Anatomic Variations of Foramen Ovale as a Predictor of Successful Cannulation in Percutaneous Trigeminal Rhizotomies.

BACKGROUND AND OBJECTIVES: Percutaneous trigeminal rhizotomies are common treatment modalities for medically refractory trigeminal neuralgia (TN). Failure of these procedures is frequently due to surgical inability to cannulate the foramen ovale (FO) and is thought to be due to variations in anatomy. The purpose of this study is to characterize the relationships between anatomic features surrounding FO and investigate the association between anatomic morphology and successful cannulation of FO in patients undergoing percutaneous trigeminal rhizotomy. METHODS: A retrospective analysis was conducted of all patients undergoing percutaneous trigeminal rhizotomy for TN at our academic center between January 1, 2010, and July 31, 2022. Preoperative 1-mm thin-cut computed tomography head imaging was accessed to perform measurements surrounding the FO, including inlet width, outlet width, interforaminal distance (a representation of the lateral extent of FO along the middle fossa), and sella-sphenoid angle (a representation of the coronal slope of FO). Mann-Whitney U tests assessed the difference in measurements for patients who succeeded and failed cannulation. RESULTS: Among 37 patients who met inclusion criteria, 34 (91.9%) successfully underwent cannulation. Successful cannulation was associated with larger inlet widths (median = 5.87 vs 3.67 mm, U = 6.0, P = .006), larger outlet widths (median = 7.13 vs 5.10 mm, U = 14.0, P = .040), and smaller sella-sphenoid angles (median = 52.00° vs 111.00°, U = 0.0, P < .001). Interforaminal distances were not associated with the ability to cannulate FO surgically. CONCLUSION: We have identified morphological characteristics associated with successful cannulation in percutaneous rhizotomies for TN. Preoperative imaging may optimize surgical technique and predict cannulation failure.

A novel swine model of selective middle meningeal artery catheterization and embolization.

BACKGROUND: Middle meningeal artery (MMA) embolization is a promising intervention as a stand-alone or adjunct treatment to surgery in patients with chronic subdural hematomas. There are currently no large animal models for selective access and embolization of the MMA for preclinical evaluation of this endovascular modality. Our objective was to introduce a novel in vivo model of selective MMA embolization in swine. METHODS: Diagnostic cerebral angiography with selective microcatheter catheterization into the MMA was performed under general anesthesia in five swine. Anatomical variants in arterial meningeal supply were examined. In two animals, subsequent embolization of the MMA with a liquid embolic agent (Onyx-18) was performed, followed by brain tissue harvest and histological analysis. RESULTS: The MMA was consistently localized as a branch of the internal maxillary artery just distal to the origin of the ascending pharyngeal artery. Additional meningeal supply was observed from the external ophthalmic artery, although not present consistently. MMA embolization with Onyx was technically successful and feasible. Histological analysis showed Onyx material within the MMA lumen. CONCLUSIONS: Microcatheter access into the MMA in swine with liquid embolic agent delivery represents a reproducible model of MMA embolization. Anatomical variations in the distribution of arterial supply to the meninges exist. This model has a potential application for comparing therapeutic effects of various embolic agents in a preclinical setting that closely resembles the MMA embolization procedure in humans.

Patients' perceptions on outcomes after mechanical thrombectomy in acute ischemic stroke.

BACKGROUND: The modified Rankin Scale (mRS) is a clinician-reported scale that measures the degree of disability in patients who suffered a stroke. Patients' perception of a meaningful recovery from severe stroke, expected value of a stroke intervention, and the effect of disparities are largely unknown. METHODS: We conducted a survey of patients, their family members, and accompanying visitors to understand their personal preferences and expectations for acute strokes potentially eligible for acute endovascular intervention using a hypothetical scenario of a severe stroke in a standardized questionnaire. RESULTS: Of 164 survey respondents, 65 (39.6%) were the patient involved, 93 (56.7%) were a family member, and six (3.7%) were accompanied visitors (friends, other). Minimally acceptable disability after a stroke intervention was considered as mRS 2 by 42 respondents (25.6%), as mRS 3 by 79 (48.2%), and as mRS 4 by 43 (26.2%) respondents. Race was associated with different views on this question (p < 0.001; Hispanic and Black patients being more likely to accept disability than Caucasian and Asian patients), while sex (p = 0.333) and age (p = 0.560) were not. Sixty-three respondents (38.4%) viewed minimally acceptable probability of improvement with an intervention as over 50%, 57 (34.8%) as 10-50%, and 44 (26.8%) as less than 10%. CONCLUSIONS: A wide range of acceptable outcomes were reported regardless of gender or age. However, race was associated with different acceptable outcome. This is an important finding to demonstrate because of the persistent racial and ethnic disparities in the utilization of endovascular therapy for acute stroke in the United States.

