BackgroundPatients with emergent large vessel occlusion secondary to intracranial atherosclerotic stenosis (ICAS-ELVO) who fail mechanical thrombectomy (MT) pose a treatment challenge. The aim of ...this study is to report our single center experience using the Neuroform Atlas stent as a potential rescue modality.MethodsData was analyzed from a prospectively maintained database at a Comprehensive Stroke Center between January 2019 and September 2021 on all ICAS-ELVO patients who underwent MT and required rescue stenting with the Neuroform Atlas. We systematically gathered demographic, clinical, procedural and functional characteristics on patients presenting with ELVO within 24 hours of last known normal. The primary outcome was the rate of revascularization following stenting.Results26 patients met the inclusion criteria with a mean age of 56.5 years old, 34.6% of whom were female. On presentation the median National Institute of Health Stroke Scale (NIHSS) was 11 and media Alberta Stroke Program Early CT Score (ASPECTS) was 9. MT was performed using A Direct Aspiration First Pass Technique (ADAPT) in all patients. Following Neuroform Atlas stent placement, 3 patients (11.5%) had moderate in stent stenosis while severe stenosis was encountered in 4 patients (15.4%). The rate of successful revascularization (TICI IIB-III) was identified in 92.3% of the patients. On follow up vascular images, re-occlusion occurred in 2 patients (7.7%) and symptomatic hemorrhage was encountered in 3 patients (11.5%). Excellent outcome at 90 days (mRS 0–2) was achieved in 13/26 (50%) of patients.Abstract E-065 Figure 1ConclusionsOur series provides preliminary safety and efficacy data regarding the use of the Neuroform Atlas stent as a rescue modality in ICAS-ELVO cases.Disclosures O. Lajthia: None. E. Almallouhi: None. K. Kicielinski: None. J. Lena: None. A. Spiotta: None. S. Al Kasab: None.
BackgroundThe use of robotic arm in neuroendovascular procedures has gained increasing popularity in the last few years. The theoretical benefits of using a robotic arm include more accurate ...deployment of stents and coils, and the ability to perform procedures remotely. However, limited evidence is currently available to support the use of robotic arm in routine neuroendovascular practice.MethodsDatabases searched include PubMed, CINAHL Complete, and Scopus from database date of inception through February, 11th2022. We included all human studies that reported the procedural and clinical outcomes of using a robotic arm as a primary approach to perform neuroendovascular procedures. The search strategies used a combination of subject headings and keywords for the following two concepts: robotic arm, and neuroendovascular procedures.ResultsA total of 11 studies were identified including 10 case reports/case series and 1 comparative study. Overall, 65 procedures were performed using the CorPath (Corindus Inc.) robotic arm including 28 diagnostic cerebral angiograms, 28 cervical carotid stents, 8 cerebral aneurysm embolization, and one selective spinal angiogram. No complications were reported and only one case (1.5%) required conversion to manual approach. In the single comparative study that compared manual vs. robotic carotid stenting, there was no difference in the procedural and clinical outcomes in both groups.ConclusionThe use of robotic arm is a promising new technology in the neuroendovascular field. Future comparative studies are needed to confirm efficacy and safety of using the robotic arm.Disclosures E. Almallouhi: None. S. Al Kasab: None. E. Brennan: None. A. Spiotta: 1; C; Stryker, Penumbra, and Medtronic.
Background and ImportanceTraumatic aneurysms are a rare sequelae of non-accidental head trauma in infants. The rate of non-accidental trauma in the pediatric population is increasing, therefore ...traumatic aneurysms are an important consideration in the evaluation of pediatric patients with abusive head trauma. We report a 4-week-old infant who suffered a traumatic aneurysm arising from the pericallosal artery.Case PresentationA 24 day old infant with no significant past medical or birth history presented with twitching and poor oral intake for one day prior to presentation. The patient was found to have bilateral SDH, multifocal contusions, and traumatic subarachnoid hemorrhage. NAT workup was remarkable for repeated and prolonged period of abuse. MRA revealed a pericallosal traumatic aneurysm that was treated by means of onyx/coil embolization.Abstract E-112 Figure 1ConclusionTraumatic intracranial aneurysms are a rare, but serious sequelae of pediatric abusive trauma. The authors present a case of a pericallosal traumatic aneurysm as a result of abuse that was treated with coil/onyx embolization of the aneurysm and parent artery occlusion. Rates of pediatric abuse are increasing, and as such traumatic intracranial aneurysms will remain a challenging entity to identify and treat. Despite new methods for management of traumatic aneurysms, prognosis remains poor due to the diffuse injury often involved in these patients.Disclosures Z. Hubbard: None. G. Porto: None. S. Al Kasab: None. M. Sattur: None. A. Spiotta: None.
