bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract Number ‐ 3: Large and Giant Aneurysms Outcome in the Multicenter Prospective Core Lab Adjudicated SMART Coils Registry
Authors: Ashouri Yazan K , Spiotta Alejandro M , Park Min S , Bellon Richard J , Bohnstedt Bradley N , Yoo Albert J , Massad Abdallah , Pabon Boris , Zaidat Osama O
Published: April 2023

Introduction

Endovascular coiling for intracerebral aneurysms has been evolving. Yet, large, and giant aneurysms (LAGA) remain a significant challenge for treatment and carry a high rate of morbidity and mortality. Previous studies have demonstrated 72–76% long‐term adequate occlusion and up to 34% retreatment rate in patients undergoing reconstructive treatment for LAGA.

Methods

The SMART registry, a prospective, multicenter outcome trial was used to identify patients with LAGA (Sac 10–24mm for large and ≥ 25mm for giant aneurysms) treated with the Penumbra SMART COIL® (SMART) system in the US and Canada. Patients’ characteristics and outcomes were then compared to patients with smaller aneurysms (SA) (Sac≤10mm). Primary effectiveness endpoint was aneurysm occlusion using Raymond‐Roy (RR) scale and safety endpoints included mortality and stroke outcomes. Fisher exact test and T‐test were used to compare categorical and continuous variables, respectively. P‐value < 0.05 was considered significant.

Results

A total of 131/903 (14.5%) patients had LAGA and 42 (32.1%) of those were ruptured. Patients with LAGA were older than SA (mean age: 61.9 vs 59.4, p = 0.04). Large aneurysms were mainly saccular in 75.6% of the cases (vs 87.7% of the ≤ 10 mm ones, p < 0.001). Fusiform LAGA were 8.4% (vs 1.4% of the ≤ 10 mm ones, p < 0.001). Furthermore, they are more likely to have wide neck (69.5% vs 59.7%, p = 0.042). They are less likely to have A‐Com aneurysm (10.7% vs 28%, p < 0.001), and more likely to have basilar tip aneurysms (3.1% vs 0.8%, p = 0.044) and cavernous aneurysms (4.6% vs 0.6%, p = 0.002) compared to patients with SA. Primary coiling was the main treatment modality for both SA and LAGA (43.3% vs 43.5%, respectively, p = 1.0). However, LAGA were more likely to be treated with flow diversion in addition to coiling (6.1% vs 1.0%, p < 0.001). Packing density was significantly lower in LAGA (mean (SD) = 21.2(13.1) vs 34.1(18.3), p < 0.001). Surprisingly, long‐term aneurysm RR occlusion Class I‐II on follow‐up imaging was 82.5% in LAGA vs 91.2% in SA, p = 0.016. Retreatment rates was 11.7% in LAGA vs 6.4% in SA, p = 0.063. mRS0‐2 score was 73.6% in LAGA vs 86.4% in SA, p = 0.007. All‐cause 1‐year mortality was 9.2% in LAGA vs 4.7% in SA, p = 0.054.

Conclusions

Despite challenges with treating Large and giant aneurysms, SMART coiling registry demonstrated high adequate aneurysm occlusion rate on follow‐up imaging, as well as a good independent functional outcome.
Abstract Number ‐ 8: HEMERA 1 CarboxyHEMoglobin OxygEn delivery for Revascularization in Acute Stroke: Phase 1 Clinical Trial
Authors: Linfante Italo , Hanel Ricardo , Reshi Rwoof , Clark Wayne M , Dabus Guilherme C , Lieberskind David , Nogueira Raul G
Published: April 2023

Introduction

Despitehigh rates ofrecanalizationafter mechanical thrombectomy(MT),only 33–71% of patients achieve functional independence at 90 days.Experimental ischemia hashighlightedthe complexity of several pathophysiological events occurring at the level of the neurovascular unit and has revealed potential targets for neuroprotection. Apossible target is to increasebloodflow in the collateral circulationwhile delivering high levels of oxygen in the ischemic area.Hemoglobin based oxygen carriers (HBOC) as a transfusion media that can treat ischemic tissue have been investigatedfor a decade. More recently, a polyethylene glycol modifiedHBOCin the carboxy state (PP‐007)increases blood flow in the collateral circulationinrat modelsof middle cerebral artery occlusion (MCAO).PP‐007 may deliver more oxygen than Hb contained in RBCs because of increased diffusional surface area in plasma, and by facilitation of oxygen transport from RBC to endothelium.In addition,dilation ofcollateral circulationby diffusion of CO mayslow down infarct expansion andimprove the efficacy of reperfusion.

Methods

HEMERA 1 is a phase 1 safety clinical trialof PP‐007 in patient with acute ischemic strokewith LVO (ClinicalTrials.gov NCT04677777). Inclusion criteria are patients with Intracranial ICA and/or MCA‐M1 or M2 occlusion,baseline NIHSS ≥ 6, Baseline ASPECTS score ≥ 5 on NCCT and/or Core Volumes <70mL + Mismatch > 50mL on CT perfusion (CTP), time fromlast seen well to start ofPP‐007infusion ≤ 24 hours,pre‐MorbidmRS< 2, and ineligibility for intravenous thrombolysis. The trial plans to enroll approximately 16–20 subjectswith3:1 randomizationtoPP‐007 (320 mg/kg with 30 min bolus + 2‐hour infusion) plus MT versus MT alone.

Results

Tenpatients have been enrolled so far.Mean age was 76.1 (STD±11.6), ASPECT score = 7.8 (±1.8), NIHSS at baseline = 17.3 (±5.6),TICI 2b or c in 7, TICI 3 in 3. Seven patients were randomized PP‐007 and received the complete infusion. Two patients were randomized to standard of care (MT only) and1was randomized to PP‐007 but not treated.Three patients had elevation of Partial Prothrombin Time (PTT) after the PP‐007 infusion that however had no clinical consequences.

