Embolization before Gamma Knife radiosurgery for cerebral arteriovenous malformations does not negatively impact its obliteration rate: a series of 190 patients.

PURPOSE: Embolization of arteriovenous malformations (AVMs) before radiosurgery has been reported to negatively impact the obliteration rate. This study aims to assess treatment outcomes in a series of 190 patients treated by Gamma Knife radiosurgery (GKRS) for previously embolized AVMs. METHODS: The institutional database of AVMs was retrospectively reviewed between January 2004 and March 2018. The clinical and radiological data of patients treated with GKRS for previously embolized AVMs were analyzed. Predicting factors of obliteration and hemorrhage following GKRS were assessed with univariate and multivariate regression analyses. RESULTS: The mean AVM size was significantly reduced after embolization (p < 0.001). The obliteration rate was 78.4%. Multivariate analyses showed that a lower Spetzler-Martin grade (p = 0.035) and a higher marginal dose (p = 0.007) were associated with obliteration. Post-GKRS hemorrhages occurred in 14 patients (7.4%). A longer time between diagnosis and GKRS was the only factor associated with post-GKRS hemorrhages in multivariate analysis (p = 0.022). Complications related to the combined treatment were responsible for a new permanent neurological disability in 20 patients (10.5%), and a case of death (0.5%). CONCLUSIONS: This study shows that the embolization of AVMs does not have a negative impact on the obliteration rate after radiosurgery. Embolization reduces the AVM size to a treatable volume by GKRS. However, the combined treatment results in an increased complication rate related to the addition of the risks of each treatment modality.

Multicenter Study for the Treatment of Sidewall versus Bifurcation Intracranial Aneurysms with Use of Woven EndoBridge (WEB).

Background The Woven EndoBridge (WEB) device was explicitly designed for wide-neck intracranial bifurcation aneurysms. Small-scale reports have evaluated the off-label use of WEB devices for the treatment of sidewall aneurysms, with promising outcomes. Purpose To compare the angiographic and clinical outcomes of the WEB device for the treatment of sidewall aneurysms compared with the treatment of bifurcation aneurysms. Materials and Methods A retrospective review of the WorldWideWEB Consortium, a synthesis of retrospective databases spanning from January 2011 to June 2021 at 22 academic institutions in North America, South America, and Europe, was performed to identify patients with intracranial aneurysms treated with the WEB device. Characteristics and outcomes were compared between bifurcation and sidewall aneurysms. Propensity score matching (PSM) was used to match by age, pretreatment ordinal modified Rankin Scale score, ruptured aneurysms, location of aneurysm, multiple aneurysms, prior treatment, neck, height, dome width, daughter sac, and incorporated branch. Results A total of 683 intracranial aneurysms were treated using the WEB device in 671 patients (median age, 61 years [IQR, 53-68 years]; male-to-female ratio, 1:2.5). Of those, 572 were bifurcation aneurysms and 111 were sidewall aneurysms. PSM was performed, resulting in 91 bifurcation and sidewall aneurysms pairs. No significant difference was observed in occlusion status at last follow-up, deployment success, or complication rates between the two groups. Conclusion No significantly different outcomes were observed following the off-label use of the Woven EndoBridge, or WEB, device for treatment of sidewall aneurysms compared with bifurcation aneurysms. The correct characterization of the sidewall aneurysm location, neck angle, and size is crucial for successful treatment and lower retreatment rate. © RSNA, 2022 See also the editorial by Hetts in this issue.

External hydrocephalus associated with dural sigmoid sinus arteriovenous fistula: a case report.

External hydrocephalus (EH) is a recognised sub-type of hydrocephalus associated with macrocephaly in infancy. EH is characterised by the enlargement of subarachnoid spaces (so-called subarachnomegaly) with a normal ventricular system on brain imaging. EH is traditionally considered benign and self-limiting, yet its pathophysiology remains puzzling. Mounting evidence for an association between EH and hydrovenous disorders reshapes our understanding of this condition and its management. To our knowledge, we report the first association between EH and dural arteriovenous fistula (dAVF) in a 17-months-old boy. As dAVF may be a life-threatening condition, early diagnosis and optimal treatment are critical. This case epitomises the intricacies of EH's aetiology and associated conditions requiring careful management. Therefore, we recommend considering MR angiography in EH's workup and long-term follow-up. Our experience supports the ongoing reconsideration of EH's presumed benignity.