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.

Clival-Meckel's Cave Angle: A Predictor of Glycerol Displacement in Percutaneous Glycerol Rhizotomy for Trigeminal Neuralgia.

BACKGROUND AND OBJECTIVES: Percutaneous glycerol rhizotomy successfully treats trigeminal neuralgia although failure rates and durability of the procedure are variable. Some of this variability in clinical outcome might be due to egress of glycerol from Meckel's cave (MC) because of surgical positioning and individual patient anatomy. In this article, we quantitatively analyzed the anatomic variances that affect glycerol fluid dynamics to better predict patients more amenable for percutaneous glycerol injections. METHODS: Computed tomography imaging of 11 cadaveric heads was used to calculate bilateral Clival-Meckel's cave (CMC) and sella-temporal (ST) angles. Twenty-two cadaveric percutaneous injections of dyed glycerol into the Meckel's cave were performed using Härtel's approach, and the fluid movement was documented at prespecified intervals over 1 hour. The relationship between the angles and glycerol migration was studied. RESULTS: Specimens with basal cistern involvement by 60 minutes had significantly greater CMC angles (median [IQR]: basal cistern involvement = 74.5° [59.5°-89.5°] vs no basal cistern involvement = 58.0° [49.0°-67.0°]), U = 6.0, P < .001. This model may predict which patients will experience glycerol migration away from the Gasserian ganglion (area under the curve: 0.950, SE: 0.046, CI: 0.859-1.041, P < .001). Increased ST angle was associated with lateral flow of glycerol (r s = 0.639, P = .001), and CMC angle was associated with total area of dispersion (r s = -0.474, P = .026). CONCLUSION: Anatomic variation in skull base angles affects glycerol migration. Specifically, a more obtuse CMC angle was associated with a higher risk of posterior migration away from the Gasserian ganglion. This may be a reason for differing rates of surgical success. These results suggest that anterior head flexion for 60 minutes may prevent percutaneous glycerol rhizotomy failures and some patients with large CMC angles are more likely to benefit from postinjection head positioning. However, this clinical effect needs validation in vivo.

A meta-analysis and systematic review of endovascular thrombectomy versus medical management for acute basilar artery occlusion.

OBJECTIVE: Acute basilar artery occlusion (BAO) is a devastating neurologic event. As endovascular thrombectomy (EVT) became more prevalent for anterior circulation strokes, investigations were conducted in the posterior circulation. Its success in improving outcomes compared to standard medical therapy (SMT) after BAO has been debated. METHODS: We conducted a systematic review and meta-analysis of all randomized controlled trials (RCTs) and observational cohort studies evaluating EVT compared to SMT in acute BAO. We queried PubMed, Embase, and Cochrane for studies. Primary outcome was good functional outcome at 90 days (modified Rankin scale (mRS) ≤ 3). We analyzed studies for risk of bias (ROB) and calculated pooled risk ratios (RRs), odds ratios (ORs), and mean differences (MDs) with 95% confidence intervals (95%CI) using the random effects model for our primary outcome and secondary positive outcomes and harms. RESULTS: We identified four RCTs (991 patients randomized) and three cohort studies (1030 patients treated in-trial) that fit inclusion criteria. Three RCTs had low ROB, one had serious ROB. One cohort study had high ROB, one had moderate ROB, and one had low ROB. EVT was statistically significantly more associated with good functional outcome than SMT in RCTs (RR=1.54, 95%CI=1.16-2.04, p = 0.003) and trended towards significance in cohort studies (RR=2.64, 95%CI=0.87-8.00, p = 0.09). Mean mRS at 90 days was lower in EVT patients in RCTs (MD=-0.65, 95%CI=-1.07--0.22, p = 0.003) though not cohort studies (MD =-0.84, 95%CI=-2.48-0.79, p = 0.31). Symptomatic intracerebral hemorrhage (sICH) was statistically significantly associated with EVT in RCTs (OR=6.36, 95%CI=2.24-18.07, p < 0.001) and statistically non-significantly in cohort studies (OR=4.51, 95CI=1.00-20.33, p = 0.05). Mortality at 90 days was statistically lower with EVT than with SMT in both RCTs (OR=0.76, 95%CI=0.65-0.88, p < 0.001) cohort studies (OR=0.36, 95%CI=0.26-0.50, p < 0.001) CONCLUSION: EVT is associated with greater rates of good functional outcomes and lower rates of death and disability despite higher rates of periprocedural sICH.

