Capitated pricing model for stroke thrombectomies: a single center experience across three companies.

BACKGROUND: With a continued rise in healthcare expenditures, there is a demonstrable focus on curbing expenses. Mechanical thrombectomy (MT) is the standard of treatment for large vessel occlusions (LVOs); however, considerable costs are associated with devices utilized in each procedure. We report our institution's experience with capitation pricing models negotiated with three different companies. METHODS: We retrospectively reviewed a prospectively maintained database from February 2018 to August 2019 identifying cases performed under capitation models. We calculated the cost of equipment for each thrombectomy using the cost for individual devices utilized (virtual) and compared this sum to the total derived from cost-negotiated bundled equipment packages. This was compared with real-world cases that did not meet capitation criteria during this study period. RESULTS: 107 cases met the criteria for capitation; 39 cases used company A's models (28 with stentrievers), 44 cases used company B's models (3 with stentrievers), and 24 cases used company C's models (14 with stentrievers). Overall, there was a net savings of $202 370.50 utilizing the capitated model ($689 435 vs $891 805.50), amounting to $1891.31 savings per case. Mean capitation was lower ($6972±2774) compared with virtual ($8794±4614) and real-world non-capitation costs ($7176±3672). CONCLUSION: The negotiated capitated pricing model yielded total cost savings associated with equipment from each company. Overall mean capitation costs were lower than virtual and real-world cases. This may serve as a model for other centers in controlling costs for patients undergoing MT for LVO.

Relationship between reperfusion and intracranial hemorrhage after thrombectomy.

INTRODUCTION: Symptomatic intracerebral hemorrhage (sICH) is a devastating complication after endovascular thrombectomy. Prior reports have demonstrated that thrombolysis in cerebral infarction (TICI) ≥2 b reperfusion is protective against sICH. We aimed to further examine the relationship between reperfusion grade and sICH, to elucidate whether a difference between TICI 2b and 3 exists, and to determine whether this relationship holds true for patients undergoing delayed thrombectomy (6-24 hours). METHODS: We performed a single-center retrospective review of prospectively-recorded data for patients undergoing endovascular thrombectomy for large vessel occlusion between January 2015 and February 2018. Multivariable logistic regression analyses were performed to identify predictors of parenchymal hematoma (PH) and sICH (NINDS-National Institute of Neurological Disorders and Stroke, SITS-MOST-Safe Implementation of Thrombolysis in Stroke Monitoring Study, ECASS III-European-Australian Cooperative Acute Stroke Study III criteria) and to identify the role of reperfusion grade. This analysis was repeated for delayed thrombectomy patients. RESULTS: 528 patients were included; mean age was 71.5% and 43% were male. Median NIHSS (National Institutes of Health Stroke Scale) and time last seen well (TLSW) to treatment were 17 and 4.8 hours, respectively. Successful recanalization was achieved in 94%. On multivariable analyses, ASPECTS (Alberta Stroke Programme Early CT Score) was a predictor of PH (OR 0.7, 95% CI 0.57 to 0.87; p=0.002) for patients achieving any reperfusion grade. For patients achieving successful reperfusion, lower ASPECTS was a predictor of PH (OR 0.73, 95% CI 0.58 to 0.91; p=0.005) and of sICH (ECASS III) (OR 0.67, 95% CI 0.45 to 0.98; p=0.04); in addition, TICI 2b as compared with TICI 3 was a predictor of PH (OR 2.1, 95% CI 1 to 4.4; p=0.04) and of sICH (NINDS) (OR 7.5, 95% CI 1 to 57; p=0.045). TLSW to treatment was not an independent predictor of PH or sICH. CONCLUSION: Higher baseline ASPECTS and higher degree of reperfusion following endovascular thrombectomy is associated with reduced likelihood of PH and sICH.

Hemodynamic differences between Pipeline and coil-adjunctive intracranial stents.

