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Background Previous randomized controlled trials (RCTs) and meta-analyses were underpowered to demonstrate the superiority of endovascular thrombectomy (EVT) over medical therapy (MEDT) in the treatment of acute ischemic stroke due to large vessel occlusion of the posterior circulation (PC-LVO). We performed an updated systematic review and meta-analysis after the publication of the BAOCHE and ATTENTION trials to determine whether EVT can benefit patients presenting with PC-LVO. Methods Using Nested Knowledge, we screened literature for RCTs on EVT in PC-LVO. The primary outcome was 90-day modified Rankin Scale (mRS) score 0–3, and secondary outcomes included 90-day mRS score 0–2, 90-day mortality, and rate of symptomatic intracranial hemorrhage (sICH). A random-effects model was used to compute rate ratios (RRs) and their corresponding 95% confidence intervals (CIs). Results Four RCTs with 988 patients, 556 patients in the EVT arm and 432 patients in the MEDT arm, were included in the meta-analysis. EVT resulted in significantly higher rates of mRS score 0–3 (RR=1.54; 95% CI 1.16 to 2.04; P=0.002) and functional independence (RR=1.83; 95% CI 1.08 to 3.08; P=0.024), and lower rates of mortality (RR=0.76; 95% CI 0.65 to 0.90; P=0.002) at 90-day follow-up compared with MEDT alone. However, EVT patients had higher rates of sICH (RR=7.48; 95% CI 2.27 to 24.61; P<0.001). Conclusions EVT conferred significant patient benefit over MEDT alone in the treatment of PC-LVO. Future studies should better define patients for whom EVT is futile and determine factors that contribute to higher rates of sICH.

Introduction Venous sinus stenting is a well established alternative to cerebrospinal fluid diversion for the treatment of idiopathic intracranial hypertension (IIH) with associated venous sinus stenosis. During this procedure, distal guide catheter placement within the venous sinuses may be desirable to facilitate stent delivery. We report our initial experience using the TracStar LDP™ (Imperative Care, Campbell, USA, 0.088-inch inner diameter) as the guide catheter for intracranial access during venous sinus stenting. Methods A multi-institutional retrospective chart review of a prospectively maintained IRB-approved database was performed. Consecutive patients who underwent venous sinus stenting from 1/1/2020-9/6/2021 for IIH were included. Patient characteristics, procedural details, TracStar distal reach, outcomes, and complications were collected and analyzed. Results Fifty-eight patients were included. The mean age was 33.8 years and 93.1% of patients were female. Visual changes prompted evaluation in 86.2% of patients. Stent placement was successful in all patients. The TracStar LDP catheter was advanced to the location of stent placement in 97.9% of cases in which it was attempted. The large 0.088-inch inner diameter lumen enabled compatibility with all desired stent sizes ranging from six to 10 millimeters. Gradient pressure across transverse sinus stenosis dropped from an average of 19.5 mmHg pre-procedure to 1.7 mmHg post-stent placement (p < 0.001). Clinical improvement was achieved in 87.9% (51/58) of patients. There were no catheter-related complications. Conclusion The TracStar LDP is a safe and effective access platform for reaching treatment locations in patients who present with idiopathic intracranial hypertension and who are candidates for venous sinus stent placement.

BACKGROUND: Several collateral venous pathways exist to assist in cranial venous drainage in addition to the internal jugular veins. The important extrajugular networks (EJN) are often readily identified on diagnostic cerebral angiography. However, the angiographic pattern of venous drainage through collateral EJN has not been previously compared among patients with and without idiopathic intracranial hypertension (IIH). OBJECTIVE: To quantify EJN on cerebral angiography among patients both with and without IIH and to determine whether there is a different EJN venous drainage pattern in patients with IIH. METHODS: Retrospective imaging review of 100 cerebral angiograms (50 IIH and 50 non-IIH patients) and medical records from a single academic medical center was performed by 2 independent experienced neuroendovascular surgeons. Points were assigned to EJN flow from 0 to 6 using an increasing scale (with each patient's dominant internal jugular vein standardized to 5 points to serve as the internal reference). Angiography of each patient included 11 separately graded extrajugular networks for internal carotid and vertebral artery injections. RESULTS: Patients in the IIH group had statistically significant greater flow in several of the extrajugular networks. Therefore, they preferentially drained through EJN compared with the non-IIH group. Right transverse-sigmoid system was most often dominant in both groups, yet there was a significantly greater prevalence of codominant sinus pattern on posterior circulation angiograms. CONCLUSION: Patients with IIH have greater utilization of EJN compared with patients without IIH. Whether this is merely an epiphenomenon or possesses actual cause-effect relationships needs to be determined with further studies.

