Faculty Bibliography

BACKGROUND AND OBJECTIVES/OBJECTIVE:The Silk Vista Baby (SVB) flow diverter (FD) stent (Balt SAS) is the first device designed for treating distally located brain aneurysms. It can be delivered through a 0.017-inch ID microcatheter, enabling access to small, distal vessels. The aim of this study was to evaluate the effectiveness, safety, technical success, occlusion rate, and clinical outcomes of the SVB device. METHODS:This retrospective, multicenter study included data from 18 centers from November 2023 to September 2024. Procedures were performed by experienced neurointerventionalists following institutional standards of care. Outcomes analyzed included effectiveness, safety, and aneurysm occlusion rates. Descriptive analyses and Pearson χ2 or Independent t-Test were used for statistical evaluation. RESULTS:A total of 95 patients, mean age 55.4 years, were included. A total of 31% of aneurysms were ruptured at admission. Most (58.3%) were located in the anterior circulation, and 45% had previous treatment, mainly coiling (69.4%). Complication rates were higher for ruptured aneurysms (24.1%) compared with unruptured ones (9.2%). Two deaths occurred, 1 (1.1%) related to the procedure. At discharge, 87% of patients had modified Rankin Scale ≤2. The latest follow-up showed overall complete/near-complete occlusion rates of 76.1%, with 81.14% for ruptured and 73.43% for unruptured aneurysms. Technical success was higher in unruptured cases (100% vs 93.1%). CONCLUSION/CONCLUSIONS:Our case series demonstrated the efficacy of the SVB with a high rate of technical success. The occlusion rates for ruptured cases are comparable with those of other FDs. However, the rates are lower for unruptured cases. This discrepancy is likely due to the characteristics of the aneurysms, particularly in the presence of side branches in bifurcation lesions. The SVB safety profile is similar to other FDs in unruptured cases, while the ruptured group presented more complications.

BACKGROUND:The Drivewire 24 (DW24) is a newly FDA-cleared 0.024 inch steerable guidewire. Its proximally controlled deflectable tip allows for intravascular steering to facilitate selective navigation of diagnostic or therapeutic catheters. We present the first clinical experience with the DW24. METHODS:All neurointerventional procedures using the DW24 from October 2024 to April 2025 were retrospectively reviewed. Indications, procedural details, DW24 performance, wire-related complications, and operator feedback were assessed. RESULTS:27 procedures were performed utilizing the DW24. Indications included aneurysm (n=16), stroke (n=5), arteriovenous fistula or malformation (n=4), and diagnostic venography (n=2). Technical success was achieved in 92.6% of cases. Target vessels included the MCA, anterior cerebral artery, posterior cerebral artery, internal carotid artery segments, transverse sinus, and torcula. The device's radiopaque, hydrophilic distal tip aided fluoroscopic visibility, and the variable support enabled articulation across a range of aspiration and delivery catheters without requiring additional support devices. The DW24's steerability enabled access to challenging cerebrovascular anatomy, including one stroke case where conventional guidewires failed to reach a distal M2 occlusion. The DW24's intravascular steering also allowed for the delivery of catheters for Pipeline Embolization Device (PED) deployment and facilitated PED post-processing to improve wall apposition without requiring wire removal, reshaping, or balloon angioplasty. Operators observed a short learning curve. There were no device-related complications, though the wire's response to rotational force was a limitation. CONCLUSION/CONCLUSIONS:The DW24 demonstrated a high technical success rate with no device-related complications. Its versatility across catheter sizes and precise controllability facilitate navigating complex cerebrovasculature. Further studies should assess efficacy in larger cohorts across additional clinical scenarios.