IntroductionChronic subdural hematoma (CSDH) is one of the most commonly encountered neurosurgical diseases. Middle meningeal artery embolization (MMAE) is a technique for the management of CSDH that ...has elicited promising results. One uncommon mechanism for this recurrence of neovascularization by means of the contralateral middle meningeal artery. Despite the encouraging results of MMAE, recurrence does occur. We describe two cases of CSDH recurrence by means of contralateral middle meningeal artery neovascularization treated with contralateral MMAE.MethodsWe identified two cases of recurrent subdural hematoma secondary to neovascularization following treatment with contralateral middle meningeal artery embolization.ResultsTwo patients initially treated with MMAE were identified with CSDH recurrence secondary to contralateral MMA neovascularization. There was no traumatic or coagulopathic contribution to CSDH recurrence. In both cases, patients underwent contralateral MMAE. Both patients were neurologically intact with radiographic improvement of CSDH at follow up.Abstract E-111 Figure 1ConclusionRe-accumulation of SDH following MMAE by means of contralateral MMA neovascularization is a rare subtype of SDH recurrence following MMAE. Within the context of re-accumulation of SDH following MMAE catheter angiography is an important diagnostic investigation to elucidate the etiology of the recurrence. Furthermore, when angiography reveals neovascularization of the contralateral MMA, embolization of the contralateral MMA achieves good clinical and radiographic result.Disclosures Z. Hubbard: None. S. Al Kasab: None. G. Porto: None. M. Sattur: None. A. Spiotta: None.
Introduction/PurposeEndovascular therapy is a widely accepted treatment modality for intracranial aneurysms due to its safety and efficacy. However, the treatment of very small intracranial aneurysms ...(≤3 mm) is still challenging, and the risk-benefit ratio of endovascular therapy for such aneurysms, especially those ruptured, remains unclear. This study aimed to systematically review the literature and conduct a meta-analysis to evaluate the safety and efficacy of endovascular treatment for ruptured very small intracranial aneurysms.Materials and MethodsWe conducted this study following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and registered it with PROSPERO (CRD42023403959). We conducted a comprehensive search of PubMed and Scopus databases up to February 18, 2023, for original articles on endovascular treatment of ruptured intracranial aneurysms ≤ 3 mm. Only studies with a sample size of more than 10 were included. Statistical analysis was performed using R version 4.2.3, and a random-effect model was applied when I2 > 50% to account for heterogeneity. Pooled prevalence rates were calculated for occlusion rates, complications, and favorable long-term outcomes. odds ratios were calculated to compare outcomes between simple coiling and stent-assisted coiling (SAC).ResultsOf the 600 studies screened, 23 studies with a total of 1335 endovascularly treated ruptured very small intracranial aneurysms were included in the final analysis. The mean age of the patients was 50.69, 482 (32.9%) patients were female, the mean Hunt-Hess Scale was 1.42, and 129 (8.8%) aneurysms originated from the posterior circulation. The overall success rate was 98%. The initial complete aneurysm occlusion rate (Raymond Roy Grade I) was 68% (95% confidence interval CI: 56.0 - 77.0), while the follow-up complete occlusion rate was 83% (95% CI: 72.0 - 90.0). Procedure-related complications included a 4% (95% CI: 3.0 - 5.0) aneurysm re-rupture rate, 4% (95% CI: 3.0 - 6.0) thromboembolism rate, 3% (95% CI: 1.0 - 7.0) coil herniation rate, and 3% (95% CI: 2.0 - 4.0) mortality rate. The recanalization rate was 7% (95% CI: 4.0 - 11.0), and the retreatment rate was 4% (95% CI: 3.0 - 6.0). The favorable long-term follow-up outcome (mRS 0-2) was observed in 90% (95% CI: 3.0 - 6.0) of cases. Comparison of outcomes between treatment by simple coiling and SAC revealed no significant difference between the two groups, except for a higher odd of recanalization in the coiling group (OR= 4.51; 95% CI: 1.31-9.54).ConclusionOur meta-analysis demonstrates that endovascular treatment of ruptured very small intracranial aneurysms with a diameter ≤3 mm is a feasible, effective, and safe approach that is associated with favorable clinical outcomes in both the short and long term. However, more studies are needed to compare endovascular therapy with the clipping of such aneurysms.Disclosures S. Samir Elawady: None. M. Mahdi Sowlat: None. S. Al Kasab: None. A. M Spiotta: None.