Conclusions

HEMERA 1 isphase 1 clinical trialcurrently enrolling patients.No safety concerns were identified so far.
Abstract Number ‐ 17: Robot‐assisted transcranial Doppler versus transthoracic echocardiography for right to left shunt detection: Final Results
Authors: Rubin Mark N , Shah Ruchir , Devlin Thomas , Youn Teddy S , Waters Michael , Volpi John J , Stayman Aaron , Douville Colleen , Lowenkopf Ted , Tsivgoulis Georgios , Alexandrov Andrei V
Published: April 2023

Introduction

Right to left shunt (RLS), including patent foramen ovale (PFO), is a recognized risk factor for stroke. RLS/PFO diagnosis is made by transthoracic echocardiography (TTE) which is insensitive, transesophageal echocardiography (TEE) which is invasive, and transcranial Doppler (TCD) which is noninvasive and accurate but scarce.

Methods

We conducted a multi‐center device clinical trial of robot‐assisted TCD (raTCD) versus TTE for RLS diagnosis in patients who presented with an event suspicious for embolic cerebrovascular ischemia. raTCD was performed with standard TCD bubble study technique. TTE bubble study was performed to local standards. The primary outcome was rate of RLS detection by raTCD versus TTE.

Results

133 patients were enrolled (intention to treat, ITT) and 126 subjects had complete data. In the ITT cohort, mean age was 60 +/‐ 15 years, 46% were women, and 92% of qualifying events were diagnosed as ischemic stroke. raTCD was positive for RLS in 82 subjects (64%) and TTE was positive in 26 (20%) [absolute difference 43.4% (95% CI 34.3%‐52.5%), p < 0.001]. On prespecified secondary analysis, large RLS was detected by raTCD in 35 subjects (28%) vs 13 (10%) by TTE [absolute difference 17.5% (95% CI 10.1%‐24.8%), p < 0.001]. There were no serious adverse events.

Conclusions

raTCD was safe and 3 times more likely to diagnose RLS than TTE. TTE completely missed or underdiagnosed two thirds of large shunts diagnosed by raTCD. The raTCD device, used by health professionals with no prior TCD training, may allow providers to achieve the known sensitivity of TCD for RLS and PFO detection without the need for an experienced operator. TCD is the superior screen for RLS compared to TTE.
Abstract Number ‐ 31: No Mercy on Stroke Campaign: The Use of Pop Culture Icons to Raise Stroke Awareness
Authors: Dammavalam Vikalpa
Published: April 2023

Introduction

About 24–46% of acute ischemic strokes are due to large vessel occlusions1, however only a small fraction2,3 of thrombectomy eligible patients undergo emergent clot retrieval. Despite advances in thrombolytics and endovascular interventions, many patients are not candidates for emergent therapies due to delay in patient presentation, prehospital delay, triage delay and limited access to care. No Mercy on Stroke (NMOS) campaign aims to raise public stroke awareness by increasing social media footprint. Thereby enabling the general population with tools for earlier symptom detection, seeking rapid medical attention and fighting for legislature to improve prehospital networks.

Methods

Society of Vascular and Interventional Neurology (SVIN) launched NMOS campaign just prior to World Stroke Day (WSD) on October 25th, 2021 via Twitter. Pop culture icon and martialist Martin Kove launched the campaign as Sensei Kreese from the movie Cobra Kai in a video encouraging viewers to “strike fast and strike hard” when treating stroke. SVIN and Kove urged followers to spread the fight against stroke by sharing karate poses with hashtag #NoMercyOnStroke. Metrics such as social media reach, impact, location and others were extracted via Tweepsmap and Tweetbinder from October 25th, 2021 to August 20th, 2022.

Results

#NoMercyOnStroke was tweeted 716 times by 211 contributors4 across 19 countries and 77 cities5 for a potential reach of 374,200 people and potential impact of 2,051,908 people4. Tweet breakdown consisted of 126 original tweets and 590 retweets4. Engagements were primarily likes recorded at 2437, and followed by 97 replies and 55 quotes. Activity timeline was highest during week of WSD and accounted for majority exposure, however, there was another small peak in activity one month later. Top 3 countries involved were USA, Canada and India although USA accounted for 90.4% of all activity. Other countries include Mexico, Colombia, Spain, Egypt, Croatia, UK, Saudi Arabia, Kenya, Libya, Vietnam, Italy, Cuba, France, Peru, Chile and Venezuela5. Top associated hash tags were #worldstrokeday, #WSD and #alz0212465.

Conclusions

Use of pop culture icon as an advocate for stroke awareness greatly increased reach and impression of the NMOS campaign by touching nearly two million followers. Compared to raw data across three social media platforms for a similar campaign by Mission Thrombectomy called #BEFASTChallenge, #NoMercyOnStroke had exponentially more engagement with almost double the original posts and triple the retweets. Still, activity was concentrated around initial launch with minimal tail in the activity timeline. The overall impact of such campaigns on the end‐goal of decreasing the ratio of eligible thrombectomies to number of thrombectomies performed is yet to be uncovered. However, it is clear that larger campaigns involving celebrity influencers and community outreach are imperative to keeping the momentum of raising stroke awareness.
Abstract Number ‐ 35: Maximum Euclidean Deflection‐A Novel Metric For Safety Of Neurovascular Devices
Authors: Desai Shashvat M , Catapano Joshua , Majmundar Neil , Ducruet Andrew , Jadhav Ashutosh P
Published: April 2023

Introduction

Endovascular thrombectomy (EVT) devices are evolving rapidly to improve safety and efficacy of EVT‐mediated recanalization of large vessel occlusion strokes, and to access medium and distal vessel occlusions. To enable effective comparative analyses, there is a need to develop an objective in‐vitro safety metric for new EVT devices.

