This report introduces a novel surgical technique for middle meningeal artery embolization (MMAE) during a mini-craniotomy for subdural hematoma (SDH) evacuation. A patient with multiple health issues presented with a 14 mm right subacute SDH. During surgery, the MMA was retrogradely catheterized and embolized using Onyx 18. This approach, combining MMAE with hematoma evacuation, resulted in successful resolution of the SDH without complications. The procedure offers a more efficient workflow by integrating 2 interventions into 1, potentially reducing recurrence rates of SDH.

Mechanical thrombectomy using a stent retriever is a widely-used technique for recanalizing occluded cerebral arteries in acute ischemic stroke. Although rare, inadvertent stent detachment has primarily been reported with earlier stent retriever designs. We present 2 cases of inadvertent stent detachment with the pRESET stent. In the first case, an elderly patient presented with right middle cerebral artery occlusion and experienced stent detachment during the second retrieval. Despite this, successful recanalization was achieved through balloon angioplasty. In the second case, an elderly patient experienced stent detachment after the third retrieval, and recanalization of the M1 segment was unsuccessful due to the inability to pass the microcatheter. The first patient had a modified Rankin scale (mRS) score of 3, while the second had a poor prognosis with an mRS score of 5. These cases highlight that inadvertent stent detachment can impact outcomes, and balloon angioplasty may serve as a useful salvage therapy.

Intracranial mycotic aneurysms (IMAs), rare and often life-threatening, result from arterial wall infections typically caused by bacteria such as Staphylococcus and Streptococcus. The standard treatment for ruptured aneurysms is not well-defined and often individualized. This study investigates the efficacy of endovascular glue embolization in managing ruptured IMAs, based on our center's experience. A retrospective analysis was conducted for ruptured IMAs treated with glue embolization between January 2016 and December 2023. The procedure involved aneurysm sac and parent vessel occlusion with glue delivery. Data included patient demographics, clinical presentations, and neuroimaging. Clinical outcomes were assessed using the modified Rankin scale (mRS) at 3 months, and angiographic follow-up was conducted at 6 months. The study included 28 patients, predominantly male (64.3%), with a mean age of 48 years. Headache was the primary symptom in 92.9% of cases, and positive blood/cerebro spinal fluid cultures were found in 82.14% of cases. All aneurysms were located in the distal circulation, primarily in the anterior circulation system. Glue embolization was successfully performed in all cases, achieving complete aneurysm sac and parent vessel obliteration. Follow-up at 3 months indicated mRS scores of 0 or 1 in 96.5% of cases. Six-month angiographic follow-up showed no aneurysm regrowth or new formations. Endovascular glue embolization demonstrated high efficacy and safety in treating ruptured IMAs, with a 100% obliteration rate and favorable clinical outcomes in this single-center experience. Despite limitations such as its retrospective design and small sample size, the study supports glue embolization as a viable, less invasive alternative to traditional surgery. Further comparative studies are needed to confirm these findings and refine treatment approaches.

The anterior choroidal artery (AChA) supplies the corticospinal tract related to the motor function of the upper and lower limbs. Aneurysms arising at the AChA are not common and exhibit various patterns of involvement of the AChA. Hence, managing an AChA aneurysm poses a high risk of neurological deficits. We report technical issues related to the outcome of coil embolization for unruptured AChA aneurysms. We obtained Institutional Review Board approval for this study. In the past 2 years, 18 consecutive patients (6 males and 12 females, aged 32-68) with unruptured AChA aneurysms were treated using embolization. We present technical details, pre- and post-procedural patient statuses, angiographic outcomes, and recurrence during a mean follow-up period of 12 months (range 3-25). The patients with AChA (n=18) underwent stent-assisted coiling (n=14), coiling (n=2), or stenting only (n=2). The technical strategy for aneurysm embolization included a low-lying approach into the aneurysm, stent-strut abutting (protecting) coil framing to block inflow and avoid compromising AChA flow, and direct intra-aneurysmal angiography via a microcatheter. Angiographic results showed complete occlusion (n=11), neck remnant (n=5), and sac remnant (n=2). During the follow-up, there were 2 recurrences, and 1 of them required a re-procedure. All patients showed no change in clinical status (modified Rankin scale score=0) and did not experience any ischemic or hemorrhagic events during the follow-up period. AChA aneurysms can be managed through embolization using various techniques. Such technical concepts may enhance the safety and improve the outcomes of AChA aneurysm embolization.

A 24-year-old male was admitted with progressive cervical hypesthesia, tetraparesis, dyspnea, and a history of craniofacial fracture. Spinal magnetic resonance imaging (MRI) showed brainstem edema extending to the thoracic spine with multiple prominent perimedullary vascular structures. Cerebral digital-substraction angiography revealed Barrow type A carotid-cavernous fistula. Total occlusion with preservation of internal carotid artery flow was achieved using 1 detachable balloon and 6 coils. Postoperatively, immediate respiratory recovery, gradual extremities strength improvement, and right abducens nerve palsy were found. One month follow-up cervical MRI showed good recovery of spinal cord edema and perimedullary veins.

