bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract Number ‐ 60: Influence of Primary Wind Diameter and Length on Coil Volume: Comparing Stryker and CEREPAK coils
Authors: Grandhi Ramesh , Kottenmeier Emilie , Khaled Alia , Brouwer Patrick
Published: April 2023

Introduction

Coiling procedures for intracranial aneurysms (IAs) performed in the US have steadily increaseda, and volumetric efficiency may become an important consideration for hospitals. Coil volume depends on length and primary wind diameter (PWD), and volumetric efficiency can be achieved by either inserting more coils or using coils with larger volumetric filling. This scenario analysis evaluates the influence of PWD and length on total coil volume by comparing four similar Stryker and CEREPAK coils.

Methods

In this analysis, we test the influence of PWD (D2) and length (L) on the Coil Volume Formula: [Π(D2/2)2(L)]c. In two hypothetical scenarios, relative percent difference in total coil volume was calculated and compared between four Stryker Target 360 coils and four similar CEREPAK coils that were matched based on closest PWD and L. In scenario I, L remained constant and D2 varied. In scenario II, D2 and L were inversely varied. In both scenarios, coil volume achieved by CEREPAK and Stryker coils was calculated and descriptively compared.

Results

Scenario I: (a) Stryker Target XL 360 10mm x 40cm (D2 = 0.014”, length = 40cm) with volume of 39.726mm3 was matched to the CEREPAK Heliform XL 10mm x 40cm (D2 = 0.015”, length = 40cm) with 15% greater volume of 45.604mm3. (b)Stryker Target 360 3mm x 6cm (D2 = 0.010”, length = 6cm) with volume 3.040mm3 was matched to the CEREPAK Freeform 3mm x 6cm (D2 = 0.012”, length = 6cm) with 44% greater volume of 4.378mm3. Scenario II: (a) Stryker Target XL 360 12mm x 45cm (D2 = 0.014”, length = 45cm) with volume 44.692mm3 was matched to the CEREPAK Heliform XL 12mm x 42cm (D2 = 0.015”, length = 42cm) with 7% greater volume of 47.884mm3. (b)Stryker Target 360 5mm x 20cm (D2 = 0.010”, length = 20cm) with volume 10.134mm3 was matched to the CEREPAK Freeform 5mm x 15cm (D2 = 0.012”, length = 15cm) with 8% greater volume of 10.945mm3.

Conclusions

The four selected CEREPAK coils compared to four equivalent Stryker coils achieved higher total coil volume in all scenarios. An increase in PWD by as little as 0.001”‐0.002”, improved relative coil volume by 15%‐44% (with equivalent coil length) and 7–8% (with varied coil length by 3–5cm). Clinicians evaluate many coil characteristics when treating an IA, however, PWD might be given consideration over length due to its impact on total coil volume.
Abstract Number ‐ 65: US Comprehensive Stroke Center Utilization of FAST and BEFAST Mnemonics for Public Education
Authors: Hogge Christopher , Aroor Sushanth , Goldstein Larry
Published: April 2023

Introduction

Symptom recognition and timely access to treatment are critical components of acute stroke care systems. Two mnemonics widely used in public educational campaigns for recognizing stroke symptoms include FAST (Face‐Arm‐Speech‐Time) and BEFAST (Balance‐Eyes‐Face‐Arm Speech‐Time). The FAST mnemonic, endorsed by the AHA/ASA can miss up to 14% of strokes. BEFAST includes common posterior circulation stroke symptoms and has been implemented by several Comprehensive Stroke Centers (CSCs).

Methods

We sought to analyze the pattern of public educational materials available on the websites US CSCs. The Joint Commission (JC) quality check website compiles a list containing the names and locations of the country’s 217 JC‐certified CSCs, which was downloaded in August, 2022. Each CSC’s website was searched for educational material containing FAST and BEFAST mnemonics for stroke symptom recognition.

Results

The FAST mnemonic was listed by 35%of CSCs, the BEFAST by 58%, with 7% listing no specific mnemonic. The highest portion of CSCs using BEFAST was in western (65%) and southeastern (63%) states. The highest percentage of CSCs with no listed mnemonic were in the northeastern (14%) and southeastern (13%) states.

Conclusions

Consistency is critical in shaping public health education related to stroke symptoms. Our study suggests further effort is needed to unify the public messaging on stroke recognition.
Abstract Number ‐ 67: A case of Carotid blowout syndrome, case report, and review.
Authors: Lakki Vinay Bhushan Reddy , Singh Abhishek
Published: April 2023

Introduction

Carotid blowout syndrome (CBS) is a potentially fatal carotid artery rupture. It is an unforeseen complication during mechanical thrombectomy that can be catastrophic without timely diagnosis and intervention. CBS develops when a damaged arterial wall cannot sustain its integrity, especially in patients who have undergone surgery or radiotherapy due to cancer. Carotid blowout syndrome is classified as threatened (type1), impending (type2), and acute (type3). Endovascular techniques have emerged as preferable alternatives to surgical ligation for treatment of CBS. Previous systemic reviews and meta‐analyses demonstrated that both coil embolization and stent grafting may be safe treatment options for CBS. This case study aims to show that early detection and endovascular management with transient distal balloon occlusion and stenting are lifesaving measures.