Methods

We utilized three FDA‐approved stent‐retrievers (4 mm diameter; variable lengths) currently available in the United States and deployed them in an in‐vitro ischemic stroke bench model (Sim Agility, Mentice Inc., Sweden). The stent‐retrievers were deployed in the M1 segment of the middle cerebral artery of the model using a system comprised of an 0.014 inch guide wire and 0.021 inch microcatheter. After unsheathing in the M1 segment, in the absence of a blood clot, the microcatheter was withdrawn back into the petrous internal carotid artery, and the whole system was withdrawn as a rate of 5 mm per second. Maximum deflection of the terminal internal carotid was measured in 3 axes using a specialized camera set‐up.

Results

A total of 3 passes were performed for each stent‐retriever (stent A, stent B, and stent C). Maximum deflection of the terminal internal carotid artery (from resting position to largest displacement during stent‐retrieval withdrawal) was measured in 3 planes and the values were as follows (Table).Maximum Euclidean Deflection (MED) ranged from 6.1 to 9.1 mm. Deflection varied based on 3 stent‐retriever designs and the plane of measurement. Figure demonstrates deflections as seen in Stent A.

Conclusions

Withdrawing an unsheathed stent‐retriever from the middle cerebral artery leads to significant deflection of the internal carotid artery terminus in an in‐vitro stroke model. The degree of deflection is variable in different planes and varies based on stent‐retriever design. Further studies are required to examine the predictors and impact of the deflection.
Abstract Number ‐ 43: Flow Diversion for Intracranial Aneurysms in Large Caliber Vessels: A Case Series
Authors: Vivanco‐Suarez Juan , Farooqui Mudassir , Rodriguez‐Calienes Aaron , Wakhloo Ajay K , Rabinovich Margarita , Abouelleil Mohamed , Altschul David , Feigen Chaim , Fifi Johanna T , Matsoukas Stavros , Al‐Mufti Fawaz , Galecio‐Castillo Milagros , Singer Justin A , Ortega‐Gutierrez Santiago
Published: April 2023

Introduction

The safe and effective profile of flow diverters (FD) has allowed neuro‐interventionalists to consider them as a versatile tool for the treatment of aneurysms with different morphologies, locations, and characteristics. Optimal deployment with complete wall apposition affects FD performance. However, few devices are suitable for aneurysms in large caliber vessels. Herein, we aimed to describe the safety and efficacy of a large caliber (5 mm) FD for the treatment of intracranial aneurysms.

Methods

We performed a retrospective, multi‐center cohort study of adult patients in whom a 5 mm Surpass Streamline FD was implanted between 2018 and 2021 in the United States. Efficacy outcome was complete occlusion at final follow‐up. Safety outcomes were ischemic/hemorrhagic events and mortality up to 30 days following the procedure. Secondary safety was assessed by the rate of adjunctive devices/treatments to overcome technical complications and improve wall apposition.

Results

A total of 29 patients harboring 29 aneurysms were treated with 39 FDs (36 large‐diameter devices). Mean age was 57.8 ± 15.7 years. Aneurysm morphologies were saccular (n = 15), pseudoaneurysm (n = 7), fusiform (n = 6), and dissecting (n = 1). Locations were internal carotid artery (ICA) petro‐cavernous segment (n = 15), ICA paraophthalmic (n = 5), ICA cervical (n = 4), basilar artery (n = 3), and vertebral artery (n = 2). Aneurysm size mean was 11.4 ± 6.7 mm, and neck size mean 6.5 ± 3.9 mm. Proximal FD landing zone vessel diameter was 4.8 ± 1.3 mm and distal 4.5 ± 1.2 mm. At a mean final follow‐up of 12 ± 6 months, 18 (65%) aneurysms were completely occluded. Ischemic/hemorrhagic events occurred in 2 (7%), and 1 patient died during hospitalization. Balloon‐assisted angioplasty was performed in 19 (66%) cases, adjunctive stenting in 8 (28%), and coiling in 1 (3%). Patients who received an adjunctive device/treatment had an 82% (14/17) complete occlusion compared to 66% (4/6) in those who did not.

Conclusions

The use of large caliber FDs to treat complex intracranial aneurysms located in large‐diameter dysplastic vessels is technically feasible and safe. The use of adjunctive devices and techniques to achieve optimal wall apposition seems crucial to optimize treatment outcomes. Comparative studies with devices specially designed for this patient population might provide further insights into the best device selection.
Abstract Number ‐ 62: Inhibiting neuron‐immune axis in acute stroke reverses microglia‐induced neuroinflammation
Authors: Guo Xiaofan
Published: April 2023

Introduction

Stroke is a major cause of adult disability and death worldwide. The subsequent development of neuroinflammation dramatically increases the risks associated with stroke. Microglia are key immune cells that respond to microenvironmental changes during ischemic stroke. The M1 subtype of microglia is a proinflammatory phenotype that promotes neuroinflammation‐induced secondary brain damage. However, the mechanism of stroke‐induced microglia M1 polarization and the interaction between microglia and neuron within the stroke area remain unclear.

Methods

Using a murine middle cerebral artery occlusion (MCAO) model and chemogenetics, we manipulated neuronal activity to study whether neuronal activity modulates microglia polarization and whether manipulating this neuron‐immune axis prevents neuroinflammation after stroke.

