Stent-assisted Woven EndoBridge embolization for the treatment of pulsatile tinnitus caused by an ipsilateral high-riding jugular bulb.

PURPOSE: Pulsatile tinnitus can be caused by a high-riding jugular bulb (HRJB), characterized by the superior position of the jugular bulb in the petrous temporal bone. The anatomical position and morphology of this entity make it challenging for endovascular treatment. We report our experience with two patients successfully treated with a stent-assisted Woven EndoBridge (WEB; Microvention, Tustin, CA, USA) device. MATERIALS AND METHODS: We describe two cases of HRJB in patients presenting with disabling pulsatile tinnitus. Temporary balloon occlusion of the jugular bulb prior to the intervention reduced tinnitus intensity. Both patients were subsequently treated under general anesthesia with the WEB device deployed in the HRJB which was held by a stent deployed in the sigmoid sinus. RESULTS: Both procedures were successful with good positioning of the WEB device and no procedural complications. Both patients had complete resolution of pulsatile tinnitus immediately after the procedure. Follow-up imaging showed successful occlusion of the venous cavity with a widely patent stent. CONCLUSION: Among patients with pulsatile tinnitus caused by an ipsilateral HRJB, a stent-assisted WEB device seems to be a viable endovascular option with angiographic and clinical success.

Embolization of a pseudoaneurysm of the innominate artery with a Woven EndoBridge (WEB) device.

The Woven EndoBridge (WEB) is an intra-aneurysmal flow disruptor designed for the treatment of broad-based arterial aneurysms with a high safety and effectiveness profile.1, 2 It does not require concomitant antiplatelet therapy compared to other devices such as flow diverters or intracranial stents. Innominate artery pseudoaneurysms are a rare consequence of blunt traumatic injury, infection, or atherosclerotic disease.3, 4 We describe the case of an innominate artery pseudoaneurysm successfully treated with a WEB SL device instead of stenting, therefore alleviating the need for dual antiplatelet therapy. The treatment was successful and uneventful and postprocedural computed tomography angiography confirmed the complete occlusion of the pseudoaneurysm.

Perfusion vs non-perfusion computed tomography imaging in the late window of emergent large vessel ischemic stroke: A systematic review and meta-analysis.

BACKGROUND: Guidelines recommend the treatment of emergent large vessel ischemic stroke (ELVIS) patients presenting beyond 6 hours of last known well time with endovascular thrombectomy (EVT) based on perfusion computed tomography (CT) neuroimaging. We compared the outcomes (long-term good clinical outcomes, symptomatic intracranial hemorrhage (sICH), and mortality) of ELVIS patients according to the type of CT neuroimaging they underwent. METHODS: We searched the following databases: Medline, Embase, CENTRAL, and Scopus from January 1, 2015, to June 14, 2023. We included studies of late-presenting ELVIS patients undergoing EVT that had with data for non-perfusion and perfusion CT neuroimaging. We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Data were pooled using a random effects model. RESULTS: We found 7 observational cohorts. Non-perfusion versus perfusion CT was not statistically significantly different for both long-term clinical (n = 3,224; RR: 0.96; 95% CI 0.86 to 1.06; I2 = 18%) and sICH (n = 3,724; RR: 1.08 95% CI 0.60 to 1.94; I2 = 76%). Perfusion CT had less mortality (n = 3874; RR: 1.22; 95% CI 1.07 to 1.40; I2 = 0%). The certainty of these findings is very low because of limitations in the risk of bias, indirectness, and imprecision domains of the Grading of Recommendations, Assessment, Development and Evaluations. CONCLUSION: The use of either non-perfusion or perfusion CT neuroimaging may have little to no effect on long-term clinical outcomes and sICH for late-presenting EVT patients. Perfusion CT neuroimaging may be associated with a reduced the risk of mortality. Evidence uncertainty warrants randomized trial data.

Endovascular treatment of wide-neck bifurcation aneurysms: the eCLIPs device.

The endovascular clip system device, eCLIPs (eVasc, Vancouver, British Columbia, Canada), was introduced almost a decade ago for the treatment of wide-neck bifurcation aneurysms,1-3 which represent a challenge for both endovascular and surgical approaches. Several techniques and devices (intrasaccular or intra-arterial) have been introduced and are currently available in order to improve the technical and clinical outcomes of aneurysm embolization. Flow diversion and flow disruption have shown controversial results in this subtype of aneurysm. In this video we present the use of the eCLIPs device to treat a ruptured, wide-neck aneurysm of the top of the basilar artery. The decisional approach, technical details, and the different steps of the endovascular treatment are described. The final part of the video is dedicated to the characteristics of the device for re-endothelialization4 and flow diversion (video 1).5 neurintsurg;16/3/229/V1F1V1Video 1 .