INTRODUCTION: Modern coil-adjunctive intracranial stent designs have increased metal surface coverage to construct putative 'flow diverter lights.' This is rooted in the assumption that flow diversion is linearly correlated with metal surface coverage rather than being a threshold to be reached by device porosity and design. OBJECTIVE: To evaluate this assumption, by performing computational flow analysis on three aneurysm models treated with low metal surface coverage stents (ATLAS and Enterprise), a Pipeline flow diverter, and the LVIS Blue stent. METHODS: Computational flow analysis was performed on virtual deployment models entailing deployment of an ATLAS, Enterprise, LVIS Blue, or Pipeline. The impact of device deployment on velocity vectors at the neck, maximum wall shear stress, inflow rate into the aneurysm, and turnover time was determined. RESULTS: Velocity vector plots demonstrated low magnitude, localized inflow jets for Pipeline only; asymmetric, selectively high inflow jets were seen for LVIS Blue, and broader velocity vector clusters were seen for Atlas and Enterprise. Reduction in wall shear stress as compared with baseline was significant for all devices and greatest for the Pipeline. Mean peak wall shear stress was significantly lower for LVIS Blue in comparison with ATLAS or Enterprise but significantly lower for Pipeline than for LVIS Blue. Reduction of inflow rate into the aneurysm was significant for LVIS Blue and Pipeline but significantly lower for Pipeline than for LVIS Blue. Turnover time was statistically similar for ATLAS, Enterprise, and LVIS Blue, but significantly increased for Pipeline. CONCLUSION: Considerable differences in peak wall shear stress, inflow rates, and turnover time between flow diverters, moderate- and low-porosity stents reinforce the assumption that effective flow diversion represents a threshold in device design, encompassing metal surface coverage only in part.

Balloon-mounted stents for acute intracranial large vessel occlusion secondary to presumed atherosclerotic disease: evolution in an era of supple intermediate catheters.

INTRODUCTION: Treatment of acute large vessel occlusion (LVO) stroke secondary to intracranial atherosclerotic disease (ICAD) is more nuanced with disparate and infrequently reported outcomes. The deployment of balloon-mounted stents presents an expedient approach with renewed feasibility in the modern era of supple intermediate catheters. METHODS: A prospectively maintained endovascular stroke database was searched for patients undergoing intracranial stenting with balloon-mounted stents for acute LVO. Demographic, angiographic, and clinical data were extracted to determine procedural technique and success, measured both angiographically and clinically. RESULTS: Sixty patients underwent stenting for acute LVO secondary to ICAD. Mean presenting National Institutes of Health Stroke Scale (NIHSS) score was 18 and 62% of treated sites were in the posterior circulation. Cases were performed under IV conscious sedation unless the patient was already intubated. Successful recanalization was achieved in 93% of cases (Thrombolysis in Cerebral Infarction (TICI) grade 2b in 48% and TICI grade 3 in 45%). Mean improvement in NIHSS score on post-procedure day 1 was 3.4. Good outcome (modified Rankin Scale score 0-2) at 3 months was 34% and the mortality rate was 34%. The rate of peri-procedural symptomatic hemorrhage was 8% and the rate of acute/subacute stent thrombosis was 7%. In this small cohort, patient age, sex, presenting NIHSS, comorbidities, smoking, tissue plasminogen activator administration, and stent location were not significant predictors of recanalization or good outcome. CONCLUSION: Treatment of acute LVO stroke with balloon-mounted stents for ICAD has reperfusion rates and clinical outcomes comparable to thrombectomy, with higher rates of hemorrhage and mortality. Because stent placement was performed after attempted thrombectomy, a trial of primary stenting versus thrombectomy should be considered in patients suspected of underlying ICAD.

A clinical comparison of Atlas and LVIS Jr stent-assisted aneurysm coiling.

BACKGROUND: Case series have described the safety and efficacy of LVIS Jr and Atlas stent-assisted aneurysm coiling, but their comparative clinical performance has not yet been formally studied. OBJECTIVE: To clinically compare LVIS Jr and Atlas stents, emphasizing comparative rates of technical success and complications. METHODS: Our institutional endovascular database was queried for aneurysms treated by stent-assisted coiling with either the LVIS Jr or Atlas stents. Demographic data, aneurysm information, treatment technique, periprocedural and device-related complications, and initial and follow-up angiographic results were evaluated. RESULTS: Thirty-seven patients underwent Atlas stent placement and 27 patients underwent LVIS Jr stent placement for aneurysm coiling. There was no significant difference in aneurysm location, size, coiling technique, and coil packing density between the two cohorts. The rate of initial Raymond 1 occlusion was significantly greater in the Atlas cohort (57% vs 41%, P=0.03). The rate of postoperative ischemic complications, both clinically apparent and as defined on postoperative MRI diffusion-weighted imaging, did not significantly differ between the two groups. Follow-up DSA demonstrated a significantly greater rate of Raymond 1 or 2 occlusion for the Atlas cohort (100% vs 81%, P=0.04), and a significantly lower rate of in-stent stenosis (0% vs 19%, P=0.04). CONCLUSION: This institutional analysis demonstrates greater obliteration rates and lower in-stent stenosis rates for aneurysms treated via Atlas stent-assisted coiling as compared with those treated via LVIS Jr stent-assisted coiling.