Safety and efficacy of a pre-treatment antiplatelet regimen of unruptured intracranial aneurysms: a single-center experience.

PURPOSE: Endovascular treatment of unruptured intracranial aneurysms with stent-assisted coiling or flow diverter stents requires a prophylactic antiplatelet premedication to avoid thrombo-embolic complications. Guidelines for optimal antiplatelet regimens are poorly defined. The aim of this study is to report our experience using a high dosage antiplatelet premedication regimen for patients with unruptured intracranial aneurysms undergoing endovascular treatment by stent-assisted coiling or flow diverter stents. METHODS: From a retrospective analysis of a prospectively maintained database, we collected clinical and angiographic data of 400 procedures in 362 patients treated by stent-assisted coiling or flow diverter stents for 419 unruptured intracranial aneurysms. Descriptive and analytic statistics were performed to report morbidity, mortality, and complication rates and to demonstrate associations between variables and outcomes. Logistic multivariable regression was performed to rule out confounding factors between subgroups. RESULTS: Thrombo-embolic complications occurred in 23/400 procedures (5.75%) and hemorrhagic complications in 19/400 procedures (4.75%). The majority of complications were minor and transient with overall procedure-related morbidity and mortality rates of 1.75% (n = 7/400) and 1.25% (n = 5/400) respectively. The co-existence of multiple cardiovascular risk factors among smoking, hypertension, dyslipidemia, and age > 65 years old was significantly associated with permanent procedure-related morbidity (p = 0.006) and thrombo-embolic complications occurrence (p = 0.034). Age alone was associated with higher permanent morbidity (p = 0.029) and was the only variable associated with higher hemorrhagic complication (p = 0.024). CONCLUSION: In this study, the use of a high dosage antiplatelet premedication was safe and effective for the treatment of unruptured intracranial aneurysms with stent-assisted coiling or flow diverter stents. Mortality and morbidity rates compare favorably with the current literature. The thrombo-embolic complications rate is low and most of them were clinically silent. However, the hemorrhagic complications rate was substantial and a significant proportion of them were associated with mortality.

Endovascular treatment of intracranial vascular malformations in children.

Paediatric intracranial vascular malformations are rare and different from adult ones in vascular anatomy, pathophysiology, and symptoms. Their impact on the brain and their symptoms will differ in the antenatal period, in neonates, infants, and children. Clinical presentation includes seizures, focal neurological deficit, haemorrhage, congestive heart failure, hydrovenous disorder, and developmental delays. These malformations are thus associated with a poor prognosis if left untreated. Therefore, aggressive management is generally recommended and must be performed by a multidisciplinary team with extensive experience. Endovascular treatment is the first-choice treatment for most paediatric intracranial vascular malformations. Indication and timing for treatment should be decided on the basis of a careful assessment of neurological symptoms, growth and development, cardiac and other systemic manifestations, and imaging of the malformation and the brain tissue. WHAT THIS PAPER ADDS: Paediatric intracranial vascular malformations are rare, but their prognosis is poor if left untreated. Improved clinical, anatomical, and pathophysiological understanding of these complex lesions has improved prognosis.

Intracranial Vessel Wall MRI in Cryptogenic Stroke and Intracranial Vasculitis.