Methods

Case‐report

Results

Case presentation: 60‐year‐old male with past medical history of lung cancer s/p chemotherapy and radiation, hypertension, and methamphetamine abuse presented with left‐sided weakness and dysarthria, onset was 2 hours prior to arrival, his NIHSS was 11, CT head was negative for hemorrhage, CT angiogram of head and neck showed tandem occlusion of right ICA and right MCA bifurcation, he was in window for intravascular thrombolysis without contraindication, so he received Alteplase, he was brought into Angio‐suite for mechanical thrombectomy, On Right CCA injection there was complete occlusion of Right ICA with TICI‐0 flow, distal branches of Right ACA and MCA were not visualized. Mechanical thrombectomy was done on Right ICA and Right MCA. During clot retrieval, flow arrest was achieved by inflating the balloon guide with diluted contrast. Post thrombectomy there was extravasation around the right CCA and ICA, so the balloon guide was reinflated to have a florist around the catheter and hemostasis in the right ICA, two carotid stents were deployed sequentially with rapid exchange technique with overlapping technique, an endovascular graft was introduced and deployed at mid cervical segment at the point of leak and dissection. Post mechanical thrombectomy, TICI‐3 flow in the right ICA, and MCA were achieved, the patient was discharged to rehab in a stable condition on dual antiplatelet regimen.

Conclusions

CBS is a rare complication during mechanical thrombectomy, early and aggressive intervention in CBS is crucial to prevent devastating consequences, Transient balloon occlusion distal to the carotid blowout of the ICA is a reasonable technique for completing endovascular management with stenting.
Abstract Number ‐ 75: Simultaneous Extracranial‐Intracranial Management of Tandem Lesion (Seimless Technique) in Posterior Circulation Stroke
Authors: Kareemchaubal Samer AbdulVarun , Kareem Mustafa Abdul , Lin Eugene , Zaidat Osama
Published: April 2023

Introduction

Simultaneous extracranial‐intracranial management of Tandem lesion in stroke (Seimless technique) is well published and important technique in treating tandem lesions in anterior circulation. However, this technique has been rarely used in the posterior circulation. We present the case of a 70 year‐old male presented with coma and was found to have right vertebral artery origin stenosis with super‐imposed thrombus and tandem occlusion of the basilar artery. We used endovascular Seimless technique successfully with TICI‐3 reperfusion score and good clinical outcome. To our knowledge, this is the first case report for endovascularSeimless technique used in the post circulation.

Methods

We reviewed our endovascular mechanical thrombectomy data from May 2019 to July 2022 and those with post circulation tandem occlusion were selected. Baseline demographics and clinical presentation were obtained including clinical outcome.

Results

70 year‐old male with history of high blood pressure presented with state of coma was found to have right vertebral artery origin stenosis with superimposed pedunculated thrombus and tandem distal third Basilar artery occlusion. Patient underwent simultaneous extracranial‐intracranial management of tandem lesions (Seimless technique) through right trans radial basilar artery thrombectomy with stent retriever and aspiration as well as right vertebral artery origin aspiration and balloon angioplasty over the wire of the stent retriever. Following day, the patient underwent right trans‐radial vertebral artery origin stenosis stenting. Patient’s neurological exam was improved from NIHSS 30 to 0 at the time of discharge. We performed Basilar artery thrombectomy using Rist catheter, Red 62 reperfusion catheter, Rebar microcatheter and Solitaire stent retriever4 mm x 41 mm. After deploying the stent retriever, we advanced sterling balloon 4 mm x 20 mm over the stent retrieverwire and performed optimal balloon angioplasty.

Conclusions

This particular technique of treating intracranial and extracranial lesion simultaneously for posterior circulation hasn’t been reported in the literature. By presenting this case, we want to conclude that in selective posterior circulation tandem occlusion strokes “Seimless technique” can be used effectively and safely without many complications.
Abstract Number ‐ 78: An Unusual Cause Of Progressive Visual Loss – Vein Of Galen Malformation
Authors: Santiago Raphael , Chin Allison , Martucci Maria , Obrzut Michal
Published: April 2023

Introduction

Vein of Galen Malformations (VOGM) are rare vascular conditions resulting from anomalous vascular shunts between primitive choroidal vessels and the Markowski Prosencephalic Vein (MPV). They comprise only 1% of all intracranial vascular malformations with a high mortality rate up to 76.7% if untreated. In this case report, we aim to bring awareness of this condition as a cause of progressive visual loss with the objective of making it relevant in our medical community.

Methods

We discuss the case of a truck driver who progressively and slowly lost his vision as a consequence of a VOGM.

Results

In this case report we present a 49‐year‐old man with a past medical history of hypertension and renal insufficiency who initially presented to his ophthalmologist for progressive vision loss accompanied by headaches. Bilateral papilledema was seen on examination as well as near complete vision loss on the right eye and 20/40 visual acuity on the left eye. He was referred to neurosurgery for suspicion of elevated intracranial pressure. CT angiogram demonstrated multiple areas of fistualization to the VOGM, including branches from the meningeal hypophyseal divisions, bilateral distal PICA divisions, and the thalamic striate divisions. A multisession endovascular treatment with multiple embolizations was pursued. Initially, the patient underwent a transarterial embolization of the left middle meningeal artery (MMA) and left occipital artery (OA) followed by embolization of the 4 branches of the right MMA. Then, he underwent embolization of 8 large feeding branches and three weeks later, transvenous coiling of the MPV was done. Post‐embolization angiograms showed progressive decrease in the size of the malformation, the degree of the shunt and, and in cortical venous reflux with near normalization of the capillary and venous phases timing in the left and right hemispheres. Although, the patient did not recover from prior visual deficits, his symptoms remained stable.

