High-volume Neurovascular Center Research Articles

Low-and intermediate-grade lateral sinus dural arterio venous fistulas: Factors affecting the outcome of endo vascular treatment over 18-year experience in a high-volume neurovascular center.

Lateral sinus dural arteriovenous fistulas (LS-DAVFs) carry a higher rate of recurrence after endovascular treatment (EVT). Our objective was to investigate the independent predictors of recurrence and unfavorable functional outcome of low-and intermediate-grade LS-DAVFs after EVT. Retrospectively reviewed our database of prospectively collected information for all patients with low and intermediate-grade LS-DAVFs that underwent EVT from May 2004 to December 2021. Patient demographic, angiographic, treatment, and outcome were analyzed to identify independent predictors of recurrence and unfavorable outcome. One hundred and seventeen patients with 117 low-and intermediate-grade LS-DAVFs underwent EVT were included in this study. The mean age of the patients was 53.0±17.5 years. Immediately complete obliteration was achieved in 103/117 (88%) patients after EVT. Clinical follow-up were available for all of 117 patients, with an unfavorable outcome rate of 5.1%. Angiographic follow-up was available in 91 patients (78%). Recurrence occurred in 16 (18%) patients and 8 (6.8%) received retreatment. Contralateral sinus severe stenosis or occlusion was an independent high-risk factor for the unfavorable outcome (OR=11.7; 95% CI: 1.9-70.9, P<0.01) and recurrence (OR=63.8; 95% CI: 10.3-396.5, P<0.01) for low-and intermediate-grade LS-DAVFs at follow-up. Contralateral sinus severe stenosis or occlusion represents a stronger independent risk factor associated with recurrence and unfavorable outcome in patients with low-and intermediate-grade LS-DAVFs when the involved ipsilateral sinus was occluded after EVT. For patients with LS-DAVFs, the patency of the contralateral sinus should be considered when therapeutic decision-making. LS-DAVFs = Lateral sinus dural arteriovenous fistulas; EVT = endovascular treatment; TAE = Transarterial Embolization; TVE = Transvenous Embolization; CN = cranial nerve; CVD = cortical venous drainage.

Woven EndoBridge versus stent-assisted coil embolization for the treatment of ruptured wide-necked aneurysms: A multicentric experience.

The potentially higher risk of hemorrhagic complications is of concern in stent-assisted coiling (SAC) of ruptured wide-necked intracranial aneurysms (IAs). The Woven EndoBridge (WEB) is considered an appealing alternative since antiplatelet therapy is not required. Herein, we aimed to compare the safety and effectiveness of WEB vs. SAC for the treatment of ruptured wide-necked IAs. This was an international cross-sectional study of consecutive patients treated for ruptured wide-neck IAs with WEB or SAC at four high-volume neurovascular centers between 2019 and 2022. Primary and secondary efficacy outcomes were radiographic aneurysm occlusion at follow-up and functional status at last follow-up. Safety outcomes included periprocedural hemorrhagic/ischemia-related complications. One hundred five patients treated with WEB and 112 patients treated with SAC were included. The median procedure duration of endovascular treatment was shorter for WEB than for SAC (69 vs. 76 min; p = 0.04). There were no significant differences in complete aneurysm occlusion rates (SAC: 64.5% vs. WEB: 60.9%; adjusted OR [aOR] = 0.70; 95%CI 0.34-1.43; p = 0.328). SAC had a significantly higher risk of complications (23.2% vs. 9.5%, p = 0.009), ischemic events (17% vs. 6.7%, p = 0.024), and EVD hemorrhage (16% vs. 0%, p = 0.008). The probability of procedure-related complications across procedure time was significantly lower with WEB compared with SAC (aOR = 0.40; 95%CI 0.20-1.13; p = 0.03). WEB and SAC demonstrated similar obliteration rates at follow-up when used for embolization of ruptured wide-necked IAs. However, SAC showed higher rates of procedure-related complications primarily driven by ischemic events and higher rates of EVD hemorrhage. The overall treatment duration was shorter for WEB than for SAC.

