18 years old) and adults (>18 years old) and those articles in which NGPAVFs were associated with the presence of a varix or a hemorrhage were statistically examined. RESULTS: A total of 242 patients in 86 articles were included. The mean patient age was 18.51 ± 18.80 years. The male-to-female ratio was 1.44:1. Headache was the most common initial presentation (42.6%) in the study cohort. Hemorrhage occurred at a significantly higher frequency in adults (P = 0.004), whereas more children presented with congestive heart failure (P < 0.001). Surgical, endovascular, and combination therapy led to comparable rates of complete NGPAVF obliteration (86.8%, 85.2%, and 88.5%, respectively). Fifty-nine patients (24.4%) experienced a complication, ranging from minor neurological deficit to severe hemorrhage. The mortality rate for the overall cohort was 3.3%, and all deceased patients had a varix associated with their fistulas. CONCLUSIONS: To our knowledge, we report the largest literature review describing the clinical course and characteristics of NGPAVFs. All treatment approaches resulted in favorable obliteration rates and overall patient outcomes.

Volumetric resolution of chronic subdural hematomas treated with surgical evacuation versus middle meningeal artery embolization during immediate, early, and late follow up: propensity-score matched cohorts.

BACKGROUND: Literature on volumetric resolution and recurrence over time between surgical evacuation alone (SEA) and standalone middle meningeal artery embolization (MMAE) in comparable chronic subdural hematoma (cSDH) patients is limited. METHODS: A retrospective database analysis of cSDH patients managed with either SEA or MMAE was conducted. Propensity-score matching was performed for axial and coronal lengths, maximum diameter, and midline shift. Volumetric measurements at multiple time intervals and recurrence were compared between the groups. RESULTS: 48 matched hematoma pairs in patients with similar demographics, comorbidities, medications, and symptoms were obtained. Median volume was significantly lower at 24 hours in the SEA group (12.6 mL vs 52.7 mL, p<0.001) but not at remaining intervals. Median volume reduction was significantly greater in the SEA group at 24 hours (39.1 mL vs 8.8 mL in the MMAE group, p<0.001) and at 3-12 weeks (50.8 mL vs 23.7 mL, p<0.001), but not at remaining intervals. The SEA group had a significantly greater median hematoma resolution rate at 24 hours (39.1 mL/day vs 8.8 mL/day, p<0.001) and 3-12 weeks (1 mL/day vs 0.4 mL/day, p<0.001), but not at remaining intervals. Near-complete resolution at 3-12 weeks and 12-60 weeks was not significantly different between groups. Overall, the recurrence rate was significantly higher in the SEA group (22.9% vs 4.2%, p=0.01). CONCLUSIONS: In comparable cSDH patients, SEA resulted in better volumetric outcomes in immediate postoperative and early follow-up periods, as expected. However, this difference was not significant at more distant follow-up intervals. Furthermore, surgical patients experienced a significantly higher rate of recurrence.

Mechanical thrombectomy with a balloon-guide catheter: sheathless transradial versus transfemoral approach.

BACKGROUND: The transradial approach (TRA) for mechanical thrombectomy (MT) for acute ischemic stroke has been limited by the size of catheters usable in the radial artery, with the smaller access site precluding balloon-guide catheter (BGC) use. However, promising results have been reported for a TRA with a sheathless BGC (sTRA). We sought to perform a comparative study of MT with a BGC via the sTRA versus the transfemoral approach (TFA). METHODS: A retrospective review of our MT database was conducted. Baseline, procedure-related, and outcome data were compared for patients aged ≥18 years with anterior circulation large vessel occlusion, Alberta Stroke Program Early CT Score ≥6, and prestroke modified Rankin Scale score ≤2 treated with either approach. RESULTS: Ninety-three consecutive patients (34 sTRA and 59 TFA) were included. Both groups had similar demographics, comorbidities, stroke severity, intravenous alteplase use, and occlusion location. Mean time from puncture to final recanalization was faster in the sTRA group (29 vs 36 min, p=0.059) despite a higher access site crossover rate in the sTRA group (11.8% vs 0%, p=0.016). There were no differences between groups regarding last modified Thombolysis in Cerebral Infarction score; first-pass or modified first-pass effect; time from last known well to puncture; use of stent-retriever, aspiration, or combination first approach; number of passes; symptomatic intracranial hemorrhage; hospital stay; 90-day functional independence; and mortality. National Institutes of Health Scale score and modified first-pass effect were the only independent predictors of poor outcomes. CONCLUSIONS: Comparable patients treated with MT via the sTRA or TFA had similar angiographic and clinical outcomes.