Results

Our findings demonstrate that the abnormal neuronal activation and depolarization induced by brain ischemia drive microglial proinflammatory M1 polarization through neuron‐derived exosome secretion through activating the NF‐kB pathway. Inhibiting the ischemia‐induced neuronal activity reversed this microglial M1 polarization and decreased the pro‐inflammatory cytokines in the mouse brain. In addition, midazolam administration inhibited the abnormal neuronal activity and the microglia pro‐inflammatory polarization.

Conclusions

Together, these findings indicate that inhibiting abnormal neuronal activation triggered by ischemia prevents the microglia‐induced neuroinflammation that could protect the brain from secondary brain damage.
Abstract Number ‐ 71: Management of Delayed Carotid Stent Fracture with an Overlapping Open Cell Design Stent: Case Report
Authors: Ravi Saisree , Desai Sohum , Hassan Ameer , Tekle Wondwossen G
Published: April 2023

Introduction

Stent fracture after carotid angioplasty and stenting is rare. Risk factors include presence of angulation, calcification, and restenosis increasing the risk of stent fracture. Although literature indicates that not all carotid stent fractures are associated with adverse outcomes, there is limited details on successful endovascular management of this entity. We describe a unique case of carotid stent fracture with symptomatic restenosis treated with an overlapping open cell stent with no residual stenosis and resolution of symptomology.

Methods

Case Report.

Results

A 79‐year‐old man with medical history of right sided symptomatic carotid artery stenosis which had been previously treated with endarterectomy and subsequently carotid stenting after a follow up carotid ultrasound demonstrated recurrence of severe right internal carotid artery (RICA) stenosis. Approximately 2 years after this index procedure, the patient returned with acute onset of left‐hand numbness. Cerebral angiography was performed that demonstrated 85% stenosis with a fractured carotid stent at segment of stenosis (Figure 1A, B). Furthermore, the lesion was found to be heavily calcified. This was determined to be the primary contributing factor in resultant artery wall stress, which over time led to carotid stent fracture. Angioplasty with placement of a new open cell stent and distal embolic protective device was performed successfully. The open cell stent was chosen for this approach as closed cell stents have been associated with an increased odds of in‐hospital stroke/death for carotid lesions, attributable to the lower degree of conformability with closed cell stents. After our stent placement, there was no significant residual stenosis visualized (Figure 1C, D). The patient’s symptoms resolved without any subsequent complaints on follow‐up visit.

Conclusions

While carotid stent fractures are a rare occurrence, we report a case of symptomatic carotid artery restenosis with a fractured stent due to significant lesion calcification and wall stress. This case was successfully treated with angioplasty and new open cell stent placement due to its potential advantages over closed cell stents in carotid artery lesions. Current literature indicates that carotid stent fractures have a low prevalence. However, there is a paucity of studies on the mechanism of stent fracture as well as optimal management of these fractured stents, suggesting a need for further study and characterization.
Abstract Number ‐ 101: Blood Pressure Interventions Are Most Common Reason for ICU Admission After MMA Embolization
Authors: Dharwadkar Niti Dharwadkar , Desai Sohum , Hassan Ameer , Tekle Wondwossen
Published: April 2023

Introduction

Middle meningeal artery embolization (MMAE) is a minimally invasive technique that is increasingly performed for the treatment of chronic subdural hematomas. In comparison to prior surgical interventions, which often resulted in complications such as insufficient drainage or recurrence of rebleeding, MMAE has greatly reduced the need for multiple inpatient hospitalizations. Some authors have described managing minimally symptomatic patients with MMAE in the outpatient setting. Our practice, however, has been routinely admitting patients to the neuro‐intensive care setting after MMAE. The objective of this research is to analyze the frequency of ICU level interventions that were administered to patients after MMAE in the neuro‐intensive care unit in order to gain a better understanding of postoperative management and assess the potential for future management in the outpatient setting.

Methods

A consecutive series of MMA embolizations for cSDH were retrospectively reviewed from 2020 to 2022 at Valley Baptist Medical Center in Harlingen, TX, USA. Frequency of ICU specific interventions such as need for post procedural mechanical ventilation, need for intravenous vasopressor or antihypertensive medications was recorded. Additional data collected included patient clinical presentations, indications for treatment, additional neurosurgical intervention, length of ICU stay, and blood pressure parameters.

Results

A total of 50 MMA embolizations were performed during the study period. The average age of patients included in the study was 63 years old +/‐ 16 years with 30% being female. 34% patients did not receive any sort of ICU level intervention at all. Among the remaining who did, 32% required mechanical ventilation post procedurally. 14% needed a vasopressor and 48% required intravenous antihypertensives to maintain systolic blood pressure within goal parameters.

Conclusions

The most common reason for an ICU intervention after MMAE was for correction of blood pressure to maintain within specified goal. 34% of patients who underwent MMAE did not require any ICU level interventions afterwards. Further investigation is warranted, but current data suggests that liberalizing blood pressure parameters could potentially reduce the need for ICU utilization after MMAE. Assessment of various components of ICU level interventions administered to patients post‐MMAE allows for a better understanding on preventive measures that can be taken in the future to reduce length of inpatient stay post procedurally, which would reduce risk of iatrogenic complications, minimize spread of nosocomial infections, andoverall increase patient comfort.
Abstract Number ‐ 111: Endovascular embolization of traumatic vessel injury using n‐butyl cyanoacrylate: A case series
Authors: Morsi Rami Z. , Thind Sonam , Baskaran Archit , Carrión‐Penagos Julián , Kramer Christopher L , Lazaridis Christos , Goldenberg Fernando , Prabhakaran Shyam , Mansour Ali , Kass‐Hout Tareq
Published: April 2023

Introduction

There is limited evidence on the use of N‐butyl cyanoacrylate (n‐BCA) liquid embolic in endovascular embolization of traumatic face and neck vessel injuries. We sought to investigate the safety and effectiveness of n‐BCA in treating traumatic vessel injuries.