Conclusions

It is important to keep this unusual cause of progressive vision loss within the differential diagnosis. The earlier this diagnosis is made, the quicker patients can receive treatment preventing long term deficits, morbidity and mortality.
Abstract Number ‐ 82: Central Retinal Artery Metallic Embolus After Ophthalmic Segment Internal Carotid Artery Aneurysm Flow‐diverter Embolization
Authors: Chaudhry Thymur A , Niemann David
Published: April 2023

Introduction

Flow‐diverting stents are effective devices in treating what would have previously been difficult to treat aneurysms such as wide‐necked, fusiform, blood blister, or giant aneurysms. Although generally safe, complications have been reported such as ischemia, in‐stent stenosis, and side branch occlusion, as well as device related complications such as stent migration and incomplete expansion. We present a case report of a patient who was incidentally found to have a reflective metallic embolus within the central retinal artery after two flow‐diverter stent embolization of the ipsilateral ophthalmic segment aneurysm.

Methods

Case report.

Results

A 44 year‐old female presented with incidental discovery of a 4mm paraopthalmic aneurysm. She underwent two flow‐diverter (Pipeline ©) embolizations with decreased although persistent filling of the aneurysm sac. After the second embolization procedure, the patient was referred to Opthalmology after incidental note of a small submillimeter reflective metallic embolus adjacent to the fovea seen on a screening Optometry exam upon workup for reader glasses. The patient was asymptomatic without visual complaints, blurriness, floaters, or change in vision.

Conclusions

We present a case of a tiny submillimeter reflective metallic embolus after flow‐diverter stent placement within the ipsilateral ophthalmic artery. This is the first report we are aware of describing such a complication after the use of flow‐diverter stent deployment. It is possible that the increased friction from two apposing stents could cause microfractures and subclinical emboli.
Abstract Number ‐ 87: Successfull thrombectomy followed by balloon mount stent placement on acute basilar artery occlusion
Authors: Ota Riichi , Neves Gabriel , Montalvan Victor , Bushnaq Saif
Published: April 2023

Introduction

Basilar artery occlusion accounts for 10% of all ischemic stroke caused by intracranial large vessel occlusion (LVO) with high morbidity and mortality. Endovascular intervention has been shown effective in the anterior circulation LVO but multiple trials, however a few trials failed to demonstrate the benefit of endovascular intervention over medical therapy, furthermore, there is no trial regarding the benefit of permanent stent deployment in the basilar artery over maximized medical therapy. Here we present a patient who presented with right side hemiplegia, facial droop, and dysmetria with National Institute of Health Stroke Scale of 19. CT head and neck angiography revealed acute basilar occlusion. Endovascular procedure was performed with successful thrombectomy utilizing stent retriever followed by placement of balloon mounted stent due to persistent critical basilar stenosis.

Methods

A case report

Results

MRI of the brain revealed acute ischemic stroke of bilateral cerebellar hemisphere, mid and left pons, left cerebral peduncles, and left thalamus. Repeat non‐contrast CT head revealed small bilateral thalamic hemorrhage but due to small size, dual antiplatelet therapy with aspirin and ticagrelor was initiated. After discharge, the patient developed upper extremity deep vein thrombosis for which apixaban was started. Despite dual antiplatelet therapy and anticoagulation, the patient continued to improve. Clinical follow‐up at 6 weeks the patient remained stable with mild residual weakness of the right extremities.

Conclusions

Thrombectomy with subsequent deployment of permanent stent can be considered as a safe and effective measure of basilar artery occlusion.
Abstract Number ‐ 92: Successful thrombectomy with Indigo Aspiration System on diffuse cerebral sinus thrombosis
Authors: Bushnq Saif , Ota Riichi , Neves Gabriel , Montalvan Victor , Windisch Thomas
Published: April 2023

Introduction

Endovascular treatment for venous sinus thrombosis is challenging. Commonly utilized aspiration catheters in neuro‐interventional procedures have diameters ranging from 2–3 mm and are much smaller than the average diameter of the major cerebral venous sinuses. Penumbra’s Indigo Aspiration System (Penumbra Inc., Place Alameda, CA) is a trackable, large‐lumen (Indigo System CAT7, 7F) catheter and aspiration system that is used for aspiration of thrombi and emboli involving the peripheral venous and arterial systems, as well as pulmonary emboli. Here, we show that this large‐lumen system may safely retrieve and successfully recanalize cerebral venous thrombosis (CVT), addressing the problem of available tools for complete thrombus removal.

Methods

Case report. I wanted to submit this abstract for: ‐Young Investigator Award ‐Best Scientific Abstract Award

Results

Here, we present the first reported case of successful endovascular thrombectomy of cerebral venous sinus thrombosis utilizing Penumbra’s Indigo System (Penumbra Inc., Place Alameda, CA), a minimally‐invasive system with a large‐lumen (Indigo System CAT7, 7F) catheter predominantly used for the removal of thrombi and emboli involving the peripheral arterial and venous systems and for the treatment of pulmonary embolism. A 30‐year‐old female presented with a hemorrhagic infarct of the left posterior temporal lobe secondary to an extensive cerebral venous thrombosis (CVT) extending from the left transverse sinus to the ipsilateral internal jugular bulb. In addition to a continuous heparin infusion, we performed an endovascular thrombectomy with the device mentioned above, resulting in a technically successful radiographic recanalization of the involved sinuses. The patient was discharged home in a stable condition. This case demonstrates that this trackable, atraumatic, large‐bore system can be safe and efficacious, permitting near complete thrombus removal.