A prospective study of the transradial approach for diagnostic cerebral arteriography.

BACKGROUND: The transradial approach for cardiac catheterization is associated with improved patient safety and satisfaction in comparison with the transfemoral approach. Prospective data for the transradial approach for cerebral arteriography are lacking. OBJECTIVE: To carry out a prospective study of consecutive patients undergoing transradial cerebral arteriography at our institution to evaluate the safety, feasibility, and limitations of this approach. METHODS: Consecutive patients referred for diagnostic cerebral arteriography at an institution with minimal transradial experience were enrolled until 50 right transradial diagnostic cerebral arteriograms were obtained. A procedural staging system was developed and goals of angiography were defined before each procedure. The primary outcome was the ability to achieve the predefined goals using the transradial approach. Secondary outcomes included the technical ability to access and inject each supra-aortic artery of interest and the incidence of complications. RESULTS: A total of 65 patients were screened; 15 were excluded owing to contraindications and 50 underwent attempted right transradial cerebral arteriography. The primary outcome was achieved in 44 patients (88%). Failures occurred at stage 1 (n=3, 6%), stage 2 (n=1, 2%), stage 3a (n=1, 2%), and stage 3b (n=1, 2%). Crossover to the transfemoral approach occurred in four patients (8%) and the procedure was terminated in two patients (4%). All supra-aortic arteries of interest were accessed and injected, with success rates between 89% and 100% with the exception of the left vertebral artery (successful in 59%). There were no major complications and five minor complications. CONCLUSION: Neurointerventionalists attempting the transradial approach can expect to achieve moderate early success and a low complication rate.

Stentriever salvage after failed manual aspiration thrombectomy.

INTRODUCTION: Manual aspiration thrombectomy (MAT) and stent retriever mediated aspiration thrombectomy (SMAT) are well described reperfusion strategies for large vessel occlusions. This study aims to identify predictors of successful crossover to SMAT after failed first pass MAT. METHODS: Prospectively collected data for patients with acute large vessel occlusions undergoing thrombectomy over a 23 month period at a comprehensive stroke center were reviewed. The primary outcome was successful removal of the index clot with resultant Thrombolysis in Cerebral Infarction 2b or greater reperfusion at any point after a failed initial MAT attempt, and multivariate logistic regression analyses were performed to determine predictors of successful crossover to SMAT. RESULTS: Of 433 large vessel thrombectomies, 319 underwent first pass MAT, and 113 patients required a repeated pass for the index thrombus. Second pass MAT was performed in 77% of cases and was successful in 54%; second pass SMAT was performed in 23% of cases and was successful in 73% (P=0.11). Third pass MAT was employed in 45% of cases and was successful in 43% while SMAT was performed in 55% of cases and was successful in 77% (P=0.03). Overall, 12% of patients undergoing MAT on the first pass crossed over to successful SMAT. Predictors of successful crossover were internal carotid artery (ICA) location and higher presenting National Institutes of Health Stroke Scale (NIHSS) score. CONCLUSION: After failed first pass MAT, subsequent passes with SMAT had higher rates of successful index clot removal; patients with a higher initial NIHSS score and ICA clot location should be considered for early crossover or even initial SMAT for their clots.

Large-bore aspiration catheter selection does not influence reperfusion or outcome after manual aspiration thrombectomy.