Treatment of broad-based intracranial aneurysms with the LVIS EVO stent: a retrospective observational study at two centers with short- and medium-term follow-up

The use of stents is well established in the treatment of broad-based intracranial aneurysms. The aim of this study is to report on safety, feasibility and midterm follow-up of the new LVIS EVO braided stent for the treatment of cerebral aneurysms. All consecutive patients with intracranial aneurysms who were treated with the LVIS EVO stent in two high volume neurovascular centers were retrospectively enrolled in this observational study. Clinical and technical complications, angiographic outcome and clinical short-term and midterm results were evaluated. The study included 112 patients with 118 aneurysms. 94 patients presented with incidental aneurysms, 13 patients with acute SAH and 2 patients with acute cranial nerve palsy. For 100 aneurysms a jailing technique was used, re-crossing of the stent was performed in 3 cases. For the residual 15 cases the stent was placed as a bail-out or as a second step. Immediate complete occlusion was observed in 85 aneurysms (72%). Midterm follow-up was available for 84 patients with 86 aneurysms (72.9%). One stent showed asymptomatic complete occlusion on follow-up imaging, in all other cases no in-stent stenosis was observed. The rate of complete occlusion was 79.1% at 6 months and 82.2% at 12–18 months. Midterm follow-up data of this retrospective observational cohort of two neurovascular centers corroborates the safety profile of the LVIS EVO device for treatment of ruptured and unruptured intracranial aneurysms.

Classification and Management Considerations for Intraosseous Dural Arteriovenous Fistulae.

Intraosseous dural arteriovenous fistulas (IODAVFs) are rare DAVFs that communicate with marrow. Given their infrequency, common nomenclature is nonexistent. Patients may present with benign symptoms, such as tinnitus, or venous hypertension symptoms including hemorrhage depending on the venous outflow pattern. To describe all available cases of IODAVF in the literature, in addition to our cases, to better define presentation, and treatment outcomes. To advance a classification system to develop common language for these lesions for clinicians and researchers. Neurointerventional procedure logs at 2 high-volume neurovascular centers were reviewed for all cases of IODAVFs, as was the English-based literature available in PubMed. The angioarchitecture, symptoms, management, and demographics were reviewed and summarized. Four institutional cases were identified, 2 of which had shunting within the marrow (clival or petrous), with venous drainage toward the heart. One case involved the dorsum sella with drainage into the superior petrosal sinus with reflux into the anterior and posterior spinal venous plexuses, and one involved the left petroclival junction, resulting in communication with the cavernous sinus with retrograde drainage into the superior ophthalmic veins. Two patients were managed by observation, one was treated with radiosurgery and one with microsurgical skeletonization. Twenty additional cases from the literature are summarized. IODAVFs of the cerebrocranial vasculature may present incidentally, with tinnitus, or with symptoms related to mass effect or venous hypertension. We propose a classification which accounts for drainage patterns. Further study is needed for these rare lesions.

Nicotine Replacement Therapy for Smokers with Acute Aneurysmal Subarachnoid Hemorrhage: An International Survey.