Methods

In a prospectively maintained database, we retrospectively analyzed consecutive patients who presented with a vessel injury caused by either a penetrating or blunt injury in a large academic Level 1 trauma center between April 2021 and July 2022. We included patients aged ≥ 18 years with any vessel injury in the face and neck circulation. The primary endpoint was effectiveness of n‐BCA by immediate control of the active bleeding post‐embolization.

Results

A total of 10 patients required neuro‐endovascular embolization of traumatic vessel injury via n‐BCA. The mean age of patients was 41.10 (95%CI 28.41, 53.79), with a male predominance (n = 8, 80.0%). The mean Glasgow Coma Scale score on presentation was 10 (95% CI 6.20, 14.40). One patient had concomitant brain injury having subdural and subarachnoid hemorrhages. The mean score for Biffl classification was 5.00. Eight patients suffered penetrating gunshot wound injuries, and two patients suffered blunt injuries. Injured vessels included facial artery (n = 4, 40.0%), buccal branch artery (n = 2, 20.0%), internal maxillary artery (n = 2, 20.0%), cervical segment of the internal carotid artery (n = 1, 10.0%), and the V2 segment of the vertebral artery (n = 1, 10.0%). All patients were successfully treated with 2:1 n‐BCA to ethiodol with immediate extravasation control. Balloon guide catheter was used in 3 patients (30.0%). There was no recurrence of bleeding via vessel imaging or need for retreatment. One patient died in‐hospital (10.0%). Most patients were discharged home (n = 5, 50.0%), one discharged home with day rehab (n = 1, 10.0%), and one to an acute rehab facility (n = 1, 10.0%). One patient developed a right posterior cerebral artery territory infarct with hemorrhagic transformation post‐embolization.

Conclusions

To the best of our knowledge, this is the first study demonstrating the safety and effectiveness of n‐BCA liquid embolic in traumatic vessel injuries, especially penetrating gunshot wound injuries. Further research is needed to investigate the safety and efficacy in this population.
Abstract Number ‐ 116: Palliative Embolization on an Infantile Dural Sinus Malformation with Giant Lakes.
Authors: Kuybu Okkes , Mendez Aldo A , Atchaneeyasakul Kunakorn , Panigrahy Ashok , Greene Stephanie , Narayanan Sandra
Published: April 2023

Introduction

Dural Sinus Malformation (DSM) is a rare and high risk mortality vascular pathology identified early postnatal due to common clinical symptoms like macrocephaly, downward wandering eyes, bulging and pulsatile fontanels and heart failure. Most DSMs resolves prenatally. It is characterized by giant venous lake at the torcular region expanding towards the infratentorial and supratentorial spaces with usually existence of Dural arteriovenous fistulas (dAVF). Pathophysiology of DSMs are ballooning and malformation of the distal jugular bulb or persistence abnormal of the transverse sinus.

Methods

We performed the staged trans arterial Onyx‐18 embolization 5 times of a 3 mo infant boy with dural sinus malformation with multiple arteriovenous fistula using the 4 French GlideSim 2 Catheter, Headway Duo 167 micro catheter, and numerous microwires including Aristotle 014, Chikai Black Soft 014 and 010 and Synchro 014, 010 and 080 through alternated sides of transfemoral accesses. Embolizations were performed through the bilateral branches of the left and right middle meningeal arteries, posterior meningeal arteries and left occipital artery. Limitations during procedure are body weight to use contrast, fluoroscopy time and access sides.

Results

Post embolization injections demonstrated significant flow reduction into the malformation through ECA branches. No neurological complications occurred due to the procedures. MRI Brains in following weeks did not show large thrombus formation, hydrocephalus, or parenchymal injury. Patient showed clinical improvements with stable macrocephaly and decreased frontal pulsation and bulging.

Conclusions

Staged trans arterial embolization seems a safe approach on high mortality DSM. Thrombus is not formed all at once and mass effect from thrombosed sinus is avoided. Sinus has time to shrink.
Abstract Number ‐ 128: Predictors of the effects of flow diversion in very large and giant aneurysms
Authors: Bae Hong‐ju , Gopal Megha
Published: April 2023

Introduction

The treatment paradigm for very large and giant aneurysms recently changed to flow diversion, in light of the results of the Pipeline for Uncoilable or Failed Aneurysms trial. However, the effects of flow diversion was definitely unknown. We explored this topic and identified predictors of such effects.

Methods

We retrospectively reviewed 51 patients with unruptured aneurysms admitted to our institution for flow diversion between February 2014 and August 2019. Patients were categorized into an effect group (no filling or remnant entry) and a no‐effect group (subtotal or total filling). We evaluated aneurysm size and shape, incorporation vessel, parent artery stenosis and curvature, stagnation of contrast medium within the aneurysm, use or not of balloon angioplasty, and intra‐aneurysm thrombus, as potential predictors of the effects of flow diversion.

Results

The effect group comprised 34 patients (66.7%, 34/51; no filling [35.3%, 18/51] and remnant entry [31.4% 16/51]). The no‐effect group comprised 17 patients (33.3%, 17/51; subtotal filling [29.4%, 15/51] and total filling [3.9% 2/51]). The presence of an incorporation vessel (odds ratio 0.13, p = 0.021) and balloon angioplasty (odds ratio 0.05, p = 0.004) were independent risk factors for poor flow diversion (no‐effect group) in multivariate logistic regression analyses.