Stent retriever for Tandem Acute Revascularization Technique (START): a novel technique for the endovascular management of tandem occlusions.

Tandem occlusions, characterized by the simultaneous presence of an intracranial large vessel occlusion and extracranial carotid artery stenosis or occlusion,1 pose a unique endovascular challenge.2 3 Typically, the extracranial occlusion is a result of atherosclerotic plaque; however, dissections are also a possible cause. It is currently uncertain whether an intracranial first approach or an extracranial first approach should be employed.4 5 A new technique has been developed which allows for the simultaneous treatment of both the intracranial and the extracranial lesion.6 We describe a variation of this technique: the stent retriever for tandem acute revascularization technique (START), which consists of simultaneously treating the intracranial lesion with stent retriever and contact aspiration, and the extracranial lesion with balloon angioplasty. We present a technical video explaining all the steps of START.(video 1)neurintsurg;jnis-2023-021011v1/V1F1V1Video 1Description and example of the START.

Use of a Woven Endobridge device (WEB) for the treatment of an aneurysmal diverticulum of the transverse sinus causing pulsatile tinnitus.

Pulsatile tinnitus is a symptom with a potentially significant impact on the quality of life of patients.1 In some cases the pulsatile tinnitus is secondary to an arterial, arteriovenous, or a venous condition that can be treated endovascularly.2-5 One of the newly recognized entities that can cause pulsatile tinnitus is the presence of an ipsilateral aneurysmal diverticulum of the transverse sinus. The Woven EndoBridge (WEB) is an intra-aneurysmal flow disruptor for the treatment of broad-based arterial aneurysms with a high safety and effectiveness profile.3 The initial version of the WEB with a dual-layer structure evolved into a single-layer structure in two different versions (WEB SL, a barrel shape, and WEB SLS, a spherical shape).4 The WEB system does not require concomitant antiplatelet therapy, unlike other intraluminal devices such as flow diverters or intracranial stents. We describe a case of pulsatile tinnitus secondary to an aneurysmal diverticulum of the transverse sinus successfully treated with a WEB SL device instead of stent-assisted coiling, therefore alleviating the need for antiplatelets (video 1). The patient had an immediate clinical response with complete and persisting disappearance of her pulsatile tinnitus.neurintsurg;jnis-2023-020981v1/V1F1V1Video 1.

Distal to proximal snaring of a fractured microcatheter during dural AVF embolization.

Detachable-tip microcatheters are frequently used for endovascular embolization of arteriovenous shunts. Occasionally, the detachable tip can break during navigation resulting in the loss of the microcatheter tip in a vessel, which can lead to thrombo-embolic complications and also limit further navigation into the vessel to complete treatment. We present a case of dural AV-fistula embolization that was complicated by the accidental detachment and loss of the tip of a microcatheter during navigation to injection site. The proximal tip of the broken catheter was not visible and therefore we were unable to capture its proximal part with a Snare. Ultimately, we navigated a microcatheter distal to the broken segment and successfully snared the microcatheter fragment retrogradely. (Video 1).

Conventional MR Imaging in Trauma Management in Adults.

MR imaging has been shown to have higher sensitivity than computed tomography (CT) for traumatic intracranial soft tissue injuries as well as most cases of intracranial hemorrhage, thus making it a significant adjunct to CT in the management of traumatic brain injury, mostly in the subacute to chronic phase, but may also be of use in the acute phase, when there are persistent neurologic symptoms unexplained by prior imaging.

Empty Sella in Neuro-Ophthalmology Patients Without Raised Intracranial Pressure.