OBJECTIVE:To validate the carotid web (CW) risk stratification assessment described in previous works within a larger cohort of patients with symptomatic and incidentally found asymptomatic CWs. METHODS:A retrospective analysis of our institution's electronic medical records identified all patients with a diagnosis of CW from 2017 to 2024. We included symptomatic patients and those with asymptomatic CWs, that is, incidentally found webs without history of stroke or transient ischemic attack. Patient charts were reviewed for demographics, imaging, comorbidities, and a diagnosis of stroke after diagnosis of asymptomatic CW. All angles were measured as described in previous work on a sagittal reconstruction of neck CT angiography in which the common carotid artery (CCA), external carotid artery, and internal carotid artery (ICA) were well visualized, together with the CW itself. Principal component analysis and logistic regression were performed to evaluate the association between high-risk angles and stroke risk.  RESULTS: Twenty-six symptomatic and 26 asymptomatic patients were identified. Of note, the number of patients with hypertension, hyperlipidemia, and smoking history was 17 (65.0%), 16 (62.0%), and 8 (31.0%) for symptomatic patients and 18 (69.0%), 17 (65.0%), and 15 (58.0%) for asymptomatic patients. All angular measurements showed statistically significant associations with stroke status. The CCA-web-pouch angle showed the strongest association (p=2.07×10⁻⁴), followed by the CCA-pouch-tip angle (p=3.23×10⁻⁴), ICA-web-pouch angle (p=0.004), and ICA-pouch-tip angle (p=0.005). Each additional high-risk angle increased the odds of stroke by 9.47-fold (p<0.0001). The associated probability of stroke increased from 6.3% with no high-risk angles to 39.1% with one high-risk angle and further to 85.9% with two high-risk angles. The model demonstrated high sensitivity, correctly identifying 84.6% of positive cases, and high specificity, correctly identifying 88.5% of negative cases. The F1 score was 0.863, indicating good overall model performance.  CONCLUSION: Given this successful stratification of CWs into high- and low-risk groups, the utilization of geometric CW parameters may play a role in improving patient selection for intervention in the setting of incidentally diagnosed CW. .

BACKGROUND AND OBJECTIVES/OBJECTIVE:Iatrogenic cerebrovascular injury can cause intracranial hemorrhage and pseudoaneurysm formation, putting patients at high risk for postoperative bleeding. No consensus for management exists. This study describes endovascular treatment of these acute injuries with flow diverter stents. METHODS:Electronic medical records were retrospectively reviewed for injury type and etiology, timing of diagnosis, and endovascular management, including antiplatelet regimens, embolization results, and clinical outcome. RESULTS:Six patients were included. Three suffered an injury to the internal carotid artery, 1 suffered an injury to the left anterior cerebral artery, 1 suffered an injury to the right posterior cerebral artery, and 1 suffered an injury to the basilar artery. Four of the 6 injuries occurred during attempted tumor resection, 1 occurred during cerebrospinal fluid leak repair, and 1 occurred during an ophthalmic artery aneurysm clipping. All injuries resulted in pseudoaneurysm formation. Four were immediately detected on angiography; 2 were initially negative on imaging. Five were treated with a pipeline embolization device, and 1 was treated with a Silk Vista Baby. Two were treated with 2 pipeline embolization devices telescopically overlapped across the pseudoaneurysm. All devices deployed successfully. No pseudoaneurysm recurrence or rebleeding occurred. No parent artery occlusion or stenosis was observed, and complete pseudoaneurysm occlusion was observed in 4 patients (in 2 patients, follow-up imaging could not be obtained). CONCLUSION/CONCLUSIONS:With proper antiplatelet regimens, flow diverter stents can be used safely to successfully treat complex acute iatrogenic injuries. Early repeat angiogram is needed when immediate postinjury imaging does not discover the point of vessel injury.