IntroductionSmoking prevalence is twice as high among patients admitted to hospital because of the acute condition of aneurysmal subarachnoid hemorrhage (aSAH) as in the general population. Smoking cessation may improve the prognosis of aSAH, but nicotine replacement therapy (NRT) administered at the time of aSAH remains controversial because of potential adverse effects such as cerebral vasospasm. We investigated the international practice of NRT use for aSAH among neurosurgeons.MethodsThe online SurveyMonkey software was used to administer a 15-question, 5-min online questionnaire. An invitation link was sent to those 1425 of 1988 members of the European Association of Neurosurgical Societies (EANS) who agreed to participate in surveys to assess treatment strategies for withdrawal of tobacco smoking during aSAH. Factors contributing to physicians’ posture towards NRT were assessed.ResultsA total of 158 physicians from 50 nations participated in the survey (response rate 11.1%); 68.4% (108) were affiliated with university hospitals and 67.7% (107) practiced at high-volume neurovascular centers with at least 30 treated aSAH cases per year. Overall, 55.7% (88) of physicians offered NRT to smokers with aSAH, 22.1% (35) offered non-NRT support including non-nicotine medication and counselling, while the remaining 22.1% (35) did not actively support smoking cessation. When smoking was not possible, 42.4% (67) of physicians expected better clinical outcomes when prescribing NRT instead of nicotine deprivation, 36.1% (57) were uncertain, 13.9% (22) assumed unaffected outcomes, and 7.6% (12) assumed worse outcomes. Only 22.8% (36) physicians had access to a local smoking cessation team in their practice, of whom half expected better outcomes with NRT as compared to deprivation.ConclusionsA small majority of the surveyed physicians of the EANS offered NRT to support smoking cessation in hospitalized patients with aSAH. However, less than half believed that NRT could positively impact clinical outcome as compared to deprivation. This survey demonstrated the lack of consensus regarding use of NRT for hospitalized smokers with aSAH.

Remote Training of Neurointerventions by Audiovisual Streaming

BackgroundRemote access of trainees to training centers via video streaming (tele-observership, e‑fellowship) emerges as an alternative to acquire knowledge in endovascular interventions. Situational awareness is a summary term that is also used in surgical procedures for perceiving and understanding the situation and projecting what will happen next. A high situational awareness would serve as prerequisite for meaningful learning success during tele-observerships. We hypothesized that live perception of the angiographical procedures using streaming technology is feasible and sufficient to gain useful situational awareness of the procedure.MethodsDuring a European tele-observership organized by the European Society of Minimally Invasive Neurological Therapy (ESMINT) and its trainee association (EYMINT), a total of six neurointerventional fellows in five countries observed live cases performed by experienced neurointerventionalists (mentors) in six different high-volume neurovascular centers across Europe equipped with live-streaming technology (Tegus Medical, Hamburg, Germany). Cases were prospectively evaluated during a 12-month period, followed by a final questionnaire after completion of the course.ResultsA total of 102/161 (63%) cases with a 1:1 allocation of fellow and mentor were evaluated during a 12-month period. Most frequent conditions were ischemic stroke (27.5%), followed by embolization of unruptured aneurysms (25.5%) and arteriovenous malformations (AVMs) (15.7%). A high level of situational awareness was reported by fellows in 75.5% of all cases. After finishing the program, the general improvement of neurointerventional knowledge was evaluated to be extensive (1/6 fellows), substantial (3/6), and moderate (2/6). The specific fields of improvement were procedural knowledge (6/6 fellows), technical knowledge (3/6) and complication management (2/6).ConclusionOnline streaming technology facilitates location-independent training of complex neurointerventional procedures through high levels of situational awareness and can therefore supplement live hands-on-training. In addition, it leads to a training effect for fellows with a perceived improvement of their neurointerventional knowledge.

Influence of operator experience on the technical and clinical results of Woven EndoBridge endovascular treatment for intracranial aneurysms

Background & purposeThe safety and efficacy of the Woven EndoBridge (WEB) device has been proven in recent multicenter trials. This study investigated whether operator experience influences WEB treatment-related outcomes. Material and methodsThis was a retrospective analysis of a prospectively collected multicenter database. The data of all patients who underwent WEB treatment for an intracranial aneurysm from March 2014 to June 2020 in two high-volume centers were pooled. Operator experience was indexed by the number of WEB treatments performed previously. The primary endpoint was the overall complication rate. Secondary endpoints were long-term adequate (Raymond-Roy classification of 1–2.) angiographic occlusion, WEB-related complications, number of WEB not deployed, procedure duration, and radiation exposure (air kerma). ResultsAmong 237 patients (mean age 59.4 +/- 11.5 years) treated with WEB (median aneurysm diameter, 5.8 mm; interquartile range 4.5–7 mm), WEB-related complications occurred in 28 patients (11.8%) and adequate long-term occlusion was achieved for 154 aneurysms (86%). The median number of WEB treatment performed previously per operator was 20 (IQR, 9-41). The overall complication rate, WEB-related complication rate and aneurysm occlusion rate were not significantly correlated with WEB operator experience. There were also no significant correlations between the WEB operator experience and the number of WEB not deployed, procedure duration or radiation exposure. ConclusionThere was no significant association between the number of WEB treatments previously performed per operator and any technical or clinical results after intracranial aneurysm treatment with WEB. These results imply a relatively short learning curve for this device in high-volume neurovascular centers.