BackgroundMore evidence is emerging in the last two years regarding the feasibility of using transradial approach (TRA) for most neuroendovascular procedures. In addition, TRA has better safety ...profile and patient satisfaction compared to the traditional transfemoral approach. In this study, we present our experience in transitioning the ‘radial-first’ approach over a course of one year.MethodsWe prospectively collected demographic and procedural variables of all patients who underwent neuroendovascular procedure using the TRA between starting from March 2019. Exclusion criteria included: 1) known vasoocclusive disease such as Raynaud disease, Takayasu arteritis, or thromboangiitis obliterans; 2) known complex radial or brachiocephalic anatomy such as aberrant right subclavian artery or situs inversus; 3) procedures that require the use of devices that are larger than 8-French. Predefined interim analyses were planned at 500, 750 and 1000 patients.ResultsA total of 750 patients included in this analysis (615 underwent cerebral angiogram and 135 underwent an interventional procedure). Mean age was 55.8 (±15.1), 442 (58.9%) were females, and 434 (57.9%) underwent the procedure in outpatient setting. The right radial artery was used in 730 (97.3%) cases, ulnar artery in 16 (2.1%), and left radial artery in 4 (0.5%) cases. A 4/5-French slender sheath was used for cerebral angiograms and a 5/6 or 6/7-French slender sheath was used for interventional procedures. Interventional procedures included flow diversion in 27 cases, 25 cerebral aneurysm primary coiling cases, 17 stent-assisted coiling cases, 11 balloon-assisted coiling cases, 26 tumor and middle meningeal artery (MMA) embolization cases, and 7 mechanical thrombectomy cases. The overall success rate was 94.8% (711/750): 95.4% (587/615) for cerebral angiograms and 91.9% (124/135) for patients who received an intervention. Overall success rate improved from 93.3% in the first 3 months of the study to 98.3% in the last 3 months (P=0.049). Complications related to access sites were seen in 7 (0.9%) patients: 5 patients had forearm hematoma and 2 had prolonged vasospasm/arm pain that resolved with conservative management. Other complications included post-procedural stroke in 2 patients and sent thrombosis in 1 patient.ConclusionIncorporation of radial-first approach for neuroendovascular procedures is safe and feasible. TRA is associated with learning curve and success rate improved during the study period.Disclosures E. Almallouhi: None. S. Al kasab: None. S. Pai: None. J. Lena: None. A. Spiotta: 1; C; Penumbra. 2; C; Penumbra, Stryker, Cerenovus, Terumo.