Conclusions

Flow diversion is effective for very large and giant aneurysms but the outcomes require further improvement. The results of this study show that an incorporated vessel and excessive balloon angioplasty might compromise flow diversion. Considering this finding can help improve the outcomes of flow diversion.
Abstract Number ‐ 135: Surpass Evolve® Flow Diversion for Embolization of Unruptured Anterior Circulation Aneurysms: 6‐month Obliteration Rates
Authors: Verhey Leonard H , Sewell Andrea , Lyons Leah , Mazaris Paul , Singer Justin
Published: April 2023

Introduction

The Surpass Evolve flow diverter (FD) is a 64‐wire cobalt‐chromium device with improved ease of deployment and conformability, compared to its predecessor. Data on procedural outcomes and aneurysm obliteration rate remain limited. The objective of this study was to describe the procedural outcomes, including 6‐month obliteration rates, for patients who underwent Surpass Evolve FD embolization of an unruptured anterior circulation aneurysm.

Methods

All consecutive patients with an unruptured anterior circulation aneurysm who were treated with the Surpass Evolve FD between Aug 2020 and May 2022 were included. Patients with a ruptured or posterior circulation aneurysm were excluded. Demographic and clinical features, aneurysm morphology, arterial access, and procedural factors and outcome were extracted from our departmental neurointerventional database. Summary statistics included frequencies, and measures of central tendency and dispersion as appropriate.

Results

Sixty patients (82% female, mean age 57.9 years ± 15.5) underwent elective Surpass Evolve flow diversion for an unruptured anterior circulation aneurysm. In 47 (78%) patients, a native aneurysm was flow‐diverted, and in 13 (22%) patients, FD was performed for a recurrent aneurysm. Distribution of aneurysm location was: supraclinoid ICA (65%), cavernous ICA (12%), cervical ICA (10%) and anterior cerebral artery (13%). Thirty‐nine (65%) patients underwent left‐sided intervention. Mean aneurysm maximal diameter was 8.7 ± 5.7 mm. The majority of patients (49, 82%) underwent radial arterial access. Balloon angioplasty or J‐wire manipulation was used to enhance apposition in 37 (62%) cases. To date, thirty‐five (58%) patients have had a follow up angiogram (mean 0.65 years ± 0.2 from intervention); in 5 patients, there was mild non‐flow‐limiting stenosis. Based on the Raymond‐Roy Occlusion Classification, 25 (71%) had complete occlusion, 1 (2%) had a residual neck, and 9 (26%) had residual aneurysm.

Conclusions

The Surpass Evolve FD is safe and associated with favorable occlusion rates at six months. In our early experience, complication rates are well within the acceptable limits.
Abstract Number ‐ 141: Microemboli Monitoring After Intrasaccular Flow Disruption: Single‐center Experience
Authors: Costa Matias , Allawi Aws , Vivanco‐Suarez Juan , Loh Yince , Patel Akshal , Monteith Stephen J
Published: April 2023

Introduction

The management of wide‐necked bifurcation aneurysms can be challenging due to multiple factors. Intrasaccular flow disruption with the Woven EndoBridge (WEB) has demonstrated a safe and effective profile. Current microemboli data after the WEB device placement is non‐existent. We evaluated the rate of embolic signals (MES) after WEB device implantation.

Methods

We performed a retrospective analysis of a prospectively maintained database including patients who underwent WEB device implantation for the treatment of unruptured intracranial aneurysms between 2021 and 2022. Variables studied included patient demographics, modified Rankin Scale (mRS) before and 3 months post‐treatment, comorbidities, aneurysm characteristics, platelet inhibition tests, and activated clotting time. All patients were on aspirin and a P2Y12 inhibitor and had therapeutic levels on platelet aggregation assays. Intraoperative heparin was given in all cases to keep a therapeutic ACT. P2Y12 drugs were stopped after the procedure. In all patients, MES monitoring was performed in the immediate postoperative period and >12 hours after the procedure.

Results

34 patients with 34 aneurysms were analyzed. Mean age was 67.4 years and 85% were females. Mean aneurysm size was 13.1 ± 2.0 mm and mean neck size 4.4 ± 1.5 mm. Locations were middle cerebral artery bifurcation and M1‐M2 segment (n = 13), basilar artery tip (n = 10), anterior communicating artery (n = 8), internal carotid artery terminus (n = 2) and pericallosal artery (n = 1). A single WEB was implanted in 100% of the cases. MES were negative in all cases. 3‐month mRS remained stable or improved in all cases. No procedure‐related complications were seen.

Conclusions

Our findings reinforce the safety profile of intrasaccular flow disruption. These findings differ from a previous analysis of unruptured aneurysms in our institution where a 7.7% incidence of MES was reported after endovascular treatment of unruptured aneurysms with primary or assisted coiling.
Abstract Number ‐ 144: Rescue Endovascular Treatment of Patients with Emergent Large Vessel Occlusion Due to Intracranial Atherosclerosis: Meta‐analysis
Authors: Almallouhi Eyad , Murad M. Hassan , Chalhoub Reda , Kicielinski Kimberly , Lena Jonathan , Brennan Emily , Zaidat Osama , de Havenon Adam , Spiotta Alejandro , Kasab Sami Al
Published: April 2023

Introduction

Acute stroke patients presenting with large vessel occlusion secondary to intracranial atherosclerosis (ICAS‐LVO) may require rescue therapy (RT) in addition to mechanical thrombectomy (MT) to achieve and maintain successful recanalization. We performed a systematic review and meta‐analysis of comparative studies that reported outcomes of RT in ICAS‐LVO patients to evaluate its safety and efficacy.

Methods

Databases searched include PubMed, CINAHL Complete, and Scopus from database date of inception through August 17, 2021. We included comparative studies that reported the outcomes of ICAS‐LVO RT compared to outcomes of ICAS‐LVO patients who did not undergo RT or to those presenting with embolic LVO patients (non‐ICAS LVO). Meta‐analysis using the random effects model was used to combine estimates reporting odds ratios (OR) and 95% confidence intervals (CI).