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.

Preliminary experience with diffuse correlation spectroscopy in acute ischemic stroke neurointerventional procedures.

BACKGROUND: Diffuse correlation spectroscopy (DCS) is a non-invasive optical technique that enables continuous blood flow measurements in various organs, including the brain. DCS quantitatively measures blood flow from temporal fluctuations in the intensity of diffusely reflected light caused by the dynamic scattering of light from moving red blood cells within the tissue. METHODS: We performed bilateral cerebral blood flow (CBF) measurements using a custom DCS device in patients undergoing neuroendovascular interventions for acute ischemic stroke. Experimental, clinical, and imaging data were collected in a prospective manner. RESULTS: The device was successfully applied in nine subjects. There were no safety concerns or interference with the standard angiography suite or intensive care unit workflow. Six cases were selected for final analysis and interpretation. DCS measurements with photon count rates greater than 30 KHz had sufficient signal-to-noise to resolve blood flow pulsatility. We found an association between angiographic changes in cerebral reperfusion (partial or complete reperfusion established in stroke thrombectomy cases; temporary flow arrest during carotid artery stenting) and those observed intraprocedurally with CBF measurements via DCS. Limitations of the current technology included sensitivity to the interrogated tissue volume under the probe and the effect of local changes in tissue optical properties on the accuracy of CBF estimates. CONCLUSION: Our initial experience with DCS in neurointerventional procedures showed the feasibility of this non-invasive approach in providing continuous measurement of regional CBF brain tissue properties.

Surgical Experience and Management of Intracranial Neurenteric Cysts: Single-Center Experience and Review of the Literature.

Introduction Neurenteric cysts (NECs) are rare, congenital lesions lined by endodermal cell-derived columnar or cuboidal epithelium. Based on previous studies, gross total removal of the capsule has been presumed to be the ideal surgical goal. Objective This series was undertaken to further understand the risk of recurrence based on the extent of capsule resection. Methods Records were retrospectively reviewed for all patients with radiographic or pathological evidence of intracranial NEC from 1996 to 2021. Results A total of eight patients were identified; four of eight (50%) presented with headache, and four had signs of one or more cranial nerve syndromes. One patient (13%) presented with third nerve palsy, one (13%) had sixth nerve palsy, and two (25%) with hemifacial spasm. One patient (13%) presented with signs of obstructive hydrocephalus. Magnetic resonance imaging demonstrated T2 hyper- or isointense lesions. Diffusion-weighted imaging was negative in all patients (100%) and T1 contrast-enhanced imaging demonstrated minimal rim enhancement in two patients (25%). In three of eight (38%), a gross total resection (GTR) was achieved, while in four (50%), a near-total resection, and in one (13%), a decompression was performed. Recurrences occurred in two (25%) patients, one with decompression and another with near-total resection, among these 1/2 required repeat surgery after a mean follow-up of 77 months. Conclusion In this series, none from GTR group demonstrated recurrence, while 40% of those receiving less than GTR recurred, underpinning the importance of maximally safe resection in these patients. Overall patients did well without major morbidity from surgery.