INTRODUCTION: Intracranial vasculopathies easily elude classic stroke work-up. We aim in this work to show that vessel wall-MRI could prove an efficient alternative to digital subtraction angiography for the diagnosis of intracranial vasculopathies by identifying intracranial arterial vessel walls anomalies and contrast enhancement, suggestive of angiitis of the central nervous system. MATERIALS AND METHODS: Clinical and imaging characteristics of stroke patients diagnosed with primary angiitis of the central nervous system based on vessel wall-MRI were retrospectively reviewed and the clinical and imaging features of angiitis associated with intracranial vessel walls anomalies and contrast enhancement detailed. RESULTS: Twenty patients were included (mean age was 59 years old). All patients were admitted for focal neurological deficits of sudden onset that were recurrent in 13 subjects. Cognitive impairment, headache and seizures occurred in, respectively, 13, 5, and 2 patients. Cerebrospinal fluid analysis was abnormal in 15 patients. In MRI, FLAIR sequences showed ischemic infarcts in 20 patients and DWI showed acute infarct in 15 patients. Digital subtraction angiography was performed in 11 patients and disclosed proximal and distal multifocal stenosis in 10 patients along distal irregularities in different vascular territories in 7. For all of our patients, VW-MRI revealed a concentric contrast enhancement of arterial walls, localized in multiple vascular territories, suggesting angiitis. Abnormalities on digital subtraction angiography and/or MR-Angiography, and vessel wall-MRI were consistent in all patients. CONCLUSIONS: This report underlies the added value of vessel wall-MRI to the diagnosis of underlying intracranial vasculopathy, particularly primary angiitis of the central nervous system, without the use of invasive endovascular techniques and the yield of vessel wall-MRI in the work-up of cryptogenic stroke.

Estimation of central arterial pressure from the radial artery in patients undergoing invasive neuroradiological procedures.

BACKGROUNDS: Central arterial pressure can be derived from analysis of the peripheral artery waveform. The aim of this study was to compare central arterial pressures measured from an intra-aortic catheter with peripheral radial arterial pressures and with central arterial pressures estimated from the peripheral pressure wave using a pressure recording analytical method (PRAM). METHODS: We studied 21 patients undergoing digital subtraction cerebral angiography under local or general anesthesia and equipped with a radial arterial catheter. A second catheter was placed in the ascending aorta for central pressure wave acquisition. Central (AO) and peripheral (RA) arterial waveforms were recorded simultaneously by PRAM for 90-180 s. During an off-line analysis, AO pressures were reconstructed (AOrec) from the RA trace using a mathematical model obtained by multi-linear regression analysis. The AOrec values obtained by PRAM were compared with the true central pressure value obtained from the catheter placed in the ascending aorta. RESULTS: Systolic, diastolic and mean pressures ranged from 79 to 180 mmHg, 47 to 102 mmHg, and 58 to 128 mmHg, respectively, for AO, and 83 to 174 mmHg, 47 to 107 mmHg, and 60 to 129 mmHg, respectively, for RA. The correlation coefficients between AO and RA were 0.86 (p < 0.01), 0.83 (p < 0.01) and 0.86 (p < 0.01) for systolic, diastolic and mean pressures, respectively, and the mean differences - 0.3 mmHg, 2.4 mmHg and 1.5 mmHg. The correlation coefficients between AO and AOrec were 0.92 (p < 0.001), 0.87 (p < 0.001) and 0.92 (p < 0.001), for systolic, diastolic and mean pressures, respectively, and the mean differences 0.01 mmHg, 1.8 mmHg and 1.2 mmHg. CONCLUSIONS: PRAM can provide reliable estimates of central arterial pressure.

Value of dual-energy CT angiography in patients with treated intracranial aneurysms.

PURPOSE: To evaluate the ability of dual-energy CT angiography (DECTA) in metal artifact reduction in patients with treated intracranial aneurysms by comparing DECTA-based virtual monoenergetic extrapolations (VMEs) and mixed images (MI). METHODS: Thirty-five patients underwent prospectively a dual-source DECTA (Somatom Force, Siemens Medical Solutions, Forchheim, Germany) after aneurysm repair. A total number of 40 aneurysms (23 treated by coil embolization and 17 treated by surgical clipping) were analyzed. Mixed images (equivalent to a conventional single-energy CT angiography) were compared to VMEs at 75, 95, and 115 keV. Artifact severity was assessed quantitatively by measuring the mean attenuation value and standard deviation within regions of interest placed in the most hypodense coil or clip artifact area. Artifact severity score and contrast vessel score were also assessed qualitatively by two independent blinded readers. RESULTS: In those aneurysms treated by surgical clipping, quantitative and qualitative analyses showed significant reduction of artifacts on VMEs compared to MI with the best compromise being obtained at 95 keV in order to keep an optimal vessel contrast in the adjacent vessel. In those aneurysms treated by coil embolization, there was no significant reduction of artifacts both on quantitative and qualitative analyses. CONCLUSION: Dual-source DECTA was helpful in order to reduce clip artifacts on VMEs with the optimal adjacent vessel visualization obtained at 95 keV, whereas this technique was not helpful in aneurysms treated by coiling.