Results

Total of 9 nonrandomized studies were included: 5 studies in ICAS‐LVO RT vs. ICAS‐LVO non‐RT analysis and 5 ICAS‐LVO RT vs. non‐ICAS LVO analysis. Rescue treatments included intra‐arterial antiplatelets, angioplasty, stenting or combination of treatments. Compared to non‐RT ICAS LVO, RT was associated with increased favorable 90‐day outcome (OR 3.19, 95% CI 1.91‐5.32, I2 14%) and decreased 90‐day mortality (OR 0.35, 95% CI 0.16‐0.76, I2 21%) (Figure 1). In the analysis of ICAS LVO vs embolic LVO, the incidence of favorable 90‐day outcome and 90‐day mortality did not differ between the ICAS‐LVO RT and non‐ICAS LVO (OR 0.97, 95% CI 0.58‐1.64, I2 50%) and (OR 1.22, 95% CI 0.90‐1.66, I2 0%), respectively.

Conclusions

Rescue treatment is associated with better outcomes in ICAS‐LVO patients. The outcomes of ICAS‐LVO patients who receive RT may be comparable to embolic LVO patients (non‐ICAS LVO).
Abstract Number ‐ 146: Re‐stenting Following Recurrence after Venous Sinus Stenosis Stenting for Idiopathic Intracranial Hypertension
Authors: D'Amato Salvatore A , Martinez‐Gutierrez Juan Carlos , Kole Matthew J , Engstrom Allison C , Nguyen Tien , Inam Mehmat E , Tang Rosa , Al‐Zubidi Nagham , Adesina Ore‐Ofeoluwatomi O , Sheth Sunil A , Chen Peng Roc
Published: April 2023

Introduction

Venous sinus stenosis (VSS) stenting in medically refractory Idiopathic Intracranial Hypertension (IIH) patients has emerged as an effective treatment with low rates of failure and recurrence. However, the best treatment strategy following recurrence of symptoms in previously stented patients with initial response is unclear and frequently leads to shunt placement. We investigated the role of re‐stenting in patients with recurrence after prior successful stenting.

Methods

This is a retrospective review of a prospectively maintained IIH registry. Inclusion criteria included patients with confirmed IIH and angiographically demonstrable VSS who underwent interventions from 2012–2022. Patients were divided into those who underwent a single stenting procedure (Group S) and those who underwent placement of an additional stent due to recurrence of clinical symptoms and angiographic stenosis (Group R). All re‐stenting was performed in adjacent or remote regions of stenosis. Bivariate analyses were utilized to compare clinical outcomes.

Results

86 patients were included with a median age of 33 [IQR 26‐39] and 94% were females. Group S (79/86) and Group R (7/86) had similar baseline characteristics. There was similar improvement in post‐stenting opening pressure (22.4±6.7 vs. 25.2±4.6 cm H2O, p = 0.35, Group S vs. Group R), change in opening pressure (11.6±10.4 vs. 5.3±12.2 cm H2O, p = 0.20, Group S vs. Group R) and resolution of tinnitus (91.8 vs. 80%, p = 0.28, Group S vs. Group R). Headache improvement was higher in Group S at 6 weeks, but similar at 6 months (92.8 vs. 60%, p = 0.02 and 88.2 vs. 80%, p = 0.59, Group S vs. Group R). Group S also had higher improvement in visual disturbances at 6 months (93.8 vs. 60%, p = 0.01, Group S vs. Group R), but similar improvement in papilledema (92.2 vs 100%, p = 0.68, Group S vs. Group R). None of the re‐stented patients required VPS rescue.

Conclusions

VSS re‐stenting in IIH patients with recurrence after initial stenting is feasible with similar efficacy in reducing intracranial pressure and symptoms.
Abstract Number ‐ 153: Mobile stroke units in acute ischemic stroke: A comprehensive meta‐analysis of nineteen controlled trials
Authors: Doheim Mohamed F , Hagrass Abdulrahman Ibrahim , Al‐kafarna Mohammed , Mostafa Mohamed Abdelhady , Elfil Mohamed , Elsayed Sarah Makram , Fayoud Aya Mamdouh , Hamdallah Aboalmagd , Hasan Mohammed Tarek , Almaghary Bashar Khaled , Ragab Khaled Mohamed , Kamal Abdallah , Al‐Mufti Fawaz
Published: April 2023

Introduction

In certain circumstances, mobile stroke units (MSU) with on‐site treatment teams and a computed tomography scanner may offer faster therapy with tissue plasminogen activator (tPA) for stroke patients who need immediate treatment. We conducted a systematic review and meta‐analysis to compare clinical outcomes in MSU patients to those in conventional care.

Methods

We searched key electronic databases from inception till September 2021. The primary outcomes were mortality at 7 days and 90 days. The secondary outcomes included modified Rankin scale (mRS) at 90 days, alarm to intravenous thrombolysis (IVT) or intra‐arterial recanalization, and time from symptom onset or last known well (LKW) to thrombolysis.

Results

We included nineteen controlled trials and cohort studies to conduct our final analysis. Our comparison revealed that 90‐day mortality rate significantly declined in MSU group as compared to conventional care group (OR = 0.81, 95%CI [0.69,0.95]), while there was no significant difference at 7 days (OR = 0.88, 95%CI [0.68,1.15]). As regard achieving functional independence at 90 days (mRS = 0–2), MSU showed better results (OR = 1.24, 95%CI [1.03,1.49]). MSU was associated with shorter time from symptoms onset or LKW to thrombolysis (MD = ‐36.79, 95%CI [‐47.48, ‐26.10]) and alarm to IV thrombolysis or intra‐arterial recanalization (MD = ‐29.69, 95%CI [‐34.46, ‐24.92]).