Rescue of inadvertent superior sagittal sinus occlusion during middle meningeal artery embolization.

Middle meningeal artery embolization is increasingly becoming popular in the treatment of chronic subdural hematomas. The safety and efficacy of the procedure has previously been demonstrated in the literature; however, complications do arise from time to time. Here we present the case of an elderly gentleman who experienced inadvertent embolization of the superior sagittal sinus through an occult arteriovenous fistula between the middle meningeal artery and the superior sagittal sinus. Multiple rescue techniques including aspiration and stent retriever thrombectomy were performed with restoration of venous flow and an overall optimal result.

FRED flow diversion with LVIS protection of large posterior communicating artery aneurysm: the "FRELVIS" technique.

Treatment of wide-necked posterior communicating artery (PCoA) aneurysms is extremely challenging, especially in fetal posterior cerebral artery (PCA) configurations. This technical video demonstrates the nuances of an innovative use of flow diversion to treat a recurrent wide-necked PCoA aneurysm. This middle-aged patient presented with recurrence of a previously ruptured, coil-embolized PCoA aneurysm. Initial attempts at Comaneci-assisted coiling were unsuccessful because the coil herniated into the middle cerebral artery (MCA). Therefore, a low-profile visualized intraluminal support (LVIS) was placed in the fetal PCA across the aneurysm ostium and a flow diverter was placed in the internal carotid artery and MCA to constitute a Y-construct. The video can be found here: https://stream.cadmore.media/r10.3171/2022.7.FOCVID2262.

Use of drug-eluting, balloon-expandable resolute onyx coronary stent as a novel treatment strategy for vertebral artery ostial stenosis: Case series.

INTRODUCTION: Vertebral artery (VA) ostial stenosis is notoriously difficult to treat using bare-metal stents owing to high rates of restenosis and stent kinking and breakage. We investigated the safety and effectiveness of treatment with a drug-eluting, balloon-expandable coronary stent (Resolute Onyx, Medtronic). METHODS: Our prospectively maintained database was retrospectively searched for consecutive patients diagnosed with VA ostial stenosis who underwent Resolute Onyx stenting with/without angioplasty between January 1, 2015 and January 1, 2022. Patient demographics and clinical and radiographic presentations were recorded. Occlusion location, stenosis severity, contralateral disease, devices used, and intraprocedural and postprocedural complications were noted. Outcomes were assessed based on new or recurrent stroke, transient ischemic attack (TIA), or intracranial hemorrhage (ICH). Patients were followed up clinically and with radiographic imaging for in-stent stenosis. RESULTS: Twenty-six patients were included in our study (21 men [80.8%]; mean age 70.3 ± 9.8 years). Symptomatic patients presented with TIA (11/26, 42.3%) and stroke (10/26; 38.5%). Mean stenosis in the study cohort was 74.9 ± 13.0%. One (3.8%) intraprocedural complication was encountered whereby the stent failed to open despite several attempts and was exchanged with a new one without issues. No in-hospital postprocedure stroke, TIA, or mortality was reported. During a mean 16.2 ± 13.6 months' follow up, two patients developed symptomatic in-stent restenosis that was treated with balloon angioplasty. CONCLUSIONS: We report the first case series of Resolute Onyx drug-eluting stenting including 30-day postprocedure stroke/TIA rates and clinical/radiographic follow up and demonstrate safe and effective treatment of symptomatic and asymptomatic VA ostial stenosis.