Treatment of intracranial aneurysms using the new Surpass Evolve flow diverter: Safety outcomes and six-month imaging follow-up

Background and purposeSeveral studies have reported good long-term results in the occlusion of intracranial aneurysms with flow diverter treatment. The aim of this study was to report the safety and six-month follow-up outcomes using the new Surpass Evolve flow diverter in the treatment of intracranial aneurysms. Materials and methodsConsecutive patients with intracranial aneurysm treated with Surpass Evolve flow diverter in two high-volume neurovascular centers between May 2019 and January 2020 were retrospectively reviewed. Procedure-related complications, aneurysm occlusion (O’Kelly-Marotta grading scale), and clinical outcomes were assessed. ResultsTwenty-nine patients with 30 aneurysms were included in the study. Favorable aneurysm occlusion (O’Kelly Marotta grading scale C-D) at six-month follow-up was achieved in 21/27 (78%) aneurysms. No clinical procedure related thromboembolic complications were encountered. Twenty-three out of 24 patients with unruptured aneurysms treated with Surpass Evolve remained clinically intact at clinical follow-up. There was one fatal hemorrhagic procedure-related complication (3%). In five patients with ruptured aneurysms, no early or late rebleeds occurred from the aneurysms. ConclusionsSurpass Evolve FD worked technically well with no intraprocedural thromboembolic complications and occlusion rates comparable to other FDs.

Can Young Vascular Neurosurgeons Become Proficient in Microsurgical Clip Reconstruction in the Endovascular Era? A Rotterdam Cohort Spanning 2 Decades with Propensity Score Matching for Complexity

Little is known about the results of young vascular neurosurgeons who perform only microsurgical clip reconstruction in the era since the International Subarachnoid Aneurysm Trial (ISAT) or about the training and caseload required to equivocate the results of senior, more experienced colleagues. The aim of this study was to compare clinical outcomes of patients treated by young and senior vascular neurosurgeons at Erasmus MC University Medical Center Rotterdam, adjusting for case mix. A partially prospective and partially retrospective database was used. Hierarchical mixed models with a random intercept for surgeon were used for confounder adjustment, and propensity score matching for complexity was used to create comparable groups. The study included 609 patients harboring 767 aneurysms. Most (86%) of the aneurysms had at least 1 complexity characteristic, with the majority having 3 characteristics. The most often encountered complexity characteristics were the presence of a broad neck and the presence of branches emerging from the aneurysm. Use of temporary clipping and skull base approaches was significantly higher in the young vascular neurosurgeons group (P < 0.0001). The complexity score differed significantly between senior and young vascular neurosurgeons (P < 0.001). After propensity score matching for complexity, multivariable logistic regression showed young vascular neurosurgeons to be significantly associated with better outcomes for ruptured aneurysms (propensity score weighted odds ratio 0.55 [95% confidence interval 0.35-0.88], P= 0.01). In a high-volume neurovascular center where both endovascular and microsurgical treatment options are available, young vascular neurosurgeons can be trained to achieve at least the same results as their senior colleagues despite increased complexity.