Leo stent for endovascular treatment of intracranial aneurysms: very long-term results in 50 patients with 52 aneurysms and literature review.

INTRODUCTION: The Leo stent was the first retrievable stent for endovascular treatment of intracranial aneurysms (IAs). We report our experience with this device with emphasis on very long-term follow-up. METHODS: This study was approved by authors' ethical committee. A retrospective review of our prospectively maintained database identified all patients treated for a saccular IA with this stent in our institution. Technical issues and immediate and long-term outcomes (at least 12 months) were evaluated. RESULTS: Between 2004 and 2015, 50 patients with 52 IAs were identified. In two patients, the stent could not safely be placed (failure rate = 3.8%). Among 48 treated patients with 50 IAs, there were 44 women and 4 men (mean age, 53 years). Mean aneurysm diameter was 7.2 mm. All IAs but six were wide-necked. There was no immediate morbidity or mortality. Anatomical results included 76% complete occlusions, 22% neck remnants, and 2% incomplete occlusions. Mean follow-up was 50.2 months (range, 12-139 months). Two patients had delayed TIAs but long-term morbidity rate remained = 0%. At follow-up, occlusion was stable in 68% IAs, showed thrombosis in 12%, and recanalization in 20% IAs. Complementary treatment was required in 8% IAs. Final results showed 70% complete occlusions, 24% neck remnants, and 6% incomplete occlusions. Asymptomatic stent occlusion and significant stenosis occurred in one and two cases, respectively. CONCLUSION: The Leo stent is safe and effective for treatment of wide-necked saccular IAs. Very long-term results show high rates of adequate and stable occlusion. Moreover, the stent is well tolerated.

Endovascular treatment of intracranial aneurysms with the p64 flow diverter stent: mid-term results in 35 patients with 41 intracranial aneurysms.

INTRODUCTION: The p64 flow diverter (FD) device is a fully resheathable and detachable stent dedicated for endovascular treatment (EVT) of intracranial aneurysms (IAs). We report our mid-term experience with this device. METHODS: Between January 2015 and February 2016, we retrospectively identified, in our prospectively maintained database, all patients treated with p64 FDs in two institutions. Independent clinical follow-up was performed by a vascular neurologist. Imaging follow-up included a digitalized subtraction angiography (DSA) at 3, 6, and 12 months and a magnetic resonance angiography (MRA) at 12 months. RESULTS: Thirty-nine patients (22 women/17 men; median age 54 years) with 48 IAs (median aneurysm size 6.2 mm; mean neck size 3.4 mm) were identified. All IAs were saccular and unruptured. Failure of safe stent delivery occurred in 15% of cases (7/48 IAs) which were excluded. Transient neurological morbidity occurred in 2/35 patients (5.7%) including one delayed thromboembolic complication. No permanent morbidity or mortality was encountered. Complete aneurysmal occlusion at 3, 6, and 12 months was 20/30 (66.6%), 18/27 (66.6%), and 24/28 (85.7%), respectively. Intra-stent stenosis was observed in 9/29 patients (31%) and classified as moderate in 4/29 (13.7%) and mild in 5/29 patients (17.2%). These stenoses gradually improved over time, with only mild stenoses being identified at 6 months and at 12 months. CONCLUSION: In our small case series, the p64 FD stent appears safe and effective for EVT of IAs. A high occlusion rate and a low morbidity rate were observed.