Mechanical Thrombectomy Versus Best Medical Management for Acute Ischemic Stroke in Elderly Patients: A Cost-Effectiveness Analysis.

OBJECTIVE: To determine the cost-effectiveness of mechanical thrombectomy (MT) versus best medical management (BMM) in patients aged ≥80 years. METHODS: We performed a systematic literature review to identify comparative studies of MT versus BMM with or without intravenous tissue-type plasminogen activator (IV tPA) in patients ≥80 years. Clinical data including outcomes and mortality categorized as modified Rankin scale scores 0-2, 3-5, and 6, were collected from identified studies, and effectiveness scores were assigned to each outcome. Costs associated with stroke outcomes were derived from previous literature, including costs associated with initial and follow-up imaging, hospitalization, physicians/associated personnel, and MT. TreeAge Pro software was used to construct a cost-effectiveness analysis model of clinical data from studies and costs derived from the literature. RESULTS: The review identified 1 relevant comparative study. The cost model demonstrated total annual cumulative overall per-patient costs of $30,064.21 for BMM with IV tPA and $21,940.36 for BMM without IV tPA. Overall effectiveness scores were 0.61 and 0.62, respectively. MT had a cumulative total annual per-patient cost of $47,849.54 and an overall effectiveness score of 0.40. The cost-effectiveness ratios of total cumulative patient cost to overall outcome effectiveness score for the 3 treatments were as follows: BMM with IV tPA = $49,285.59, BMM without IV tPA = $35,387.58, and MT = $119,623.85. BMM with or without IV tPA was found to be more cost-effective than MT. CONCLUSIONS: This study utilized stroke outcomes data for patients aged ≥80 years to conduct a cost-effectiveness analysis. MT was found to be less cost-effective than BMM with and without IV tPA.

Pretreatment and Posttreatment Factors Associated with Shunt-Dependent Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis.

BACKGROUND: Hydrocephalus is a common complication after aneurysmal subarachnoid hemorrhage (aSAH). This study aimed to evaluate novel preoperative and postoperative risk factors for shunt-dependent hydrocephalus (SDHC) after aSAH via a systematic review and meta-analysis. METHODS: A systematic search was conducted using PubMed and Embase databases for studies pertaining to aSAH and SDHC. Articles were assessed by meta-analysis if the number of risk factors for SDHC was reported by >4 studies and could be extracted separately for patients who did or did not develop SDHC. RESULTS: Thirty-seven studies were included, comprising 12,667 patients with aSAH (SDHC 2214 vs. non-SDHC 10,453). In a primary analysis of 15 novel potential risk factors, 8 were identified to be significantly associated with increased prevalence of SDHC after aSAH, including high World Federation of Neurological Surgeons grades (odds ratio [OR], 2.43), hypertension (OR, 1.33), anterior cerebral artery (OR, 1.36), middle cerebral artery (OR, 0.65), and vertebrobasilar artery (2.21) involvement, decompressive craniectomy (OR, 3.27), delayed cerebral ischemia (OR, 1.65), and intracerebral hematoma (OR, 3.91). CONCLUSIONS: Several new factors associated with increased odds of developing SDHC after aSAH were found to be significant. By providing evidence-based risk factors for shunt dependency, we describe an identifiable list of preoperative and postoperative prognosticators that may influence how surgeons recognize, treat, and manage patients with aSAH at high risk for developing SDHC.

Vein of Galen Malformations in adults.