Conclusions

Cerebral Venous Thrombosis (CVT) recanalization is an important outcome measure in trials investigating endovascular therapies for dural venous sinus clots.Most endovascular tools used for aspiration of CVT are designed for arterial, not venous, vasculature.Penumbra’s Indigo Aspiration System, a large‐lumen catheter can be considered as a valid, safe, and effective alternative for the treatment of diffuse CVT.
Abstract Number ‐ 95: Common Data Elements Analysis of Mechanical Thrombectomy Clinical Trials for Acute Ischemic Large Core Stroke
Authors: Jabal Mohamed Sobhi , Ibrahim Mohamed , Thurnham Jade , Kallmes Kevin , Kobeissi Hassan , Ghozy Sherief , Hardy Nicole , Tarchand Ranita , Bilgin Cem , Heit Jeremy , Brinjikji Waleed , Kallmes David
Published: April 2023

Introduction

Various clinical trials addressing large core acute ischemic stroke (AIS) are ongoing from multiple international groups. Future development of clinical guidelines depends on meta‐analyses of these trials calling for a degree of homogeneity of elements across the different studies. The aim of this common data element study was to provide an overview of the key features of pertinent large core infarct trials.

Methods

PubMed and ClinicalTrials.gov databases were screened for published and ongoing clinical trials assessing mechanical thrombectomy in patients with AIS with large core infarct. Nested Knowledge AutoLit living review platform was utilized to categorize primary and secondary outcomes as well as inclusion and exclusion criteria for patient selection in the clinical trials.

Results

The most reported data element was ASPECTS score, but with varied definitions of what compromises large core. Non‐utility‐weighted modified Rankin Score (mRS) was reported in 6/7 studies as the primary outcome, while the utility‐weighted mRS was the outcome of interest in the TESLA trial, all of them at the 3‐months mark, with only LASTE looking for mRS shift at the 6‐months mark. Secondary outcomes had more variations. Mortality is reported separately only in 4/7 trials, all at the 3‐month mark. Additionally, the TENSION trial reports the frequency of serious adverse events, including mortality, at the 1‐week and 12‐month mark.

Conclusions

In the published and the ongoing large core trials, there is a large degree of variability in the collected data elements. Differences in definition and timepoints renders reaching a unified standard difficult, which hinders high quality meta‐analyses and cohesive evidence‐driven synthesis.
Abstract Number ‐ 96: The COGNITIVE study: Cognition and Imaging with Tigertriever
Authors: Singer Justin , Mufti Fawaz Al , Tateshima Satoshi
Published: April 2023

Introduction

Results of systematic reviews and studies evaluating treatment effects of cerebrovascular interventions on the prevalence of post‐stroke cognitive impairment vary likely due to heterogeneity in populations, sample size, variable treatment effect, and time and methods of cognitive examination. Like thrombolytic therapy, endovascular therapy (EVT) in large vessel occlusion (LVO) stroke is strongly associated with successful reperfusion, reduced mortality, and good clinical outcomes. Nevertheless, the effect of successful reperfusion after EVT on cognitive function remains unexplored.

Methods

Four hundred (400) patients aged 18–75 will be enrolled in the USA and outside USA clinical centers. The primary endpoint will be the association between successful reperfusion, defined as eTICI ≥ 2b50, and cognitive benefit, defined as delta Montreal Cognitive Assessment (MoCA) from 4 days to 180 days post‐EVT or MoCA ≥ 26 at 180 days post‐EVT. Secondary endpoints will include first pass successful revascularization, reduction in hypoperfusion volumes within 24 h, functional evaluations (NIHSS, mRS), MoCA and cognitive battery evaluations, and QOLs at various timepoints, baseline to 180 days post‐EVT. The correlation between cognitive function and stroke characteristics, imaging variables, functional ability, and demographic and socio‐behavioral factors will be explored. Safety endpoints will include all‐cause mortality, symptomatic intracranial hemorrhage within 24 h, and device‐related serious adverse events. Key inclusion criteria are per instructions for use (IFU) and pre‐stroke mRS ≤1. Key exclusion criteria are per IFU, prior hemorrhage or stroke within 3 months, and pre‐existing cognitive impairment and/or dementia.

Results

More study details including the statistical analysis plan and study status will be discussed.

Conclusions

COGNITIVE is a very first multi‐center, post‐market, prospective, single‐arm EVT study to evaluate whether successful reperfusion with the Tigertriever device is associated with cognitive benefit in subjects with LVO. The study is a superiority design to evaluate whether Tigertriever treatment significantly reduces cognitive impairment.
Abstract Number ‐ 97: Middle meningeal artery embolization to treat chronic subdural hematomas – Retrospective study of morphological parameters
Authors: Syed Shoaib , Syed Shoaib , John Kevin , Dashti Reza , Fiorella David , Sadasivan Chander
Published: April 2023

Introduction

Chronic subdural hematomas are a common neurovascular condition that involve the gradual and continual exudation of fluid from a compromised cell layer lining the dura [1]. Embolization of the middle meningeal artery (MMAE) results in lower recurrence rates as compared to traditional surgical burr hole evacuation [2‐4]. Liquid embolic agents such as cyanoacrylates or ethylene vinyl alcohol copolymers can potentially provide a distinct advantage with greater distal penetration resulting in faster hematoma resolution [5]. Their inherent radiopacity (after pre‐mixing) also allows for accurate visualization and control over embolization. The hypothesis of this study is that liquid embolic surface area would correlate with more effective cSDH volume resolution in patients.

Methods

Under IRB approval, we retrospectively analyzed non‐contrast head CTs and immediate post‐embolization flat‐detector CTs from 45 patients who underwent first‐line MMAE with a liquid embolic. Patients who received any neurosurgical intervention were excluded. 3D‐Slicer was used to segment and calculate hematoma volumes pre‐embolization, as well as at 1‐month, 3‐months, and 6‐months post‐embolization. The flat‐detector CT scans were also segmented to calculate the surface area of the liquid embolic.