INTRODUCTION: Various large-bore catheters can be employed for manual aspiration thrombectomy (MAT); clinical differences are rarely explored. METHODS: Prospectively collected demographic, angiographic, and clinical data for patients with acute internal carotid artery, middle cerebral artery M1, or basilar occlusions undergoing MAT over 23 months at a comprehensive stroke center were reviewed. We excluded patients in stentriever-based randomized trials/registries. The four most commonly utilized aspiration catheters were analyzed, and multivariate logistic regression analyses were performed to determine the effect of primary aspiration catheter choice on first-pass success, final reperfusion, and modified Rankin Scale (mRS) score at 90 days. RESULTS: Of 464 large vessel thrombectomies, 180 were performed via MAT on the first pass with one of four catheters. First-pass success was achieved in 42% of cases overall; this rate did not differ significantly between catheters: 50% for Sofia, 45% for CAT6, 40% for 0.072 inch Navien, and 36% for ACE68, p=0.67. Final Thrombolysis in Cerebral Infarction 2b or 3 reperfusion was achieved in 94% of cases overall: 97% of cases with CAT6, 95% with Sofia, 92% with Navien, and 92% with ACE68, p=0.70. Mean number of passes for index thrombus (2.0 overall), median procedure time (32 min overall), 90-day good outcome (mRS 0-2, mean 36%), and 90-day mortality (mean 27%) did not differ significantly between patients treated with different initial catheters. CONCLUSION: Among large-bore aspiration catheters, catheter selection is not an independent predictor of first-pass success, final reperfusion, or clinical outcome.

Validation of an extrinsic compression and early ambulation protocol after diagnostic transfemoral cerebral angiography: a 5-year prospective series.

BACKGROUND AND PURPOSE: Access-site complications constitute a substantial portion of the morbidity associated with transfemoral cerebral angiography, yet no standardized protocol exists for femoral closure and practice patterns vary widely. The objective of this single-arm prospective cohort study was to validate the efficacy and safety of a standardized femoral closure strategy for all diagnostic angiography, regardless of antiplatelet regimen. METHODS: A single-arm, prospective study was designed enrolling consecutive patients undergoing diagnostic transfemoral cerebral angiography by a single neurointerventional surgeon from March 2013 - March 2018. The closure protocol consisted of 20 minutes of manual compression to the site of arterial access and 2 hours of bedrest. The primary outcome was hematoma or oozing after manual compression. Demographic, clinic, and laboratory data were collected and analyzed, and patients were stratified by antiplatelet use. RESULTS: Of 525 angiograms, 263 (50.1%) were on patients taking antiplatelet medication, with 66 (12.6%) on dual antiplatelet regimens. Five patients (0.95% of all patients) met the primary outcome: in all five cases, there was no further oozing or enlarging hematoma after the additional compression period. There were not significant differences in primary outcome in groups stratified by antiplatelet use, and there were no instances of delayed hematoma, pseudoaneurysm, or arteriovenous fistula. CONCLUSION: In this single-arm cohort study of 525 consecutive transfemoral angiograms with a standardized extrinsic compression protocol, hemostasis was achieved without complication in >99% regardless of antiplatelet strategy. This protocol is effective and safe for diagnostic transfemoral angiography regardless of a patient's antiplatelet use.

Maturing institutional experience with the transradial approach for diagnostic cerebral arteriography: overcoming the learning curve.

BACKGROUND: Despite growing interest in the transradial approach for neurovascular procedures, prospective data about the learning curve for neurointerventionalists adopting this approach are limited. METHODS: A subsequent prospective series of 50 consecutive right transradial diagnostic cerebral arteriograms was compared with our initial institutional experience using a procedural staging system. The primary outcome was the ability to achieve the predefined procedural goals using the radial approach. Secondary outcomes included the technical ability to access and inject each supraaortic artery of interest and the incidence of complications. RESULTS: The primary outcome was achieved in 49 patients (98%) compared with 88% in the initial series (p=0.05). One stage 2 failure (2%) occurred. Crossover to the transfemoral approach occurred in one patient (2%) compared with 8% in the initial series (p=0.16). All supraaortic arteries of interest were accessed and injected with success rates between 93% and 100%. There were no major complications and two minor complications. CONCLUSION: Neurointerventionalists can overcome the right transradial learning curve and achieve high success rates and low crossover rates after performing 30-50 cases.

Dump the pump: manual aspiration thrombectomy (MAT) with a syringe is technically effective, expeditious, and cost-efficient.