Comparative analysis of CGUARD embolic prevention stent with Casper-RX and Wallstent for the treatment of carotid artery stenosis

Stent protected Angioplasty of extracranial carotid artery stenosis using the dual-layered CGUARD stent is a novel treatment option. In this study we evaluate the feasibility and the safety of the CGUARD in symptomatic and asymptomatic patients in comparison to Casper-RX and Wallstent. This is a multi-center study of consecutive patients treated with the CGUARD, Casper-RX and Wallstent at two German high volume neurovascular centers between April 2017 and May 2018. Patient characteristics, neuroimaging data and angiographic outcome were retrospectively analyzed. The primary end points of the study were acute occlusion of the carotid stent and symptomatic intracerebral hemorrhage (sICH). Carotid artery stenting was performed in 76 patients; of those 26 (34%) were treated with the CGUARD, 25 (33%) with Casper-RX, and 25 (33%) with Wallstent. In 58/76 (76%) cases carotid artery stenosis was symptomatic with a median baseline National Institutes of Health Stroke Scale of 4. Angioplasty and stenting as part of a mechanical thrombectomy for acute ischemic stroke was performed in 25/76 (33%) patients. Baseline patient characteristics were similar between the treatment groups, except for a higher portion of scheduled cases in the Casper-RX group. There were no significant differences in the rate of acute in stent occlusions (CGUARD, 2/26 (8%); Casper-RX, 1/25(4%); Wallstent, 1/25 (4%)) and postinterventional sICH (1/26 (4%), 0/25(0%), 0/25 (0%)). Clinical outcome at discharge did not differ between groups. Treatment of carotid artery stenosis using CGUARD is feasible with a good safety profile comparable to that of Casper-RX and Wallstent.

Vessel wall magnetic resonance imaging in intracranial aneurysms: Principles and emerging clinical applications.

Intracranial high-resolution vessel wall magnetic resonance imaging is an imaging paradigm that complements conventional imaging modalities used in the evaluation of neurovascular pathology. This review focuses on the emerging utility of vessel wall magnetic resonance imaging in the characterization of intracranial aneurysms. We first discuss the technical principles of vessel wall magnetic resonance imaging highlighting methods to determine aneurysm wall enhancement and how to avoid common interpretive pitfalls. We then review its clinical application in the characterization of ruptured and unruptured intracranial aneurysms, in particular, the emergence of aneurysm wall enhancement as a biomarker of aneurysm instability. We offer our perspective from a high-volume neurovascular center where vessel wall magnetic resonance imaging is in routine clinical use.

Treatment of Recurrent and Residual Aneurysms with the Woven EndoBridge Device: Analysis of 11 Patients and Review of the Literature

The Woven EndoBridge (WEB) device is an innovative tool for endovascular treatment of wide-necked bifurcation aneurysms. Numerous studies of primary aneurysm treatment with the WEB device have been reported. We analyzed the safety and efficacy of WEB embolization for recurrent and residual aneurysms. We performed a retrospective observational study of consecutive patients with initially endovascularly or surgically treated aneurysms and an aneurysm recurrence or remnant retreated with the WEB device at 3 German high-volume neurovascular centers from May 2011 to February 2018. The technical success, complications, and angiographic outcomes were evaluated. Eleven patients (median age, 65 years; 5 women) with 11 aneurysms (median size, 6.8 mm) were identified. The aneurysms were located at the anterior communicating artery in 4, basilar tip in 4, internal carotid artery in 1, middle cerebral artery in 1, and posterior communicating artery in 1 patient. Three aneurysms had been previously clipped and 8 had undergone endovascular therapy. WEB embolization was feasible in 10 patients. Ancillary devices were used for 4 aneurysms. Perforation occurred in 1 aneurysm, which resolved without sequelae. Of the 9 patients available for angiographic follow-up (median follow-up, 6 months), complete and near-complete aneurysm occlusion was achieved in 3 (33%) and 7 patients (78%), respectively. Three patients underwent repeat treatment (33%). The results of the present study have indicated that WEB embolization of previously treated aneurysms is reasonably safe. However, careful aneurysm selection could be necessary to achieve adequate mid-term occlusion rates.