Results

There was significant reduction in hematoma volume at 1‐, 3‐ and 6‐months with respect to the preoperative cSDH volume (Figure A, Pre: pre‐treatment, mo: month). The liquid embolic surface area significantly correlated with (a) pre‐embolization hematoma volume (R2 = 0.27, p = 0.0002, n = 45), (b) the reduction in volume at 1‐month post‐embolization (R2 = 0.16, p = 0.007, n = 41), (c) volume reduction at 3‐months post‐embolization (R2 = 0.29, p = 0.0015, n = 32), (d) hematoma volume resorption rate (cc/day) calculated at 1‐month post‐embolization (R2 = 0.16, p = 0.011, n = 39), and (e) hematoma volume resorption rate calculated at 3‐months post‐embolization (R2 = 0.34, p = 0.0003, n = 34, Figure B). The liquid embolic surface area was not correlated to the volume reduction at 6‐months (p = 0.3, n = 26).

Conclusions

The luminal surface area of MMA vasculature embolized with liquid embolics may be correlated to the reduction in cSDH volumes. The liquid embolic segmentation method used here needs further refinement to improve accuracy. Additional data sets are required to confirm the correlations reported here.
Abstract Number ‐ 102: Middle Meningeal Artery Embolization Failure Profile: A Single Institution Retrospective Study
Authors: Mahmoud Noor A , Coulibaly Nangorgo J , Ernst Griffin , Raney Brasen C , Shakir Hakeem J
Published: April 2023

Introduction

Middle Meningeal Artery (MMA) embolization has emerged as a qualitative treatment option for subdural hematomas (SDH). Multiple studies have compared MMA embolization to other alternatives, namely surgery, and conservative treatment, with some indicating that MMA embolization was as effective and safe as the other two options. This study aimed to identify predictors of failures in SDH patients undergoing an MMA embolization.

Methods

We retrospectively reviewed 52 patients receiving MMA embolization for subdural hematoma management at our institution from 2020 until July 5, 2022 either as primary or adjunctive management. Patients who were under the age of 18 were excluded. Our definition of failure was any MMA embolization requiring an additional surgical procedure to evacuate the hematoma or relieve persistent symptoms.

Results

52 patients with mean age of 71±14 and male gender 36 (69.2%) were reviewed. Most common presenting symptom was headache27 (51.9%) followed by gait instability22 (42.3%).35 out of 52 patients underwent MMA embolization as primary management of chronic subdural hematoma without prior surgical treatment. Six out of the 35 patients (17.1%) required a rescue surgical treatment due to increased hematoma size or recurrence of symptoms. Our early trend shows that half of the patients whose MMA embolization failed had a possible onset of SDH between 2 to 4 weeks prior the embolization. This trend is similar to Khorasanizadeh et al. description in which they concluded that late‐stage SDH was more predicated to have a failure of MMA embolization compared to early‐stage SDH (1). Of the remaining three patients, one was diagnosed with metastatic prostate cancer to the bones and kidney. This patient passed away 12 days after the procedure despite a craniotomy post‐embolization.

Conclusions

More clinical trials are needed to further establish MMA embolization as standard of care in the management of cSDH in a subset profile of patients with higher success rates.
Abstract Number ‐ 106: Particle Versus Liquid Embolic Materials in Middle Meningeal Artery Embolization for Chronic Subdural Hematoma
Authors: Krothapalli Neeharika , Patel Smit , Fayad Mohamad , Elmashad Ahmed , Patel Raj , Sussman Eric , Bruno Charles , Ollenschleger Martin , Mehta Tapan
Published: April 2023

Introduction

Chronic subdural hematoma (cSDH) is one of the most common neurosurgical diagnoses with a high recurrence rate in the aging population. The primary pathologic process is repeated micro bleeding from fragile neo‐vessels supplied by peripheral branches of the middle meningeal artery (MMA). MMA embolization is an efficacious minimally invasive neuroendovascular technique for the management of chronic subdural hematoma. It has demonstrated reduced incidence of re‐bleeding and recurrence of cSDH in elderly patients. Particle and liquid embolic materials are commonly used to devascularize the MMA however studies comparing the safety and outcomes between these two materials are limited. Our objective was to perform a descriptive analysis to investigate differences and outcomes among two most frequently employed materials for MMA embolization.

Methods

We performed a single center retrospective review of patients ≥ 18 years who had MMA embolization for cSDH between July 2020 and May 2022. The primary safety, radiation dosage, fluoroscopy time, radiographic and clinical outcomes were compared between particle and liquid embolization. A descriptive analysis for continuous and categorical variables was performed using SAS 9.4 version.

Results

In a cohort of 116, 48 (41.38%) were treated with liquid embolic material and 68 (58.62%) were treated with particle. The median age of the cohort was 73 years in particle group and 73.5 years in liquid embolic group. There was no significant difference in radiation dose or duration among both groups. There was no reported mortality associated to procedure. One patient experienced non‐disabling ischemic stroke in the particle group. Based on imaging follow‐up, three patients in particle group and one in liquid embolic group had asymptomatic recurrence. One patient in each group had symptomatic recurrence requiring hematoma evacuation. Index median size of hematoma was 12 mm in particle group and 11 mm in liquid embolic group. At approximately one month follow up, the median size of hematoma reduced to 6 mm in both groups.

Conclusions

Our series demonstrates that liquid embolic and particle embolization are equally safe and effective among patients undergoing MMA embolization for management of cSDH.
Abstract Number ‐ 123: Retained microvascular wire during acute stroke thrombectomy and stenting.
Authors: Giurgiutiu Dan‐Victor , Tong Brian
Published: April 2023

Introduction

There is limited information on retained wires during neuro interventional ischemic cases, although there is a wealth of information on cardiac cases. Retained wires can present with thrombosis, perforation, or may be followed for longer period of time, with no complications. Changes in outcome vary on the ability of the wire to migrate, the size of the vessel adjacent to the wire, and the difficulty in retrieving the retained item.