OBJECTIVE: Vein of Galen Malformations (VoGM) are rare vascular malformations, typically seen in pediatric age groups. Even more rarely, VoGM's may be seen later in adulthood. In this case report and systematic review, we provide a thorough description of the current literature as well as provide a case example exploring the diagnosis, imaging, treatment, and management of VoGM in adults. METHODS: In accordance with PRISMA guidelines, we performed a systematic literature search for all relevant cases and case series of VoGM in adult patients. The reference list of all articles were reviewed for additional relevant cases. Articles were included if they described a VoGM of a patient over the age of 18 years old and published in English. 149 articles were originally identified and 26 described cases met our inclusion criteria. RESULTS: In our literature review we found 26 patients that met our inclusion criteria. We found 14 male patients and 12 female patients. The mean age at presentation was 37.2 years (median=34 years, SD= 13.6 years). The most common presenting symptoms of patient were headache (n = 9), seizure (n = 6), and vomiting (n = 4). Of the 12 cases which clearly reported the subtype of VoGM, the choroidal type was more frequently seen (n = 10) compared to the mural type (n = 2). In 3 patients, the VoGM was thrombosed at time of diagnosis. Of the 26 patients, endovascular treatment was performed most frequently (n = 8) but some received microsurgical treatment (n = 4) or were treated conservatively (n = 6). Other treatment modalities included (ventriculoperitoneal shunt, ventriculostomy) (n = 5). In 3 cases treatment was not specified. In comparison to VoGM seen in pediatric or neonatal populations, VoGM in adults generally resulted in more favorable outcomes with only 2 patients reported to have passed away following treatment. CONCLUSION: VoGM remains a rare finding amongst the adult population. Hence, we described the clinical presentation, treatment modalities, and outcomes of the cases described in the English literature. Perhaps due to the rate of thrombosis and the unique angioarchitecture seen in adult VoGM patients, outcomes were generally more favorable than those described in the literature in pediatric or neonate VoGM patients.

The Role of Oxidative Stress in the Progression of Secondary Brain Injury Following Germinal Matrix Hemorrhage.

Germinal matrix hemorrhage (GMH) can be a fatal condition responsible for the death of 1.7% of all neonates in the USA. The majority of GMH survivors develop long-term sequalae with debilitating comorbidities. Higher grade GMH is associated with higher mortality rates and higher prevalence of comorbidities. The pathophysiology of GMH can be broken down into two main titles: faulty hemodynamic autoregulation and structural weakness at the level of tissues and cells. Prematurity is the most significant risk factor for GMH, and it predisposes to both major pathophysiological mechanisms of the condition. Secondary brain injury is an important determinant of survival and comorbidities following GMH. Mechanisms of brain injury secondary to GMH include apoptosis, necrosis, neuroinflammation, and oxidative stress. This review will have a special focus on the mechanisms of oxidative stress following GMH, including but not limited to inflammation, mitochondrial reactive oxygen species, glutamate toxicity, and hemoglobin metabolic products. In addition, this review will explore treatment options of GMH, especially targeted therapy.

Predictive Value of K i -67 Index in Evaluating Sporadic Vestibular Schwannoma Recurrence: Systematic Review and Meta-analysis.

Introduction K i -67 is often used as a proliferation index to evaluate how aggressive a tumor is and its likelihood of recurrence. Vestibular schwannomas (VS) are a unique benign pathology that lends itself well to evaluation with K i -67 as a potential marker for disease recurrence or progression following surgical resection. Methods All English language studies of VSs and K i -67 indices were screened. Studies were considered eligible for inclusion if they reported series of VSs undergoing primary resection without prior irradiation, with outcomes including both recurrence/progression and K i -67 for individual patients. For published studies reporting pooled K i -67 index data without detailed by-patient values, we contacted the authors to request data sharing for the current meta-analysis. Studies reporting a relationship between K i -67 index and clinical outcomes in VS for which detailed patients' outcomes or K i -67 indices could not be obtained were incorporated into the descriptive analysis, but excluded from the formal (i.e., quantitative) meta-analysis. Results A systematic review identified 104 candidate citations of which 12 met inclusion criteria. Six of these studies had accessible patient-specific data. Individual patient data were collected from these studies for calculation of discrete study effect sizes, pooling via random-effects modeling with restricted maximum likelihood, and meta-analysis. The standardized mean difference in K i -67 indices between those with and without recurrence was calculated as 0.79% (95% confidence interval [CI]: 0.28-1.30; p = 0.0026). Conclusion K i -67 index may be higher in VSs that demonstrate recurrence/progression following surgical resection. This may represent a promising means of evaluating tumor recurrence and potential need for early adjuvant therapy for VSs.

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.

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.