Background The benefit of mechanical thrombectomy (MT) and efficacy of different first-line MT techniques remain unclear for distal and medium vessel occlusions (DMVOs). In this systematic review, we aimed to compare the performance of three first-line MT techniques in DMVOs. Methods The PubMed database was searched for studies examining the utility of MT in DMVOs (middle cerebral artery M2-3-4, anterior cerebral artery, and posterior cerebral artery). Studies providing data for aspiration thrombectomy (ASP), stent retriever thrombectomy (SR), and combined SR+ASP technique were included. Non-comparative studies were excluded. Safety and efficacy data were collected for each technique. The Nested Knowledge AutoLit platform was utilized for literature search, screening, and data extraction. Pooled data were presented as descriptive statistics. Results 13 studies comprising 2422 MT procedures were identified. The overall successful recanalization rate was 77.0% (1513/1964) for DMVOs. SR+ASP had a successful recanalization rate of 83.7% (297/355), SR had a 75.6% rate (638/844), while ASP alone had a 74.2% rate (386/520). The overall functional independence rate was 51.3% (851/1659) among DMVOs. The ASP alone group had a functional independence rate of 46.9% (219/467), while functional independence rates of the SR and SR+ASP groups were 51.5% (372/723) and 61.7% (174/282), respectively. Finally, the subarachnoid hemorrhage rates were 1.8% (4/217) for the ASP group, 9.3% (26/281) for the SR group, and 11.9% (41/344) for the SR+ASP group. Conclusions Our systematic review supports the proposition that MT is a safe and effective treatment option for DMVOs. Additionally, while the SR+ASP group had consistently high rates of clot clearance and good neurological outcomes, the SR and SR+ASP groups also had higher rates of subarachnoid hemorrhage, highlighting the need for improved DMVO treatment devices.

Abstract Background Hemangioblastomas pose an inherent surgical risk due to the potential for high intraoperative blood loss, especially in larger tumors. One approach to minimize this risk is to use preoperative embolization. Herein, we present our institutional experience treating large and giant cerebellar hemangioblastomas. Methods We performed a retrospective chart review of 19 patients with cerebellar hemangioblastomas that had a maximal diameter of >3 cm. We performed a literature review and included individual patient-level data that met our >3 cm diameter cerebellar hemangioblastoma inclusion criteria. Results Our cohort consisted of 19 patients that received a total of 20 resections for their cerebellar hemangioblastomas. Preoperative embolization was utilized in eight cases (38.1%). One patient experienced transient neurological complications after embolization (12.5%). Tumors of patients in the embolization group had larger median total, solid, and cystic volumes and were more likely to involve the cerebellopontine angle than those in the non-embolized group. Compared with non-embolized patients, embolized patients had less decrease in their hemoglobin, lower volumes of estimated blood loss, reduced rates of postoperative complications and permanent deficits, and greater instances of neurological improvement. The larger cohort (obtained from the combining our cohort with patients identified during a literature review) consisted of 99 patients with 39 receiving preoperative embolization. Conclusion It is important to examine individual patient characteristics when determining eligibility for preoperative embolization. However, improvements in endovascular techniques have made preoperative embolization a safe and effective procedure with minimal risks that can be performed in many patients.

BACKGROUND: Loeys–Dietz syndrome (LDS) is an autosomal dominant connective tissue disorder characterized by a classic triad of hypertelorism, bifid uvula and/or cleft palate, and generalized arterial tortuosity. There are limited data on the prevalence and rupture risk of intracranial aneurysms (IAs) in the setting of LDS, with no established guidelines. OBJECTIVE: To analyze the prevalence and rupture risk of IA in LDS. METHODS: Electronic medical records of patients with a confirmed diagnosis of LDS and available cerebrovascular imaging were reviewed. Patients were divided into 2 groups based on the presence of IA. Unmatched and propensity-matched analyses were used to identify potential risk factors for aneurysm formation. RESULTS: Records of 1111 patients were screened yielding a total of 60 patients with a diagnosis of LDS. Eighteen (30%) patients had IA, 4 (22.2%) of whom had multiple aneurysms for a total of 24 IAs. Twenty-three (95.8%) aneurysms were located in the anterior circulation; none of them were ruptured. On unmatched analysis, age ( P = .015), smoking history ( P = .034), hypertension ( P = .035), and number of extracranial aneurysms ( P < .001) were significantly higher in patients with IA. After matching for age, sex, race, stroke history, family history, and extracranial aneurysms, smoking history ( P = .009) remained significant. CONCLUSION: Patients with LDS have an increased risk of IAs, especially with a history of smoking. The prevalence rate of IAs in our series was 30%. Screening imaging should be considered at diagnosis, and patients should be encouraged to abstain from smoking. Further studies are needed to elucidate the risk of IA rupture and treatment considerations in this unique population.