Stent-assisted coiling of wide-neck bifurcation aneurysms with a branch incorporated in the aneurysm base: long-term follow-up in 49 patients with 53 aneurysms.

PURPOSE: Wide-neck bifurcation intracranial aneurysms (WNBA) with a branch incorporated in the aneurysm base remain difficult to treat by embolization. We aim to report our long-term follow-up of stent-assisted coiling (SAC) in this subgroup of patients. METHODS: This study was approved by our local ethical committee. A retrospective review of our prospectively maintained database identified all patients treated in our institution by SAC for a WNBA with a branch incorporated in the aneurysm base. Technical issues, immediate, long-term outcomes were evaluated. RESULTS: Between 2007 and 2015, 49 patients with 53 intracranial aneurysms (IAs) (52 unruptured, 1 ruptured) were identified and successfully treated. No morbidity/mortality occurred. The incorporated branch was preserved in all patients but one who was treated during a vasospasm phase. At the first 6-month imaging control, the branch was patent. Immediate occlusion was near-complete in 11/53 aneurysms (20.8%), neck remnant in 20/53 aneurysms (37.7%), and incomplete in 22/53 aneurysms (41.5%). Available imaging follow-up of 47 IAs, ranging from 3 to 84 months (mean 26 months ± 19.6 months), showed 27 progressive thrombosis (57.4%), 17 stable occlusions (36.2%), 1 minor recanalization (2.1%), and 2 significant recanalizations that were retreated (4.3%). The latest imaging control showed 30 near-complete occlusions (63.8%), 13 neck remnants (27.7%), and 4 incomplete occlusions (8.5%). CONCLUSION: Stent-assisted coiling is safe and effective for the treatment of WNBA with a branch incorporated in the aneurysm base. Despite poor immediate anatomical results, long-term follow-up shows a high rate of progressive thrombosis achieving adequate and stable occlusion in most patients.

Stent-assisted coiling of intracranial aneurysms located on small vessels: midterm results with the LVIS Junior stent in 40 patients with 43 aneurysms.

INTRODUCTION: The Low-profile Visualized Intraluminal Support (LVIS) Junior stent is dedicated for endovascular treatment of wide-neck intracranial aneurysms located on small-diameter vessels (2-3.5 mm). This study reports midterm clinical and anatomical results of this device. METHODS: This study was approved by authors' ethical committees. A retrospective review of our prospectively maintained database identified all patients treated by this stent in three institutions. Technical issues and immediate and mid-term anatomical and clinical outcomes were evaluated. RESULTS: Forty patients (30 women/10 men, mean age of 55 years) with 43 aneurysms were identified. Mean aneurysm diameter was 5.6 mm (range, 2-13 mm). In all patients, treatment was successful and the stent could be precisely placed. There were three procedure-related complications, one stent thrombosis and two aneurysm ruptures, leading to immediate morbidity in one patient. Delayed ischemic events occurred in three patients including two transient attacks and one permanent deficit. The overall permanent morbidity rate was thus 5 %. No mortality occurred. Immediate aneurysm occlusion consisted of 36 complete occlusions (83.7 %), five neck remnants (11.6 %), and two incomplete occlusions (4.7 %). Twenty-seven patients (29 aneurysms) and 11 patients (11 aneurysms) had a 12- and 6-month angiographic follow-up, respectively. Final anatomical results included 36 complete occlusions (90 %) and four neck remnants (10 %). Two minor recanalizations were seen but did not require retreatment. Non-significant intrastent stenosis occurred in 7/40 followed-up cases (17.5 %). CONCLUSION: The LVIS Junior stent appears safe and effective for endovascular treatment of wide-neck intracranial aneurysms located on small vessels. Midterm results show high rates of adequate and stable occlusion.

Detection and characterization of unruptured intracranial aneurysms: Comparison of 3T MRA and DSA.