Ruptured posterior circulation aneurysms: epidemiology, patterns of care, and outcomes from the Swiss SOS national registry.

The treatment of ruptured posterior circulation aneurysms remains challenging despite progresses in the endovascular and neurosurgical techniques. To provide epidemiological characterization of subjects presenting with ruptured posterior circulation aneurysms in Switzerland and thereby assessing the treatment patterns and neurological outcomes. This is a retrospective analysis of the Swiss SOS registry for patients with aneurysmal subarachnoid hemorrhage. Patients were divided in 3 groups (upper, lower, and middle third) according to aneurysm location. Clinical, radiological, and treatment-related variables were identified and their impact on the neurological outcome was determined. From 2009 to 2014, we included 264 patients with ruptured posterior circulation aneurysms. Endovascular occlusion was the most common treatment in all 3 groups (72% in the upper third, 68% in the middle third, and 58.8% in the lower third). Surgical treatment was performed in 11.3%. Favorable outcome (mRS ≤ 3) was found in 56% at discharge and 65.7% at 1year. No significant difference in the neurological outcome were found among the three groups, in terms of mRS at discharge (p = 0.20) and at 1year (p = 0.18). High WFNS grade, high Fisher grade at presentation, and rebleeding before aneurysm occlusion (p = 0.001) were all correlated with the risk of unfavorable neurological outcome (or death) at discharge and at 1year. In this study, endovascular occlusion was the principal treatment, with a favorable outcome for two-thirds of patients at discharge and at long term. These results are similar to high volume neurovascular centers worldwide, reflecting the importance of centralized care at specialized neurovascular centers.

Pipeline Embolization of Vertebrobasilar Aneurysms—A Multicenter Case Series

The Pipeline Embolization Device (PED) has been increasingly used for the treatment of posterior circulation aneurysms. The purpose of the present study was to examine the clinical and angiographic outcomes of patients with vertebrobasilar aneurysms treated with the PED. We performed a retrospective review of vertebrobasilar aneurysms treated with the PED at 4 high-volume neurovascular centers. Patient, aneurysm, and procedural data were collected, including perioperative and delayed complications. Aneurysm occlusion on follow-up imaging studies was defined as complete (100%), near-complete (>90%), or incomplete (<90%) occlusion. The cohort included 35 patients with 37 vertebrobasilar aneurysms who underwent 36 treatment sessions. Of the 35 patients, 10 were men (29%), and the mean patient age was 54.1 years (range, 32-75). Eight patients (23%) underwent urgent treatment because of a ruptured aneurysm (n= 6), brainstem perforator stroke (n= 1), or post-traumatic pseudoaneurysm (n= 1). Of the 37 aneurysms, 22 arose from the vertebral artery (59%) and 15 from the basilar artery (41%). Also, 19 were saccular aneurysms (51%), with a mean size of 7.7 mm (range, 1.7-38.0); 17 were fusiform aneurysms (46%), with a mean size of 11.0 mm (range, 4.3-34); and 1 was a 2.9-mm blister aneurysm. The overall procedural complication rate was 14% (5 of 36), including 3 neurologically symptomatic complications. At a mean follow-up period of 14 months (range, 3-59), 24 of 34 aneurysms (71%) were completely occluded and 29 of 34 (85%) were completely or near-completely occluded. Our results show that Pipeline embolization of vertebrobasilar aneurysms is associated with acceptable occlusion and complication rates.

Riskier-than-expected occlusive treatment of ruptured posterior communicating artery aneurysms: treatment and outcome of 620 consecutive patients.