Transvenous Onyx embolization was recently described as an effective treatment of spontaneous intracranial hypotension caused by CSF-venous fistulas. Patients with CSF-venous fistulas can present with a wide spectrum of clinical and imaging findings, sometimes including spontaneous subdural hematomas, subdural hygromas, or a combination of both. Here, we describe four patients with spontaneous intracranial hypotension complicated by subdural fluid collections caused by CSF-venous fistulas. The patients were treated with transvenous Onyx embolization of their CSF-venous fistulas and transarterial particle embolization of the bilateral middle meningeal arteries, with both procedures performed in a single treatment session. All four patients had clinical improvement and decreased size or resolution of their subdural fluid collections. Based on our findings, we believe that middle meningeal embolization could be a useful adjunct to CSF-venous fistula embolization. A case-control study comparing patients who did or did not undergo middle meningeal embolization will be necessary to validate this supposition.

Introduction SOFIA catheter is a relatively new and recently FDA-approved aspiration catheter. This systematic review aims to investigate the safety and efficacy of SOFIA catheter for treatment of acute ischemic stroke (AIS) via ADAPT and Solumbra techniques. Methods Search of all studies evaluating the SOFIA catheter for mechanical thrombectomy (MT) for treatment of AIS via ADAPT and Solumbra techniques from inception through 2020 on Pubmed, PMC, and Embase was performed. We analyzed the angiographic and clinical outcomes of both techniques with SOFIA catheter using the random-effects model. Results From 18 studies, 1836 patients were included with 1365 receiving MT using ADAPT and 471 with solumbra technique. The mean age was 69.8 years and 51.1% of the patients were women. The rate of rescue therapy was 30%. The outcomes rates of ADAPT group were as follows; mFPE (59.3%), FPE (34.4%) final TICI 2b/3 (89.3%), procedural complications (8%), embolization to new territory (ENT) (2.3%), symptomatic ICH (5.4%), mean NIHSS (8.97), 90-day-mRS 0–2 (48.8%), and mortality (15.3%). The outcomes rates of Solumbra group were as follows; mFPE (60.5%), FPE (46.7%), final TICI 2b/3 (93%), procedural complications (6.4%), ENT (2%), symptomatic ICH (6%), mean NIHSS (7.59), mRS 0–2 (53.8%), and mortality (10.8%). ICA and posterior circulation strokes, and tandem lesions had worse outcomes (P < .005). MCA strokes were associated with better outcomes (P = .005). ASPECT scores’ association with the clinical outcomes was found statistically significant. Conclusion SOFIA catheter is effective and safe to treat acute ischemic stroke regardless of applied MT technique.

Objectives To integrate morphological, haemodynamic and mechanical analysis of carotid atheroma driving plaque disruption. Materials and methods First, we analysed the phenotypes of carotid endarterectomy specimens in a photographic dataset A, and matched them with the likelihood of preoperative stroke. Second, laser angioscopy was used to further define the phenotypes in intact specimens (dataset B) and benchmark with histology. Third, representative vascular geometries for each structural phenotype were analysed with Computational Fluid Dynamics (CFD), and the mechanical strength of the complicated atheroma to resist penetrating forces was quantified (n=14). Results In dataset A (n=345), ulceration (fibrous cap disruption) was observed in 82% of all plaques, intraplaque haemorrhage in 68% (93% subjacent to an ulcer) and false luminal formation in 48%. At least one of these ‘rupture’ phenotypes was found in 97% of symptomatic patients (n=69) compared with 61% in asymptomatic patients. In dataset B (n=30), laser angioscopy redemonstrated the structural phenotypes with near-perfect agreement with histology. In CFD, haemodynamic stress showed a large pulse magnitude, highest upstream to the point of maximal stenosis and on ulceration the inflow stream excavates the necrotic core cranially and then recirculates into the true lumen. Based on mechanical testing (n=14), the necrotic core is mechanically weak and penetrated by the blood on fibrous cap disruption. Conclusions Fibrous cap ulceration, plaque haemorrhage and excavation are sequential phenotypes of plaque disruption resulting from the chiselling effect of haemodynamic forces over unmatched mechanical tissue strength. This chain of events may result in thromboembolic events independently of the degree of stenosis.