IntroductionThe transradial approach (TRA) is being employed to a greater degree in neuroendovascular procedures. Multicenter studies examining TRA versus transfemoral approach (TFA) across all ...neuroendovascular procedures have demonstrated lower rates of both minor and major complications using TRA. Previous studies have described TRA for flow diversion using the Pipeline embolization device (ev3/Chestnut Medical, Menlo Park, California) with good result. The Surpass Evolve device (SED; Stryker Neurovascular, Kalamazoo, Michigan, USA) is a new 64-wire flow diverting stent that obtained FDA approval in 2020. In this study we present a single center experience of patient who underwent TRA for placement of Surpass Evolve flow diversion for treatment of cerebral aneurysms.MethodsWe performed a retrospective review of patient who underwent TRA for SED placement for treatment of aneurysm between August 2020 to February 2021. Patient demographic, procedural techniques, clinical and angiographic data were recorded.Results15 patients underwent SED placement for treatment of aneurysm (age 46.6, 62.5% female). 81% of patients had hypertension, 43% had hyperlipidemia, and 75% were current or former smokers. 3 (20%) patients presented with ruptured aneurysms. 7 (47%) patients had underwent previous aneurysm treatment. 5 patients (33%) had recurrence of their previously treatment aneurysm. 1 patient was converted to TFA after attempted TRA due to vasospasm. The following aneurysms were treated: anterior communicating artery aneurysm in 3 patients, ophthalmic artery aneurysm in 3 patients, anterior choroidal artery aneurysm in 3 patients, superior hypophyseal artery aneurysm in 3 patients, vertebral artery aneurysm in 2 patients, posterior communicating artery aneurysm in 1 patient, cervical carotid artery aneurysm in 1 patient, and a fusiform cavernous carotid aneurysm in 1 patient. The right radial artery was used in all cases. Mean radial artery diameter was 2.64 mm. A 5/6 French slendersheath was utilized in all cases. Coaxial system was used in all cases. Mean smallest parent vessel diameter measured 3.52mm, and mean largest parent vessel diameter measured 4.06 mm. Placement of the TFA flow diversion device was successful in all cases. Balloon angioplasty was used in 5 (33%) patients to achieve wall apposition. No patients had access site complications. There were no procedural or postoperative neurological complications. 1 patient had proximal shelfing of SED. The patient required retreatment with good outcome using an atlas stent.ConclusionsTRA is a safe and feasible approach for flow diversion using the Surpass Evolve device. Rates of access site complications is favorable. Overall rate of conversion to TFA is low. Our early experience suggests frontline TRA is feasible for the utilization of Surpass Evolve flow diverting device.Disclosures Z. Hubbard: None. B. Saway: None. K. Zilinskas: None. G. Porto: None. S. Al Kasab: None. M. Sattur: None. A. Spiotta: None.
IntroductionClinical trials have shown that A Direct Aspiration first Pass Technique (ADAPT) is non-inferior to Stentretriever first (SR) technique for mechanical thrombectomy (MT) in stroke patients ...presenting with emergent large vessel occlusion (LVO). However, longitudinal data regarding the outcomes and evolution of this technique is scarce.MethodsThis is a planned analysis of a prospective cohort study that enrolled all patients who underwent ADAPT MT in a comprehensive stroke center between January 2013 and December 2020. We did exploratory analysis of the characteristics and outcomes of patients who had intracranial internal carotid artery (ICA) or M1 segment of middle cerebral artery (MCA) occlusion based on the aspiration catheter bore size (small (041, 054, 058, 060-inch) vs. medium bore (0.064, 0.068-inch), and medium vs. large bore (0.071, 0.072, 0.074-inch)).ResultsDuring the 8 years study period, a total of 1004 patients were included. Median age was 69, 49% were females, and 60.6% were white. Most common LVO was M1 occlusion in 427 (42.5%) patients followed by M2 occlusion in 217 (21.6%). Symptomatic hemorrhagic transformation was observed in 47 (4.7%) patients and 366 (36.5%) patients achieved modified Rankin scale (mRS) of 0-2 at 90 days after the stroke. For patients with intracranial ICA or M1 occlusion, medium bore aspiration catheters were more likely to achieve successful recanalization after first aspiration attempt (63.9% vs. 51.4%, P=0.015), and had a faster groin to reperfusion time (16 vs. 20 min, P=0.001) when compared with small bore catheters. However, these differences were not significant when comparing medium to large bore catheters (figures 1 and 2).Abstract O-017 Figure 1Abstract O-017 Figure 2ConclusionThis study provides a longitudinal overview of the ADAPT MT technique. Medium bore catheters had better performance measures compared to small bore catheters. However, large bore catheters did not show significantly better performance results which suggest a plateau effect.Disclosures S. Al Kasab: None. E. Almallouhi: None. R. Chalhoub: None. A. Alawieh: None. M. Sattur: None. G. Porto: None. E. Bass: None. A. Spiotta: 1; C; Stryker, Penumbra, and Medtronic. 2; C; Stryker, Penumbra, and Terumo.