PURPOSE: To compare magnetic resonance angiography (MRA) at 3 Tesla (3T) and digital subtraction angiography (DSA) for the detection and characterization of unruptured intracranial aneurysms (UIA). MATERIALS AND METHODS: This study has been approved by our local ethical committee. From February to August 2010, 40 consecutive patients with UIA contemporarily underwent MRA at 3T including time-of-flight (TOF-MRA) and contrast enhanced (CE-MRA) techniques and DSA. MR images were independently reviewed by 3 radiologists and DSA images were reviewed by 2 radiologists together. Interobserver and intertechnique agreements were assessed for aneurysm detection and characterization including maximal diameter, neck width and the presence of a bleb or a branch arising from the sac. RESULTS: DS angiography revealed 56 aneurysms. Mean sensitivity and positive predictive value of MRA were 91.4% and 93.4% respectively. For UIA < 3 mm and those ≥ 3 mm, MRA had a mean sensitivity of 74.1% and 100% respectively. Intertechnique and interobserver agreements were substantial for the measurement of UIA maximal diameter (mean κ, 0.607 and 0.601 respectively) and were moderate and fair for neck width measurement respectively (mean κ, 0.456 and 0.285 respectively). For bleb detection, intertechnique and interobserver agreements were fair and slight respectively (mean κ, 0.312 and 0.116 respectively) whereas both were slight for detection of branches arising from the sac (mean κ, 0.151 and 0.070 respectively). CONCLUSION: MR angiography at 3T has a high sensitivity for the detection of UIA. However, it remains significantly inferior to DSA for morphological characterization of UIA.

Stent-assisted coiling of unruptured intracranial aneurysms: long-term follow-up in 164 patients with 183 aneurysms.

PURPOSE: Stent-assisted coiling (SAC) is increasingly used to treat complex unruptured intracranial aneurysms (UIA) including wide-necked and fusiform IA. However, few data are available over the long-term results of this technique. We report our 9-year-experience of SAC of UIA. METHODS: A retrospective review of our prospectively maintained database identified all patients treated by SAC for an UIA in 2 institutions. The clinical charts, procedural data and angiographic results were reviewed. RESULTS: Between 2004 and 2012, we identified 164 patients with 183 UIA. There were 115 women and 49 men with a mean age of 46 years. Embolization was successful in all patients. Procedural morbidity and mortality rates were 2.2% and 0% respectively. Immediate anatomical outcome included 54 complete occlusion (29.5%), 43 neck remnants (23.5%) and 86 incomplete occlusions (47%). Imaging follow-up was available in 137 patients (mean=26 months, range 3 to 99 months) and it showed 104 complete occlusions (75.9%), 23 neck remnants (16.8%) and 10 incomplete occlusions (7.3%). At follow-up, only 3 patients developed a significant intrastent stenosis, one of which was induced by radiosurgery. One of these patients had a symptomatic thrombo-embolic complication 3 years after stent placement. CONCLUSION: SAC of complex UIA is effective and associated with low complication rates. Even if immediate anatomical results are relatively unsatisfying, mid- and long-term follow-up show a major improvement with a high rate of adequate occlusion that is stable over time. Moreover, the long-term clinical and angiographic tolerance of intracranial stents is excellent.

Anticoagulation helps shrink giant venous lakes and arteriovenous fistulas in dural sinus malformation.

BACKGROUND: Dural sinus malformations (DSMs) associated with high flow arteriovenous shunts are a challenging disease in babies that can lead to severe neurological damage or death. We report our treatment strategy in seven consecutive DSMs. METHODS: We performed a retrospective analysis of seven consecutive patients from four centres, treated with transarterial embolization and anticoagulants. RESULTS: Mean clinical and imaging follow-up was 2.8 years (IQR1-3 1.8-5.3). At baseline, the median size of the dilated venous pouch (giant lake) was 35 mm (IQR1-3 24-41) that decreased to a normal or near normal venous collector diameter of median size 11.5 mm (IQR1-3 8.5-13.8). This was achieved after a median of two embolization sessions targeted on dural feeders (IQR1-3 1.5-2.5), leaving associated pial feeders untreated. There were no cerebral hemorrhagic complications during the anticoagulation treatment. Median percentage of shunt remaining after embolization was 30% (IQR1-3 12-30), which spontaneously decreased with anticoagulation and even after discontinuation of anticoagulation, in parallel with the reduction in diameter of the dilated sinus, up to healing (or near healing). At the last clinical assessment, the modified Rankin Scale score was 0 in four patients, 1 in one patient, and 3 in two patients. CONCLUSIONS: Anticoagulants may help to potentiate transarterial embolization in DSMs in babies by decreasing venous dilatation and reducing the remaining arteriovenous shunt, particularly the pial feeders. We did not observe recurrence of arteriovenous shunts after treatment, especially during anticoagulation treatment. Further studies are needed to support our findings.