INTRODUCTION: Syringe aspiration for manual aspiration thrombectomy (MAT) is a cost- and time-efficient alternative to an aspiration pump with likely similar efficacy. It is counterintuitive to expect the pump to perform better than direct vacuum with a syringe, as the pump must deliver vacuum additionally through a canister and meters of tubing. OBJECTIVE: To present in vitro and clinical results of MAT with a syringe. METHODS: An in vitro analysis was performed comparing vacuum pressures generated by syringe aspiration and with pump aspiration. This was then complemented with prospective clinical data providing details of angiographic and clinical outcomes for syringe MAT. RESULTS: The in vitro analysis demonstrated that equal to slightly greater vacuum pressures were generated by a 60 cc syringe as compared with the pump in both static and partial flow conditions. In our clinical series, 106/113 acute stroke thrombectomies over a 6-month period were performed with syringe MAT on the first pass. Syringe usage instead of pump tubing and a canister led to a total savings of $58 300. The rate of Thrombolysis in Cerebral Infarction 2b/3 recanalization was 93%. Adjunctive stentriever usage was performed in 23% of cases. Median puncture to reperfusion time was 25 min; mean change in National Institute of Health Stroke Scale score at 24 hours was an improvement of 5.1 (median 6). The in-hospital mortality rate was 10%. Seventy percent of patients were discharged to home (modified Rankin Scale (mRS) score 0-2) or a rehabilitation facility (mRS score 2-4). CONCLUSION: MAT using a syringe is a safe, fast, and more cost-effective approach than using an aspiration pump.

Thrombectomy 6-24 hours after stroke in trial ineligible patients.

BACKGROUND AND PURPOSE: The DAWN and DEFUSE-3 trials demonstrated the benefit of endovascular thrombectomy (ET) in late-presenting acute ischemic strokes due to anterior circulation large vessel occlusion (ACLVO). Strict criteria were employed for patient selection. We sought to evaluate the characteristics and outcomes of patients treated outside these trials. METHODS: A retrospective review of acute ischemic stroke admissions to a single comprehensive stroke center was performed during the DAWN trial enrollment period (November 2014 to February 2017) to identify all patients presenting in the 6-24 hour time window. These patients were further investigated for trial eligibility, baseline characteristics, treatment, and outcomes. RESULTS: Approximately 70% (n=142) of the 204 patients presenting 6-24 hours after last known well with NIH Stroke Scale score ≥6 and harboring an ACLVO are DAWN and/or DEFUSE-3 ineligible, most commonly due to large infarct burden (38%). 26% (n=37) of trial ineligible patients with large vessel occlusion strokes received off-label ET and 30% of them achieved functional independence (modified Rankin Scale 0-2) at 90 days. Rates of symptomatic intracranial hemorrhage and mortality were 8% and 24%, respectively CONCLUSION: Trial ineligible patients with large vessel occlusion strokes receiving off-label ET achieved outcomes comparable to DAWN and DEFUSE-3 eligible patients. Patients aged <80 years are most likely to benefit from ET in this subgroup. These data indicate a larger population of patients who can potentially benefit from ET in the expanded time window if more permissive criteria are applied.

Angioplasty and stenting for symptomatic extracranial non-tandem internal carotid artery occlusion.

INTRODUCTION: Symptomatic internal carotid artery occlusion (ICAO) can lead to neurologic decline, recurrent stroke, and mortality. OBJECTIVE: We sought to evaluate the safety and feasibility of endovascular revascularization for ICAO without tandem intracranial large vessel occlusion (LVO). DESIGN, SETTING, AND PARTICIPANTS: This is a retrospective cohort analysis of all patients presenting to a single academic center with ischemic stroke and ipsilateral cervical ICAO from November 2003 through April 2016. Patients were excluded if pre-procedural angiography demonstrated tandem LVO or if patients were known to have chronic ICAO. MAIN OUTCOMES AND MEASURES: Study endpoints included discharge neurologic examination, post-procedural infarct burden, 3-month functional outcomes, and treatment durability. RESULTS: A total of 107 patients with symptomatic angiographically-confirmed cervical ICAO without tandem LVO were identified. Median admission NIH Stroke Scale (NIHSS) score was 8 (IQR 11). Baseline radiographic stroke severity was assessed by ASPECT score (median 9; IQR 2), perfusion mismatch (present in 93%), and clinical imaging mismatch (42%). Median time from symptom onset to treatment was 25 hours (IQR 61). Successful revascularization was achieved in 92% of patients. At discharge, 83% had stable/improved NIHSS score, while at 3 months 65% achieved independence (modified Rankin Scale score ≤2). The most common complication was distal embolization (22%) of which 16% required intra-arterial treatment. Rate of significant restenosis (≥70%) was 15% at 1 year. CONCLUSIONS: Stenting in selected patients at risk of neurologic deterioration due to symptomatic ICAO can be performed with high rates of technical success and good clinical outcomes. Because of significant peri-procedural risks and high rates of restenosis, randomized studies are necessary to understand the benefit of this approach.

Solitaire salvage: a stent retriever-assisted catheter reduction technical report.