BackgroundMechanical thrombectomy (MT) is the standard of care for patients with emergent large-vessel occlusion (LVO). Despite improved endovascular techniques, advances in catheter and stent ...retriever technology, and accumulated user experience, MT fails to achieve successful revascularization in approximately 20% of AIS patients. The aim of this study is to report the etiology and frequency of failed MT.MethodsA prospectively maintained database of MT performed at a comprehensive stroke center in the south-eastern United States between January 2013 and August 2021 was interrogated. We systematically gathered demographic data, clinical presentation, procedural details and MT failure etiology on all adult patients who underwent MT with subsequent failed recanalization. Angiographic images were interpreted by an independent neuro-interventionalist.ResultsOut of a total of 1053 MT procedures, 122 cases (11.6%) were unsuccessful with a final TICI of 0–2a. The mean age was 67.3 years old (±14.5), 62 patients (50.8%) were male and the most common risk factor identified was hypertension in 96 patients (78.7%). On presentation the average National Institute of Health Stroke Scale (NIHSS) was 14.9, mean Alberta Stroke Program Early CT Score (ASPECTS) of 7.9 and most common vessel occluded was the left middle cerebral artery in 41 patients (33.6%). The femoral artery was the access site in 120 cases (94.8%), the average procedure length was 56.3 minutes (±24.8) and the mean number of attempts was 4.6. No patients in our cohort failed MT at the access site, 4 cases (3.3%) failed at the aortic arch and there were no failures at the neck. 118 patients (96.7%) had MT failure once intracranial access had been obtained and most commonly secondary to Intracranial Atherosclerosis (ICAS) seen in 49 cases (41.5%), followed by recalcitrant clot in 35 patients (29.57%) and distal embolization in 6 cases (5.1%).ConclusionFailed MT was encountered in approximately 12% of cases. The most common location of failed MT was intracranial and this was predominantly due to ICAS. Further studies to evaluate better treatment modalities of ICAS related LVO are warranted.Disclosures O. Lajthia: None. H. Ali: None. R. Neyes: None. E. Almallouhi: None. R. Chalhoub: None. K. Kicielinski: None. J. Lena: None. M. Sattur: None. G. Porto: None. A. Spiotta: None. S. Al Kasab: None.
Introduction/PurposeThe treatment of intracranial aneurysms has significantly advanced with the introduction of flow diverters. This retrospective cohort study aimed to compare the efficacy and ...safety of flow diversion with coil embolization for very small brain aneurysms (≤ 3mm).Materials and MethodsThe study utilized data from the aneurysm database at the Medical University of South Carolina from 2017 to 2023 and included patients very small intracranial aneurysms (≤ 3mm) who underwent endovascular treatment with either coil embolization or flow diversion. Both clinical and angiographic data were collected and analyzed retrospectively.ResultsOf 1,199 patients underwent endovascular treatment for intracranial aneurysms, 198 patients with very small aneurysms were included in the study. Of these, 116 (58.6%) were treated with coiling and 82 (41.4%) were treated with flow diversion. The baseline characteristics of the two groups were similar. Of the included patients, 73 (37.5%) presented with ruptured aneurysms, with 53 (46.5%) in the coiling group and 79 (85.4%) in the flow diversion group. Aneurysm occlusion was evaluated using the Raymond-Roy grading system. In the coiling group, 46.5% achieved RR grade 1, 32.6% achieved RR grade 2, and 20.9% achieved RR grade 3. In the flow diversion group, immediate occlusion was achieved at a rate of 42.9% for RR grade 1, 9.5% for RR grade 2, and 47.6% for RR grade 3. The coiling group had statistically significant better initial occlusion rates compared to the flow diversion group (p-value = 0.02). Follow-up was performed for a mean of 86 months in the coiling group and showed RR grade 1 in 61.1% of patients, RR grade 2 in 38.9%, and RR grade 3 in 0.0%. Follow-up was performed for a mean of 25 months in the flow diversion group and showed RR grade 1 in 88.9% of patients, RR grade 2 in 0.0%, and RR grade 3 in 11.1%. Retreatment was required in 16.0% of the coiling group and 0.0% of the flow diversion group (p-value: 0.006). There was no statistically significant difference between the two groups in terms of procedure-related complications.ConclusionIn patients with very small aneurysms (≤ 3mm), coil embolization is associated with better immediate outcomes than flow diversion, while flow diversion achieves higher rates of permanent occlusion.Disclosures M. Mahdi Sowlat: None. S. Samir Elawady: None. A. S. Sumal: None. S. Al Kasab: None. A. M Spiotta: None.
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