BACKGROUND: Empty sella often supports a diagnosis of raised intracranial pressure (ICP) but is also seen in normal individuals. This study's objective was to determine the prevalence of empty and partially empty sella in neuro-ophthalmology patients undergoing MRI for indications other than papilledema or raised ICP. METHODS: Consecutive patients without papilledema or suspected raised ICP who underwent brain MRI between August 2017 and May 2021 were included in this study. Sagittal T1 images were evaluated by 2 independent, blinded neuroradiologists who graded the sella using the published criteria (Categories 1-5, with 1 being normal and 5 showing no visible pituitary tissue). Clinical parameters were also collected. RESULTS: A total of 613 patients (309 men; average age 56.69 ± 18.06 years) were included in this study with optic neuropathy as the most common MRI indication. A total of 176 patients had moderate concavity of the pituitary gland (Category 3), 81 had severe concavity (Category 4), and 26 had no visible pituitary tissue (Category 5). Sella appearance was mentioned in 92 patients' radiology reports (15%). There was a statistically significant difference in age between composite Categories 1 and 2 (mean 52.89 ± 18.91; P < 0.001) and composite Categories 4 and 5 (mean 63.41 ± 15.44), but not the other clinical parameters. CONCLUSION: Empty sella is common in neuro-ophthalmology patients without raised ICP; 17.4% of patients have severe concavity or no pituitary tissue visible. An isolated finding of empty or partially empty sella on imaging is therefore of questionable clinical value in this patient population.

Surgical or Endovascular Management of Middle Cerebral Artery Aneurysms: A Randomized Comparison.

OBJECTIVE: There are few randomized data comparing clipping and coiling for middle cerebral artery (MCA) aneurysms. We analyzed results from patients with MCA aneurysms enrolled in the CURES (Collaborative UnRuptured Endovascular vs. Surgery) and ISAT-2 (International Subarachnoid Aneurysm Trial II) randomized trials. METHODS: Both trials are investigator-led parallel-group 1:1 randomized studies. CURES includes patients with 3-mm to 25-mm unruptured intracranial aneurysms (UIAs), and ISAT-2 includes patients with ruptured aneurysms (RA) for whom uncertainty remains after ISAT. The primary outcome measure of CURES is treatment failure: 1) failure to treat the aneurysm, 2) intracranial hemorrhage during follow-up, or 3) residual aneurysm at 1 year. The primary outcome of ISAT-2 is death or dependency (modified Rankin Scale score >2) at 1 year. One-year angiographic outcomes are systematically recorded. RESULTS: There were 100 unruptured and 71 ruptured MCA aneurysms. In CURES, 90 patients with UIA have been treated and 10 await treatment. Surgical and endovascular management of unruptured MCA aneurysms led to treatment failure in 3/42 (7%; 95% confidence interval [CI], 0.02-0.19) for clipping and 13/48 (27%; 95% CI, 0.17-0.41) for coiling (P = 0.025). All 71 patients with RA have been treated. In ISAT-2, patients with ruptured MCA aneurysms managed surgically had died or were dependent (modified Rankin Scale score >2) in 7/38 (18%; 95% CI, 0.09-0.33) cases, and 8/33 (24%; 95% CI, 0.13-0.41) for endovascular. One-year imaging results were available in 80 patients with UIA and 62 with RA. Complete aneurysm occlusion was found in 30/40 (75%; 95% CI, 0.60-0.86) patients with UIA allocated clipping, and 14/40 (35%; 95% CI, 0.22-0.50) patients with UIA allocated coiling. Complete aneurysm occlusion was found in 24/34 (71%; 95% CI, 0.54-0.83) patients with RA allocated clipping, and 15/28 (54%; 95% CI, 0.36-0.70) patients with RA allocated coiling. CONCLUSIONS: Randomized data from 2 trials show that better efficacy may be obtained with surgical management of patients with MCA aneurysms.

Comprehensive Aneurysm Management (CAM): An All-Inclusive Care Trial for Unruptured Intracranial Aneurysms.

BACKGROUND: In the absence of randomized evidence, the optimal management of patients with unruptured intracranial aneurysms (UIA) remains uncertain. METHODS: Comprehensive Aneurysm Management (CAM) is an all-inclusive care trial combined with a registry. Any patient with a UIA (no history of intracranial hemorrhage within the previous 30 days) can be recruited, and treatment allocation will follow an algorithm combining clinical judgment and randomization. Patients eligible for at least 2 management options will be randomly allocated 1:1 to conservative or curative treatment. Minimization will be used to balance risk factors, using aneurysm size (≥7 mm), location (anterior or posterior circulation), and age <60 years. RESULTS: The CAM primary outcome is survival without neurologic dependency (modified Rankin Scale [mRS] score <3) at 10 years. Secondary outcome measures include the incidence of subarachnoid hemorrhage during follow-up and related morbidity and mortality; morbidity and mortality related to endovascular treatment or surgical treatment of the UIA at 1 year; overall morbidity and mortality at 1, 5, and 10 years; when relevant, duration of hospitalization; and, when relevant, discharge to a location other than home. The primary hypothesis for patients randomly allocated to at least 2 options, 1 of which is conservative management, is that active UIA treatment will reduce the 10-year combined neurologic morbidity and mortality (mRS score >2) from 24% to 16%. At least 961 patients recruited from at least 20 centers over 4 years will be needed for the randomized portion of the study. CONCLUSIONS: Patients with unruptured intracranial aneurysms can be comprehensively managed within the context of an all-inclusive care trial.