Occlusive treatment of posterior communicating artery (PCoA) aneurysms has been seen as a fairly uncomplicated procedure. The objective here was to determine the radiological and clinical outcome of patients after PCoA aneurysm rupture and treatment and to evaluate the risk factors for impaired outcome. In a retrospective clinical follow-up study, data were collected from 620 consecutive patients who had been treated for ruptured PCoA aneurysms at a single center between 1980 and 2014. The follow-up was a minimum of 1 year after treatment or until death. Of the 620 patients, 83% were treated with microsurgical clipping, 8% with endovascular coiling, 2% with the two procedures combined, 1% with indirect surgical methods, and 6% with conservative methods. The most common procedural complications were treatment-related brain infarctions (15%). The occurrence of artery occlusions (10% microsurgical, 8% endovascular) was higher than expected. Most patients made a good recovery at 1 year after aneurysmal subarachnoid hemorrhage (modified Rankin Scale [mRS] score 0-2: 386 patients [62%]). A fairly small proportion of patients were left severely disabled (mRS score 4-5: 27 patients [4%]). Among all patients, 20% died during the 1st year. Independent risk factors for an unfavorable outcome, according to the multivariable analysis, were poor preoperative clinical condition, intracerebral or subdural hematoma due to aneurysm rupture, age over 65 years, artery occlusion on postoperative angiography, occlusive treatment-related ischemia, delayed cerebral vasospasm, and hydrocephalus requiring a shunt. Even though most patients made a good recovery after PCoA aneurysm rupture and treatment during the 1st year, the occlusive treatment-related complications were higher than expected and caused morbidity even among initially good-grade patients. Occlusive treatment of ruptured PCoA aneurysms seems to be a high-risk procedure, even in a high-volume neurovascular center.

Documentation of Improved Outcomes for Intracranial Aneurysm Management Over a 15-Year Interval

Despite rapid advancements in intracranial aneurysm management, there is no evidence as of yet that this has translated into improvement in overall prognosis. We compared 2 periods of aneurysm management, 1998 to 2003 (n=1023 aneurysms) and 2007 to 2013 (n=1499 aneurysms), at a single, high-volume neurovascular center. Our outcome of interest was low or moderate disability (Glasgow Outcome Scale score of 4 or 5) at 6 months or more post treatment. There were significant improvements in outcome for surgical, endovascular, and overall treatment of unruptured (adjusted odds ratio [OR], 2.33; P=0.0091; adjusted OR, 4.40; P=0.0271; and adjusted OR, 2.58; P=0.0008, respectively) and ruptured (adjusted OR, 3.18; P=0.0004; adjusted OR, 3.54; P=0.0001; and adjusted OR, 3.11; P<0.0001, respectively) aneurysms from the first to the second time period. In 2007 to 2013, the proportion of cases with low or moderate disability at 6 months post subarachnoid hemorrhage was 75.6% for surgical clipping and 76.6% for endovascular therapy. We report significantly improved outcomes over time for overall aneurysm management and for multiple patient subgroups, associated with increased usage of endovascular therapy.

Microsurgery for cerebral arteriovenous malformations: postoperative outcomes and predictors of complications in 264 cases.

The authors conducted a study to assess the safety and efficacy of microsurgical resection of arteriovenous malformations (AVMs) and determine predictors of complications. A total of 264 patients with cerebral AVMs were treated with microsurgical resection between 1994 and 2010 at the Jefferson Hospital for Neuroscience. A review of patient data was performed, including initial hemorrhage, clinical presentation, Spetzler-Martin (SM) grade, treatment modalities, clinical outcomes, and obliteration rates. Univariate and multivariate analyses were used to determine predictors of operative complications. Of the 264 patients treated with microsurgery, 120 (45%) patients initially presented with hemorrhage. There were 27 SM Grade I lesions (10.2%), 101 Grade II lesions (38.3%), 96 Grade III lesions (36.4%), 31 Grade IV lesions (11.7%), and 9 Grade V lesions (3.4%). Among these patients, 102 (38.6%) had undergone prior endovascular embolization. In all patients, resection resulted in complete obliteration of the AVM. Complications occurred in 19 (7.2%) patients and resulted in permanent neurological deficits in 5 (1.9%). In multivariate analysis, predictors of complications were increasing AVM size (OR 3.2, 95% CI 1.5-6.6; p = 0.001), increasing number of embolizations (OR 1.6, 95% CI 1.1-2.2; p = 0.01), and unruptured AVMs (OR 2.7, 95% CI 1-7.2; p = 0.05). Microsurgical resection of AVMs is highly efficient and can be undertaken with low rates of morbidity at high-volume neurovascular centers. Unruptured and larger AVMs were associated with higher complication rates.