Conclusions

Stroke patients treated in MSU had a lower incidence of the 90‐day mortality. They also had better functional independence at 90 days and time from symptom onset or LKW to thrombolysis than those treated with conventional care.
Abstract Number ‐ 156: Transradial versus Transfemoral Access for Mechanical Thrombectomy: A Meta‐Analysis of Nine Studies (2,161 Patients)
Authors: Elfil Mohamed , Doheim Mohamed F , Ghaith Hazem S , Salem Mohamed M , Aboutaleb Pakinam E , Aladawi Mohammad , Al‐Mufti Fawaz , Nogueira Raul G
Published: April 2023

Introduction

Previous studies have compared the transradial access (TRA) with the transfemoral access (TFA) in patients undergoing mechanical thrombectomy (MT) for acute ischemic stroke (AIS). We conducted this meta‐analysis to provide comprehensive evidence regarding the comparison of procedural and clinical outcomes of the TRA versus the TFA in AIS patients undergoing MT.

Methods

We performed a comprehensive literature search of four electronic databases (PubMed, Scopus, Web of Science, Cochrane CENTRAL) from inception until 1 May 2022. All duplicates were removed, and all references of the included studies were screened manually for any eligible studies. The full‐text articles of eligible abstracts were retrieved and screened for continued eligibility. Relevant data were extracted and then analyzed. For outcomes that constitute continuous data, the mean difference (MD) between the two groups and its standard deviation (SD) were pooled. For outcomes that constitute dichotomous data, the frequency of events and the total number of patients in each group were pooled as odds ratio (OR) between the two groups.

Results

Nine studies were included in this meta‐analysis, all of which were observational studies. The population of the studies was homogenous comprising a total of 2,161 patients who underwent MT, including 446 in the TRA group and 1,715 in the TFA group. There were no significant differences across the two groups in terms of successful recanalization (Thrombolysis in cerebral Infarction [TICI] score of 2b‐3: OR 0.83, 95% CI [0.55 to 1.25], P = 0.36) (Figure 1, A), complete recanalization (TICI 3: OR 1.16, 95% CI [0.50 to 2.68], P = 0.73), favorable functional outcome (90‐day modified Rankin scale [mRS] score of 0–2 (OR 0.86, 95% CI [0.53 to 1.41], P = 0.56), first‐pass reperfusion (OR 0.88, 95% CI [0.64 to 1.19], P = 0.41), number of passes (MD 0.12, 95% CI [‐0.18 to 0.42], P = 0.43) (Figure 1, B), access‐to‐reperfusion time (MD ‐3.92 minutes, 95% CI [‐9.49 to 1.65], P = 0.17), the amount of contrast used (MD 5.03 mL, 95% CI [‐20.27 to 30.33], P = 0.70), or symptomatic intracranial hemorrhage (OR 0.86, 95% CI [0.47 to 1.57], P = 0.62). However, access‐site complications were significantly less frequent in the TRA group as compared to the TFA group (OR 0.18, 95% CI [0.06 to 0.51], P = 0.001) (Finger 1, C).

Conclusions

In patients undergoing MT for AIS, the collective evidence suggests that the TRA seems to result in lower rates of access‐site complications than the TFA without any significant compromise in other clinical or procedural metrics. Large prospective studies are warranted.
Abstract Number ‐ 160: Insurance Status as a Predictor of Outcome in Mechanical Thrombectomy
Authors: Fedorova Margarita , Rodriguez Wilson , Christopher Kara , Linares Guillermo
Published: April 2023

Introduction

Multiple studies have shown socioeconomic disparities in accessing treatment for acute ischemic stroke. Recent studies revealed that mechanical thrombectomy (MT) is more likely to be performed in patients with commercial insurance compared to other insurance types (Medicare, Medicaid, and uninsured). Insurance status can be used as a proxy for the patient’s socioeconomic status (SES), however, limited published data is not indicative of significant influence of SES on outcomes. We aimed to compare outcomes of MT in association with patients’ primary insurance.

Methods

Patients who received mechanical thrombectomy at our institution between 2019 and 2022 were reviewed and categorized according to their insurance status with the following parameters: commercial insurance, Medicare, Medicaid, and uninsured. Baseline and outcome data including demographic characteristics, past medical history, and unfavorable outcome (defined by 3–6 on the 90‐day modified Rankin Scale) were assessed.

Results

Insurance status was available for 172 patients, 55% of which had Medicare as their primary payer, 19% had commercial insurance, 17% had Medicaid, and 9% were uninsured. The mean age was 64.9 years; uninsured 55.4, Medicaid 52.2, commercial 55.3. Patients on Medicare were significantly older at 73.9 (F = 48.94, p< 0.001). Post‐hoc tests showed that those with Medicare were significantly older than those who had commercial insurance, Medicaid, or were uninsured (p< 0.001 for each post‐hoc comparison). Multivariate logistic regression revealed that, compared to those with commercial insurance, those with Medicare had lower odds of having an unfavorable mRS at 90 days (aOR = 0.28, 95% CI = 0.10‐0.80). There were no significant differences for those uninsured or on Medicaid.

Conclusions

Patients with Medicare as their primary payer were found to have 72% lower odds of poor functional outcome at 90 days compared to those with commercial insurance, however, patients undergoing MT at our site were primarily Medicare eligible. These results are promising because they highlight non‐inferior outcomes with Medicaid and superior outcomes with Medicare compared to commercial insurance despite previous studies reporting limited access to MT.