Scalp arteriovenous fistulas (AVFs) are rare vascular anomalies characterized by abnormal connections between arterial and venous systems in the scalp. These lesions can lead to significant complications, including chronic headaches, tinnitus, cosmetic deformities, and in severe cases, high-output cardiac failure or intracranial hemorrhage. We present a case of a middle-aged female patient with a 20-year history of a pulsating mass on the left parietal scalp. Magnetic resonance imaging and cerebral angiography confirmed the presence of a scalp AVF with multiple arterial feeders from the external carotid artery and venous drainage into the left external jugular vein. Due to the tortuosity of the feeding arteries, a transarterial approach was unsuccessful, leading to the decision to perform transvenous embolization with balloon occlusion using Onyx-18. The procedure resulted in complete obliteration of the AVF without complications. This case highlights the efficacy of transvenous embolization with balloon occlusion as a treatment option for complex scalp AVFs, particularly when transarterial access is challenging.

The present report describes a patient with spinal cord arteriovenous malformation (AVM) and an associated anterior spinal artery aneurysm presenting with subarachnoid hemorrhage. Diagnostic spinal angiography revealed an intramedullary AVM, located at the T10-T11 level, and a prenidal saccular aneurysm at the junction of the radiculomedullary artery and the anterior spinal axis, fed by the right T8 segmental artery. The patient underwent successful selective coil embolization of the aneurysm. Follow-up angiography 3 months postoperatively showed no recurrence of the aneurysm.

The direct aspiration first pass technique (ADAPT) is an effective and safe endovascular treatment for distal medium vessel occlusions (DMVOs). We evaluated technical features and initial results of a novel reperfusion catheter (REDTM 62) used for frontline aspiration thrombectomy of M2 occlusions in acute ischemic stroke patients. Appropriate aspiration catheters are crucial for a successful ADAPT maneuver; however, the selection of catheters suitable for smaller-sized vessels is scarce compared to the ones for large vessel occlusions. All patients treated with ADAPT using REDTM 62 as the frontline treatment approach for acute M2 occlusions between December 2022 and February 2024 were retrospectively enrolled. Demographic data, procedural timings and safety, recanalization rates, and outcome data were recorded. Twenty patients with a median admission National Institutes of Health Stroke Scale (NIHSS) score of 8 were identified. Successful revascularization (DMVO-thrombolysis in cerebral infarction [TICI]≥2b) with REDTM 62 aspiration thrombectomy was obtained in 65.0% (13/20) of cases. The first pass effect was 45.0% (9/20). In 2 cases, the REDTM 62 did not reach the clot due to marked distal vessel tortuosity. Stent retrievers were additionally used in 9 cases and led to an overall DMVO-TICI 2c/3 of 90.0% (18/20). Mean procedural time was 48 minutes. No complications directly related to ADAPT occurred. In-hospital mortality rate was 20.0% (4/20). The median discharge NIHSS score was 2.5. A good functional outcome at discharge (modified Rankin scale 0-2) was achieved in 55.0% (11/20) of cases. Our initial experiences with the novel REDTM 62 reperfusion catheter for treatment of M2 occlusions is in line with published data. ADAPT using this catheter may be considered as a safe and effective first-line treatment option. Further studies are warranted to validate the initial results.

We report our initial experience with endovascular embolization of intracranial aneurysms using this new self-expanding open-cell stent system (pEGASUS stent system) with the antithrombogenic hydrophilic polymer coating. We retrospectively reviewed all patients treated with stent-assisted coiling or the Woven EndoBridge device using the pEGASUS stent system between September 2022 and June 2023. Demographic, clinical, and angiographic data were analyzed as well as short-term follow-up, including procedural complication rates and aneurysmal occlusion rates using the Raymond-Roy occlusion classification (RROC). Twelve patients with 12 wide-necked intracranial aneurysms were treated with the pEGASUS stent system, including 2 acutely ruptured aneurysms embolized in an emergency setting. The treated aneurysms were located at the anterior communicating artery (25.0%), the basilar artery (50.0%), the middle cerebral artery (16.7%), and the internal carotid artery (8.3%). All stents were deployed successfully. Immediate complete aneurysmal occlusion (RROC class I) was achieved in 83.3% (10/12) and near-complete occlusion (RROC II) in 16.7% (2/12). No periprocedural complications occurred in patients treated in the elective setting. A single case of intraoperative in-stent thrombus formation occurred during the treatment of an acutely ruptured basilar aneurysm and was resolved with intravenous Tirofiban. No other periprocedural complications occurred. Eleven out of 12 patients were available for follow up (mean 7.4 months). Complete aneurysmal occlusion without in-stent stenosis (ISS) was seen in 10 patients (90.9%). One patient (9.1%) showed aneurysmal reperfusion (RROC IIIb) with asymptomatic moderate ISS. Our initial results demonstrate that the pEGASUS stent system appears to be a safe and effective device for stent assisted embolization of wide-necked intracranial aneurysms. More data is necessary to evaluate long-term follow-up.