Methods

We present a case report on a 56‐year‐old man who presented in 2018 with a left internal carotid occlusion horizontal petrous level, with no early signs of stroke on CT, and 106 mL penumbra on CT perfusion (CTP), with dense expressive and receptive aphasia.

Results

Patient developed hemiparesis while sitting sitting up, and drops in blood pressure, below the presenting blood pressure of 200 over 100 mmHg. The patient was taken for emergent thrombectomy. Patient underwent petrous thrombectomy with a residual high grade stenosis. This was followed by cavernous angioplasty, and Wingspan stenting. We attempted to cross the stenosis with a Gateway balloon and Synchro2 microwire. The wire tip was trapped and separated after extensive rotation, with a retained 5 mm tip. After inspecting the wire, there is no clear evidence of any a retained product. The tip was secured with a Wingspan stent. After thrombectomy and stenting aphasia improved. Four days later the patient developed worsening aphasia, and was found to have stent reocclusion. During CT angiography (CTA) it became apparent that a small wire extended from the left internal carotid petrous segment at the level of the wingspan stent down to the descending aorta. CT angiography of the chest and abdomen after reperfusion found that the wire was anchored in the left internal carotid, and extended down to the renal artery. Thrombus was aspirated, and ICA reconstructed with coronary stents in the petrous, and self‐expanding stents in the cervical segments, with TICI 3 reperfusion. Follow‐up imaging with CT chest and abdomen at six months, one year, and four years found the wire to be still anchored to the left internal carotid stent, and stable in the superior mesenteric artery. There is no evidence of thrombus formation, or distal embolization. We examined a Synchro2 microwire ex vivo were able to detach the tip, and have the inner core unravel up to a meter in length. Given that the wire shaft did not appear to be altered, the retained product was likely an unraveled inner core.

Conclusions

Retained neurovascular products can predispose to reocclusion, and should be secured. Once secured the course can be benign. When a wire with a wound core is fractured, unwound core can remain behind with the wire appearing as if it has been fully retrieved.
Abstract Number ‐ 126: Use of Woven EndoBridge device for Aneurysms in Off‐Labeled Locations: Systematic Review and Meta‐Analysis
Authors: Rodriguez‐Calienes Aaron , Vivanco‐Suarez Juan , Galecio‐Castillo Milagros , Malaga Marco , Zevallos Cynthia , Farooqui Mudassir , Moran‐Mariños Cristian , Fanning Noel F. , Algin Oktay , Pabon Boris , Mouchtouris Nikolaos , Jabbour Pascal , Ortega‐Gutierrez Santiago
Published: April 2023

Introduction

The Woven EndoBridge (WEB) device was originally approved to treat intracranial wide‐necked saccular bifurcation aneurysms. Recent studies have suggested its use for the treatment of intracranial aneurysms (IA) in alternative locations with variable success. We aimed to evaluate the safety and efficacy of the WEB for IAs in off‐labeled locations using a meta‐analysis (MA) of the literature.

Methods

We performed a systematic review of all studies including patients treated with WEB for IAs in locations different than what is currently on‐label FDA until May 2022. Our primary efficacy and safety outcomes were adequate occlusion at last follow up and a composite of intraprocedural and postprocedural complications, respectively. The Raymond‐Roy (RR) scale and the Bicêtre Occlusion Scale Score (BOSS) were used to define complete (RR: 1; BOSS: 0‐0’) and adequate (RR:1‐2; BOSS: 0–2) occlusion. Additional safety outcomes included intraprocedural (thromboembolic, hemorrhagic, device deployment, or air embolism) and postprocedural (ischemic or hemorrhagic) complications, and mortality. We performed a random‐effects MA of proportions and assessed the certainty of the evidence using the GRADE approach. Statistical heterogeneity across studies was assessed with I2 statistics. Logistic regression of the patient level data was used to study the predictors of complete occlusion.

Results

Ten studies were selected, and 285 patients (79% female; mean age 58 years) with 288 aneurysms (35% ruptured) were included. Adequate and complete occlusion rates were 89% (95% CI 81–94%; I2 = 0%; moderate‐certainty evidence) and 64% (95% CI 57–70%; I2 = 13%; moderate‐certainty evidence), respectively. The composite safety outcome rate was 8% (95% CI 3–17%; I2 = 34%; very low‐certainty evidence). The intraprocedural and postprocedural complication rates were 6% (95% CI 4–10%; I2 = 0%; very low‐certainty evidence) and 1% (95% CI 0–1%; I2 = 33%; very low‐certainty evidence), respectively. The mortality rate was 2% (95% CI 1–7%; I2 = 0%; very low‐certainty evidence). Aneurysm width (OR = 0.5; p = 0.03) was the only significant predictor of complete occlusion.

Conclusions

The preliminary studies evaluating the use of WEB for the treatment of IAs in off‐labeled locations has demonstrated rates of adequate occlusion and procedural complications comparable to the landmark studies that evaluated the use of the WEB for on‐label bifurcation aneurysms. Given the level of evidence, we consider the interpretation of our results should be done cautiously until confirmation from larger prospective studies are obtained.
Abstract Number ‐ 134: How far can we go? WEB technology for the treatment of sidewall IA. Single Institution.
Authors: Pabon Boris , Torres Victor , Patiño Manuel , Pelaez Juan , Mutis Jorge , Cardozo Margarita
Published: April 2023

Introduction

Few years after introduction, Flow disruption technology using WEB device has been used safely for the treatment of wide‐neck bifurcation aneurysms, but the use of this endosaccular approach to treat side‐wall lesions in terms of feasibility, safety, stability and aneurysm occlusion rate after this treatment is unknown.