Elective treatment of intracranial stenosis with the balloon-expandable Pharos Vitesse stent: 30-day stroke rate and complications

Background and purposeAnalysis of procedural results and 30-day outcome after intracranial angioplasty and stenting (ICAS) with the balloon-expandable Pharos Vitesse stent system in carefully selected high-risk patients in two high-volume...

Results of endovascular treatment of middle cerebral artery aneurysms after first giving consideration to clipping

Middle cerebral artery (MCA) aneurysms are among the more challenging aneurysms for endovascular treatment. We report a contemporary 5-year experience with endovascular therapy for MCA aneurysms at a high-volume neurovascular center. Review of prospectively maintained intracranial aneurysm database. Between 2005 and 2009, 148 patients underwent treatment of 149 MCA aneurysms at our hospital, of which 33 patients with 34 aneurysms underwent endovascular therapy. Among these 33 patients, 14 presented with subarachnoid hemorrhage. Eleven patients were treated with stent-assisted coiling, 1 with balloon-assisted coiling, and the remainder with coiling alone. Three patients required repeat endovascular treatment. There were 7 periprocedural complications, including intraprocedural aneurysm rupture resulting in death in 2 patients. Two patients died at later dates from remote aneurysm rehemorrhage. Average follow-up of remaining patients was 17.1 months radiographically, and 20.3 months clinically. Average modified Rankin scale (mRS) score at last follow up was 2.09, with 17 patients with mRS 0/1 and 5 patients with mRS 2. Fifteen patients showed evidence of radiographic residual at last follow up: 13 were simple neck residuals. Unruptured status and saccular aneurysms were associated with mRS 0/1 outcome (each p < 0.05). At our hospital, MCA aneurysms are being treated with endovascular techniques, but in a minority of patients. Despite the rate of residual neck remnants, few retreatments were necessary and few rehemorrhages occurred. The periprocedural complication rate was not insignificant; therefore, in more recent years and at present, most MCA aneurysms are considered for clipping first at our center.

Radiation-Induced Complications in Endovascular Neurosurgery

The incidence of radiation-induced complications is increasingly part of the informed consent process for patients undergoing neuroendovascular procedures. Data guiding these discussions in the era of modern radiation-minimizing equipment is lacking. To quantify the rates of skin and hair effects at a modern high-volume neurovascular center, and to assess the feasibility of accurately quantifying the risk of future central nervous system (CNS) tumor formation. We reviewed a prospectively collected database of endovascular procedures performed at our institution in 2008. The entrance skin dose and brain dose were calculated. Patients receiving skin doses >2 Gy were contacted to inquire about skin and hair changes. We reviewed several recent publications from leading radiation physics bodies to evaluate the feasibility of accurately predicting future cancer risk from neurointerventional procedures. Seven hundred two procedures were included in the study. Of the patients receiving >2 Gy, 39.6% reported subacute skin or hair changes following their procedure, of which 30% were permanent. Increasing skin dose was significantly associated with permanent hair loss. We found substantial methodological difficulties in attempting to model the risk of future CNS tumor formation given the gaps in our current understanding of the brain's susceptibility to low-dose ionizing radiation. Radiation exposures exceeding 2 Gy are common in interventional neuroradiology despite modern radiation-minimizing technology. The incidence of side effects approaches 40%, although the majority is self-limiting. Gaps in current models of brain tumor formation after exposure to radiation preclude accurately quantifying the risk of future CNS tumor formation.