The endovascular management of giant aneurysms often proves difficult with standard techniques. Obtaining distal access to allow catheter reduction is often key to approaching these aneurysms, but several anatomic challenges make this task unsafe and not feasible. Obtaining distal anchor points and performing catheter reduction maneuvers using adjunctive devices is not a novel concept, however using the Solitaire in order to do so may have some distinct advantages compared with previously described methods. Here we describe our novel Solitaire salvage technique, which allowed successful reduction of a looped catheter within an aneurysm in three cases. While this technique is expensive and therefore best performed after standard maneuvers have failed, in our experience it was effective, safe, and more efficient than other methods.

Solitaire salvage: a stent retriever-assisted catheter reduction technical report.

The endovascular management of giant aneurysms often proves difficult with standard techniques. Obtaining distal access to allow catheter reduction is often key to approaching these aneurysms, but several anatomic challenges make this task unsafe and not feasible. Obtaining distal anchor points and performing catheter reduction maneuvers using adjunctive devices is not a novel concept, however using the Solitaire in order to do so may have some distinct advantages compared with previously described methods. Here we describe our novel Solitaire salvage technique, which allowed successful reduction of a looped catheter within an aneurysm in three cases. While this technique is expensive and therefore best performed after standard maneuvers have failed, in our experience it was effective, safe, and more efficient than other methods.

Facial and neck hematoma after carotid artery stenting: an uncommon misadventure in endovascular carotid revascularization.

The complication rates of carotid artery stenting (CAS) vary from 3.0% to 4.4%, and most commonly include ischemic stroke, intracranial hemorrhage, or groin complications. We present the rare complication of a patient who underwent CAS for a symptomatic 90% left internal carotid artery stenosis and developed an expanding cervical hematoma after the procedure with imminent respiratory compromise. After intubation, an arteriogram revealed perforation of the external carotid artery trunk, proximal to the origin of the internal maxillary artery. The artery was subsequently embolized and the hematoma resolved without further intervention. We present a potential catastrophic complication and suggest potential causes and treatment options available.

Facial and neck hematoma after carotid artery stenting: an uncommon misadventure in endovascular carotid revascularization.

The complication rates of carotid artery stenting (CAS) vary from 3.0% to 4.4%, and most commonly include ischemic stroke, intracranial hemorrhage, or groin complications. We present the rare complication of a patient who underwent CAS for a symptomatic 90% left internal carotid artery stenosis and developed an expanding cervical hematoma after the procedure with imminent respiratory compromise. After intubation, an arteriogram revealed perforation of the external carotid artery trunk, proximal to the origin of the internal maxillary artery. The artery was subsequently embolized and the hematoma resolved without further intervention. We present a potential catastrophic complication and suggest potential causes and treatment options available.

Manual aspiration thrombectomy for cerebral venous sinus thrombosis.

BACKGROUND: Hydration and anticoagulation are the standard of care for cerebral venous sinus thrombosis (CVST) but some patients remain refractory to medical management and warrant more aggressive therapy. Here we present the technique of endovascular transvenous manual aspiration thrombectomy (MAT) in six patients. OBJECTIVE: Present an alternative technique for endovascular transvenous thrombectomy in a series of CVST patients. METHODS: We reviewed the records of six patients with medically refractory CVST. Transvenous access via the femoral vein was used to advance an aspiration catheter of varying internal diameter (0.044, 0.054, 0.057, 0.070, 0.072) up to and through the thrombus. Tissue plasminogen activator was administered in select cases. Manual aspiration with a 20 ml syringe applied to the catheter hub was applied as the catheter was slowly retracted. Presentation, technique, and outcome were evaluated. RESULTS: Clinical presentation included vomiting, dehydration, mental status changes, headaches, and acute motor deficits. On imaging, four of the six patients had hemorrhage, edema, and mass effect present before treatment, while two had edema only. All patients demonstrated continued deterioration despite early and aggressive medical anticoagulation therapy, warranting aggressive intervention. Aspiration of the superior sagittal sinus, transverse sinuses, straight sinus, sigmoid sinus, and internal jugular vein were performed in this series. There were no procedural complications. Revascularization was achieved in all instances. A modified Rankin Scale score of 1-3 was attained in 5/6 patients, while one patient died. CONCLUSIONS: In this series, transvenous MAT was a safe, simple, and effective revascularization technique to treat patients with CVST who remained refractory to medical management.