Methods

Patients were carefully selected. IRB approved. Clinical, anatomical, angiographical and technical considerations were analyzed. Procedure related complications, procedural time, antiplatelet therapy requirements. Web Occlusion Scale (WOS) was used for the Follow‐up.

Results

From August 2017 and March 2021 a total of 14 wide‐necked, sidewall, IA were selected for WEB treatment. Aneurysm mean size 5.3mm in width and 5.8 in height. Aneurysm Location: ICA 8 cases (five PComA, two Carotid‐ophtalmic segment, one AChoA segment), Superior Cerebellar Artery SCA in 5 patients (35%), and one impressive case in posterior circulation associated with a basilar fenestration next to VBJ. Eight cases were unruptured (57%), and six cases with history of SAH‐ acute setting. DAPT used pre operatively in all elective cases but none patient remain under antiplatelets after procedure. Technical success of 100%. Mean procedure time: 24 min. None related procedure complications recorded. Immediately angiographic occlusion was evidenced in 9 cases. Radiological Follow up (ranging 1‐ 26 months) available in 9/14 showed a WOS adequate occlusion in all cases.

Conclusions

In our early experience using WEB device to treat different conditions than bifurcation IA´s, the results showed that endossacular approach was feasible in highly selected patients, safety profile in agreement with previous bifurcation experiences and very effective to treat challenge cases with a high probability of recurrence or therapeutic failure. Larger series and controlled studies are required to expand its indications in a near future.
Abstract Number ‐ 138: Complex symptomatic dissecting pseudoaneurysm with inflow zone stenosis required angioplasty before flow‐diversion‐a technical report.
Authors: Lodi Yahia M , Campos Jessica K
Published: April 2023

Introduction

16.4 percent of patients diagnosed with fibromuscular dysplasia (FMD) are found to have internal carotid artery (ICA) dissection [1] which may lead to life threatening ICA dissecting pseudoaneurysm (ICADPA). Endovascular repair of ICADPA may be urgent when ICADPA is symptomatic, potential for rupture with no good alternatives. Tortuous anatomy with FMD and ICADS can represent a significant endovascular challenge, especially if there is an aneurysmal inflow‐zone stenosis.Objective: We present a unique case of right ICADPA with an inflow‐zone parent artery stenosis underwent angioplasty and repair with surpass evolve flow diverter (SEFD).

Methods

Case report and chart review.

Results

49‐year‐old man history of hypertension, hyperlipidemia, and left ICADPA status post stenting/stent‐assisted coiling in 2017, who presented with right‐sided pulsatile tinnitus after a facial injury. Cerebral angiography revealed a tortuous right ICA with FMD, and presence of a right ICADPA at the skull base measuring 16×8 mm with inflow zone stenosis and a post‐stenotic dilatation. An emergency repair was performed with an informed consent under general anesthesia. In order for the SEFD to deploy properly, an angioplasty of inflow‐zone parent artery stenosis was performed with a 3×20mm Maverick balloon. Subsequently, a SEFD measuring 5×40 mm was deployed to cover the dissecting pseudoaneurysm, and a second SEFD measuring 5×20 mm was deployed covering the ICADS resulting in good apposition of SEFD and securement of ICADS.Use of a metal self‐deployable stent prior to flow diversion was not an option due to the presence of extreme tortuosity and acute angulations on the parent artery.patient was discharged home after 24 hours with 325 mg of aspirin and 75 mg of clopidogrel and good blood pressure control. 90‐days follow‐up, demonstrated good recovery with modified Rankin score of 0 with no symptoms.

Conclusions

ICADPA with aneurysmal inflow zone parent artery stenosis and the presence of extream tortuosity and acute angulations, may require angioplasty prior to the flow diversion for successful repair. Further studies are required.
Abstract Number ‐ 140: Transcranial Doppler Emboli Monitoring for Stroke Prevention after Flow Diversion: A Single Center Experience
Authors: Costa Matias , Allawi Aws , Vivanco‐Suarez Juan , Jaleel Naser , Douville Colleen , Loh Yince , Patel Akshal , Monteith Stephen J
Published: April 2023

Introduction

Following the favorable clinical and radiographical results of flow diversion, its use has continually expanded for the treatment of complex intracranial aneurysms. The high metal surface of flow diverters (FD) increases the risk of thromboembolic complications. Current emboli monitoring data after FD placement is limited. Transcranial doppler (TCD) offers a non‐invasive evaluation of microembolic signals and might be a valuable tool to prevent ischemic complications. We evaluated the rate of embolic signals and their management after FD implantation.

Methods

We performed a retrospective, single‐center evaluation of adult patients who underwent a FD procedure with the Pipeline Embolization Device (PED) for unruptured intracranial aneurysms between 2012 and 2016. Covariates included patient demographics, comorbidities, aneurysm characteristics, procedure characteristics, and post‐procedure TCD emboli monitoring (immediate and >12 hours post‐operative). TCD emboli signals were classified as positive (< 15 microembolic signals) and strongly positive (>15 signals). The primary outcome was the rate of symptomatic stroke at 2 and 12 weeks in these patients.

Results

105 patients with 132 aneurysms were analyzed. Mean age was 59.7 years, and 78% were females. Mean aneurysm size was 7.8 ± 6.4 mm. Most of them were located in the paraclinoid region (40%). Two PEDs were implanted in 12 (11%) cases and adjunctive coiling was performed in 15 (14%) cases. Microemboli were detected in 11.4% of cases (12/105 patients) after PED deployment. In 5/12 patients, the emboli resolved upon repeat testing with no intervention. In 6/12 patients, further heparinization, additional clopidogrel administration, or change in antiplatelet agents were needed. These treatments reduced the microembolic events. In 1 patient who was clopidogrel‐resistant and a ticagrelor super‐responder, mechanical thrombectomy was necessary due to acute in‐stent thrombosis. There were no symptomatic strokes at 2 and 12 weeks.