Diagnostic Pitfalls of Macrocephaly and Intracranial Dural Arteriovenous Fistulas: Connecting the Dots With the Red Flags.

Macrocephaly is defined as an abnormal increase in head circumference greater than two standard deviations above the mean for a given age and sex. We present the case of a 16-month-old boy with congenital progressive macrocephaly, who was referred to our hospital for a ventriculoperitoneal shunt placement for external hydrocephalus diagnosed at 13 months of age. The patient had a febrile seizure 12 hours after the shunt was placed and the emergency CT exam revealed collapsed ventricles and a right frontal subdural collection, suggestive of an over-drainage and intracranial hypotension. A subsequent electroencephalogram (EEG) revealed some anomalies, but the patient was discharged two days later due to having no neurological symptoms after being placed on anticonvulsants. The patient returned to the hospital one week later due to recurrent seizures. Further clinical examination revealed prominent and tortuous veins of the skull, palpated in the left occipital region. A thrill and a left carotid murmur were heard during auscultation. A subsequent brain MRI with MR arteriography and venography was performed in search of an explanation for hydrocephaly. The sequences were suggestive of a dural arteriovenous fistula, which was confirmed and then treated using coils during an interventional angiography. A second procedure was performed two months later to complete the embolization, with subsequent imaging follow-ups showing the procedure to have been successful. The measurement of the cranial circumference, its regular evaluation, and its evolution allow a hierarchical diagnosis strategy by distinguishing primary and secondary macrocephaly, progressive or not. Dural arteriovenous fistulas (DAVF) are an under-appreciated cause of macrocephaly, with which they are associated in 35% of cases. Intracranial DAVFs are pathologic shunts between dural arteries and dural venous sinuses, meningeal veins, or cortical veins. Patients with DAVFs may be completely asymptomatic. Symptoms, when present, may range from neurological deficits, seizures, and hydrocephaly to fatal hemorrhage. The symptoms depend on the location and venous and drainage patterns of the DAVF. They can be difficult to identify on routine MRIs unless specifically searched for, especially in cases of technically suboptimal examinations. We aim to give a practical approach to identify the clinical clues that warrant further investigation. Several specific protocols exist regarding the management of macrocephaly and should be followed carefully once a diagnosis has been reached, but further studies are needed to integrate more clinical and neuroimaging findings to permit an early diagnosis.

Treatment of Cerebral Vasospasm Following Aneurysmal Subarachnoid Hemorrhage using the Neurospeed Semi-compliant Balloon.