Diagnostic Reliability of Leptomeningeal Disease Using Magnetic Resonance Imaging.

Brain metastases are seen in 20%-50% of patients with metastatic solid tumors. On the other hand, leptomeningeal disease (LMD) occurs more rarely. The gold standard for the diagnosis of LMD is serial cerebrospinal fluid (CSF) analyses, although in daily practice, the diagnosis of LMD is often made by neuroimaging. Leptomeningeal metastases (LM) have been a relative contra-indication to radiosurgery. It can be noted that focal LMD can be difficult to distinguish from a superficially located/cortical-based brain metastasis which is not a contra-indication for radiosurgery. Hence, justifying the need of a reliable diagnosis method. The goal of this study was to determine the inter-observer reliability of contrast-enhanced magnetic resonance imaging (gdMRI) in the differentiation of focal cortical-based metastases from leptomeningeal spread. This is a retrospective review of a prospectively collected database of patients with brain metastases. A total of 42 cases with superficial lesions were selected for review. Additionally, eight control cases demonstrating deep and/or white-matter based lesions were included in the study. Three neuroradiologists and three radiation oncologists were asked to review each study and score the presence of LM. Inter-observer agreement was calculated using group-derived agreement coefficients (Gwet's AC1 and Gwet's AC2). Pair-wise inter-observer agreement coefficients never reached substantial values for trichotomized outcomes (LMD, non-LMD or indeterminate) but did reach a substantial value in a minority of cases for dichotomised outcomes (LMD or non-LMD). The control subgroup analysis revealed substantial agreement between most pairs for both trichotomized and dichotomised outcomes. We observed low inter-observer agreement amongst specialists for the diagnosis of focal LMD by gdMRI. Neuroimaging should not be relied upon to make treatment decisions, notably to deny patients radiosurgery.

Cervical Internal Carotid Occlusion versus Pseudo-occlusion at CT Angiography in the Context of Acute Stroke: An Accuracy, Interobserver, and Intraobserver Agreement Study.

Purpose To evaluate the diagnostic accuracy and reliability of computed tomographic (CT) angiography to distinguish true cervical internal carotid artery (ICA) occlusion from pseudo-occlusion (defined as an isolated intracranial thrombus that impedes ascending blood flow) in the context of acute stroke. Materials and Methods This was a retrospective study of patients who underwent thrombectomy with preprocedural CT angiography that helps to demonstrate a lack of attenuation in the cervical ICA on the symptomatic side (24 men and 13 women; mean age, 63 years; age range, 30-86 years). Seven readers, including five neuroradiologists and two interventional neuroradiology fellows, independently reviewed the CT angiography images to assess whether there was true cervical ICA occlusion. Their results were compared with digital subtraction angiography (DSA) as the reference standard. Sensitivity and specificity for detecting true occlusion as well as accuracy and diagnostic odds ratio were calculated, with inter- and intraobserver κ statistics. Results Cervical ICA pseudo-occlusion occurred in 12 of 37 patients (32.4%) with nonattenuation of the cervical ICA on the symptomatic side. Interobserver agreement coefficients did not reach the substantial value of 0.61 for either pairs or groups of readers. The cohort's average sensitivity and specificity was 68% (95% confidence interval [CI]: 59%, 76%) and 75% (95% CI: 71%, 80%), respectively, with a diagnostic odds ratio of 8 (95% CI: 3, 18) and only fair interobserver agreement (κ = 0.32; 95% CI: 0.16, 0.47). Conclusion In the context of acute ischemic stroke with ipsilateral ICA nonattenuation at single-phase CT angiography, even specialized radiologists may not reliably distinguish true cervical occlusion from pseudo-occlusion. © RSNA, 2017 Online supplemental material is available for this article.