Conclusions

TCD emboli monitoring can be a powerful non‐invasive tool for the early identification and prevention of thromboembolic events after FD implantation. Early detection of microembolic signals offers the possibility to modify postoperative management, avoid silent emboli, and potentially avoid symptomatic strokes.
Abstract Number ‐ 143: Middle Meningeal Artery Embolization of Septated Chronic Subdural Hematomas
Authors: Martinez‐Gutierrez Juan Carlos , D'Amato Salvatore A , Zeineddine Hussein A , Nahhas Michael I , Kole Matthew J , Kim Youngran , Kim Hyun Woo , Chen Peng Roc , Blackburn Spiros L , Spiegel Gary , Sheth Sunil A , Kitagawa Ryan S , Dannenbaum Mark J
Published: April 2023

Introduction

Chronic Subdural Hematoma (cSDH) is projected to be the most common neurosurgical disease in the US by the end of the decade. MMA embolization is a promising new treatment; however, its efficacy in patients with complex, septated cSDH remains uncertain.

Methods

From our prospectively maintained registry of patients with cSDH treated with MMA embolization (with or without concurrent surgical drainage), we identified patients with and without septations. Septations were defined as hyperdense septa between the inner and outer membranes on a lower‐density background. The primary outcome was recurrence of cSDH, which was defined as any radiographic evidence of increase in thickness and/or new acute hemorrhage. Secondary outcomes included reduction in cSDH thickness, midline shift and rate of reoperation.

Results

Among 84 patients with 100 cSDHs, median age was 70 [IQR 59‐77] with 26.2% females. 35 CSDHs (35%) had membranes identified on imaging. Evacuation with burr holes was performed in 45.2% and craniotomy in 16.7% of the total cohort. Baseline characteristics between the patients with no septations (no SEP) and those with septatations (SEP) were similar except for median age (no SEP vs SEP, 66 vs 74, p = 0.006). Recurrence rate was lower in the SEP group (no SEP vs SEP, 21.5 vs 2.9%, p = 0.017) even when adjusting for clinically relevant factors (OR 0.07, p = 0.017). Despite larger baseline thickness in the SEP groups, the mean absolute reduction in thickness was more pronounced (no SEP vs SEP, ‐4.6 vs ‐8.0 mm, p = 0.016) with similar midline shift change. Rate of reoperation did not differ (6.2 vs 2.9%, p = 0.65). Recurrence free survival was significantly improved in patients with septations even after adjustment for age and evacuation strategy (Figure 1, p = 0.04).

Conclusions

MMAE in traditionally higher risk septated cSDHs appears to be highly effective with an even larger reduction in volume and lower risk of recurrence than non‐septated hematomas. These findings support the mechanistic theory of MMAE as a devascularization procedure of membrane neovasculature and may aid in improved patient selection.
Abstract Number ‐ 162: Hydration Status and Functional Outcomes in Patients with Large Vessel Occlusion Stroke Undergoing Endovascular Therapy
Authors: Baldwin‐LeClair Abigail , Patel Avish , Patel Karan N , Siegler James E , Kamen Scott , Thau Lauren , Wolfe Jared , Zhang Linda , Thomas Kavya , Vigilante Nicholas , Thon Jesse M
Published: April 2023

Introduction

Large vessel occlusion (LVO) and dehydration are both independently associated with poor functional outcomes and increased odds of mortality in acute ischemic stroke. Dehydration has previously been shown to affect collateral blood flow in LVO stroke, but it is unclear if this leads to worsened clinical outcomes.

Methods

A stroke center registry (10/2019‐12/2021) of consecutive adults who had undergone successful endovascular therapy (EVT, with thrombolysis in cerebral infarction score 2b/3) for anterior circulation LVO (ICA, M1, or M2) was queried. Dehydration on presentation was defined using laboratory surrogates: blood urea nitrogen/creatinine ratio >15 or serum osmolality >296 mOsm/kg. The primary outcome was a favorable shift in 90‐day modified Rankin Scale (mRS) using a proportional odds model, adjusting for age, pre‐stroke mRS, National Institutes of Health Stroke Scale (NIHSS), and Alberta Stroke Program Early Computed Tomography Scale (ASPECTS). Secondary outcomes included early improvement in 24h NIHSS.

Results

Of the 318 patients with anterior LVO who underwent EVT, 206 (65%) met criteria for dehydration, and 181 (87.9%) had both mRS and ASPECTS data available. Younger age, lower NIHSS, lower mRS, and higher ASPECTS were all strongly and independently associated with a favorable shift in 90d mRS. Dehydrated patients had similar changes in 24‐hr NIHSS scores (‐5 [interquartile range, IQR ‐10 to 0] vs. ‐5 [IQR ‐8 to 0], p = 0.37). Dehydration was not associated with a less favorable shift in 90‐day mRS (odds ratio [OR] 0.74, 95% confidence interval [CI] 0.41‐1.33), which remained non‐significant after multivariable adjustment (OR 1.46, 95%CI 0.74‐2.86). With serum osmolality assessed continuously, higher serum osm was associated with a less favorable shift in mRS at 90d (OR 0.95, 95%CI 0.92‐0.99, p = 0.009), but this did not persist after multivariable adjustment (p = 0.92) and was driven by the association between higher osmolality and age (r = 0.24, p(bonferroni)< 0.01) and pre‐stroke mRS (r = 0.20, p(bonferroni) = 0.04).

Conclusions

There was no association between dehydration and lower odds of early clinical improvement or long‐term functional recovery following successful endovascular thrombectomy.