BACKGROUND AND PURPOSE: Cerebral vasospasm (CV) following aneurysmal subarachnoid hemorrhage (aSAH) may lead to morbidity and mortality. Endovascular mechanical angioplasty may be performed if symptomatic CV is refractory to noninvasive medical management. Off-label compliant remodelling balloons tend to conform to the course of the vessel, contrary to noncompliant or semi-compliant balloons. Our objective is to describe our initial experience with the semi-compliant Neurospeed balloon (approved for intracranial stenosis) in cerebral vasospasm treatment following aSAH. METHODS: All patients included in the prospective observational SAVEBRAIN PWI (NCT05276934 on clinicaltrial.gov) study who underwent cerebral angioplasty using the Neurospeed balloon for the treatment of medically refractory and symptomatic CV after aSAH were identified. Patient demographic information, procedural details and outcomes were obtained from electronic medical records. RESULTS: Between February 2022 and June 2023, 8 consecutive patients underwent CV treatment with the Neurospeed balloon. Angioplasty of 48 arterial segments (supraclinoid internal carotid artery, A1 and A2 segments of the anterior cerebral artery, M1 and M2 segments of the middle cerebral artery) was attempted and 44/48 (92%) were performed. The vessel diameter significantly improved following angioplasty (+81%), while brain hypoperfusion decreased (-81% of the mean TMax). There was no long-term clinical complication, 4% periprocedural complications occurred. CONCLUSION: The semi-compliant Neurospeed balloon is effective in the treatment of cerebral vasospasm following aSAH, bringing a new device into the armamentarium of the neurointerventionalist to perform intracranial angioplasty.

Comprehensive functional mapping scheme for non-invasive primary sensorimotor cortex mapping.

We introduce a novel multimodal scheme for primary sensorimotor hand area (SM1ha) mapping integrating multiple functional indicators from functional magnetic resonance imaging (fMRI) and magnetoencephalography (MEG). Ten right-handed healthy subjects (19-33 years; 5 females, 5 males) and four patients (24-64 years; 2 females, 2 males) suffering from space-occupying brain lesion close to the central sulcus were studied. Functional indicators of the SM1ha were obtained from block-design fMRI motor protocol, and six MEG protocols: somatosensory evoked fields to electrical median-nerve stimulation, mu-rhythm suppression (~10 and ~20 Hz), corticomuscular coherence, and corticokinematic coherence with and without finger contacts. To assess the spatial spread of the functional indicators, their coordinates were subjected to principal component analysis to produce a centered ellipsoid with axis along principal components. Five to seven functional indicators were obtained for each participant. In all participants, the ellipsoid co-localized with the anatomical SM1ha. In healthy subjects, 50-100% of functional indicators were located within 10 mm from the center of the ellipsoid. In patients, 17-100% of functional indicators were located within 10 mm from the center of the ellipsoid. In conclusion, the multimodal scheme proposed led to a functional mapping of SM1ha that co-localized with anatomical SM1ha in all participants. The spread of the SM1ha functional indicators in some patients with brain lesions highlights the potential benefit of the proposed multimodal approach to assess the reliability of the non-invasive SM1ha mapping.

Solitaire AB stent-assisted coiling of wide-necked intracranial aneurysms: short-term results from a prospective, consecutive, European multicentric study.

INTRODUCTION: Solitaire AB stent-assisted coiling facilitates the endovascular treatment of wide-necked intracranial aneurysms. Solitaire Aneurysm Remodeling is the first prospective, consecutive, European multicentric study whose main objective was to evaluate the safety, short-, and long-term efficacy of the Solitaire AB stent. This first analysis is focused on the short-term results. METHODS: After exclusion of one patient, 66 Solitaire AB stents were used to treat via endovascular approach 64 aneurysms (63 patients) in seven European centers. Technical and clinical complications were recorded. A core laboratory evaluated the angiographic efficacy by using the Raymond classification scale. RESULTS: The mean width of aneurysm sac was 7.5 mm, and the mean diameter of aneurysm neck was 4.7 mm. Complete occlusion was achieved in 27 aneurysms (42.2 %); neck remnant was seen in 25 aneurysms (39.1 %) and aneurysm remnant in 12 aneurysms (18.7 %). Technical and clinical complications related to the procedure were encountered in eight patients (12.7 %). Postprocedural modification of the clinical status was observed in one patient (1.6 %). No patients died (0 %); one had a permanent deficit (1.6 %), and one had a transient deficit (1.6 %). Treatment-related mortality was 0 %, and permanent morbidity was 1.6 %. CONCLUSION: The Solitaire AB stent has an excellent rate of technical success navigation with the absence of dislodgement. The safety and short-term efficacy are comparable to those previously reported with coiling alone. Mid- and long-term follow-up will be required to elucidate the impact of the Solitaire AB stent on recanalization rate.