BACKGROUND:Intravenous thrombolysis (IVT), utilizing the clot-dissolving medications alteplase (rt-PA) or tenecteplase (TNK), is the cornerstone in acute ischemic stroke (AIS) emergency intervention. However, the impact of prior antiplatelet therapy (APT) on post-IVT outcomes when utilizing alteplase remains controversial. We conducted a systematic review and meta-analysis to evaluate the effect of prior APT on the outcomes after using alteplase in AIS patients. METHODS:We conducted a systematic review and meta-analysis synthesizing studies, which were retrieved by systematically searching PubMed, Web of Science, SCOPUS, and Cochrane through June 30, 2024. We used the R language V. 4.3. to pool dichotomous data using odds ratio (OR) with a 95% confidence interval (CI). PROSPERO ID/UNASSIGNED:CRD42024495393. RESULTS:Thirty studies were included in our analysis, with 436,232 patients. Prior APT was significantly associated with increased odds of symptomatic intracranial hemorrhage (sICH) (OR, 1.78; 95%CI [1.48, 2.13]; P < 0.01), any ICH (OR, 1.44; 95%CI [1.16, 1.78]; P < 0.01), mortality (OR, 1.39; 95%CI [1.23, 1.58]; P < 0.01), and poor functional outcomes (modified Rankin Scale score of 3-6 [mRS 3-6]) (OR, 1.81; 95%CI [1.03, 3.19]; P = 0.04). Additionally, prior APT significantly reduced the odds of good functional outcome [mRS 0-2] (OR, 0.85; 95%CI [0.74, 0.97]; P = 0.02). CONCLUSION/CONCLUSIONS:Prior APT increased hemorrhagic complications, mortality, and poor functional outcome, while reducing the odds of good functional outcome after IV alteplase. Future research should focus on identifying adjunctive agents that may decrease hemorrhagic complications and investigate the impact of various APT regimens and alternative thrombolytics beyond alteplase in this specific population.

Tethered postoperative drains are not uncommon complications that often require open removal in the operating room, which can increase risks of surgical site infection as well as length of hospitalization. We present a novel method of tethered drain removal through guidewire electrification. A retained deep drain following a posterior cervical laminectomy and fusion was identified after failed manual removal. Under fluoroscopic guidance, the retaining suture was indirectly identified through the obstruction of an inserted guidewire, through which monopolar cautery was applied, breaking the suture and allowing drain removal. The original incision did not need to be re-opened. While further investigation is necessary for validation, this technique shows great promise as an alternative to open removal.

BackgroundLarger "macrowires" may facilitate microcatheter-free delivery of large-bore aspiration catheters (ACs) for intracranial endovascular mechanical thrombectomy. We examined the safety and efficacy of the Aristotle Colossus Guidewire for this use.MethodsIn this retrospective analysis of prospective data from 12 institutions, we identified anterior circulation endovascular mechanical thrombectomy cases involving the Aristotle Colossus guidewire over a 12-month period. The primary efficacy endpoint was successful delivery of the AC to the site without the use of adjunct devices. Multivariable logistic regression was performed with clinically relevant covariables.ResultsIn 122 patients (median age 74 years (interquartile range (IQR) 63-82)), most intracranial occlusions were in the M1 segment of the middle cerebral artery (95/122, 78.0%). The primary endpoint of microcatheter-free AC delivery was met in 87.7% (107/122) of patients; 93/122 (76.2%) patients underwent microcatheter-free delivery with successful reperfusion via contact aspiration (modified thrombolysis in cerebral infarction grade ≥ 2B). The median number of passes was 1 (IQR 1-2). Multivariable regression demonstrated that severe internal carotid artery tortuosity or cervical loop presence (odds ratio (OR): 0.09, 95% confidence interval (CI): 0.01-0.54, p = 0.01) and presence of intracranial atherosclerotic disease (OR: 0.15, 95% CI: 0.03-0.83, p = 0.03) were significantly associated with lower odds of successful AC delivery over the guidewire. Intraprocedural vasospasm occurred in 4.9% (6/122) of cases; there were no reports of vessel dissection or perforation.ConclusionsWe demonstrate the favorable performance of the Aristotle Colossus guidewire for anterior circulation ischemic stroke intervention. The macrowire appears to safely facilitate navigation of the neurovasculature by large-bore ACs without the need for microcatheter and/or stentriever.

The presence of tantalum opacified liquid embolic in incompletely treated dural arteriovenous fistulae (dAVFs) limits visibility of critically important angioarchitectural features. Modern cone beam CT imaging can resolve the anatomy of dAVFs allowing for a targeted embolic approach. However, distortion from beam hardening artifact is particularly limiting in cone beam CT imaging. We present a case of a dAVF embolized 4 times without cure at an outside hospital and ultimately referred to our practice for treatment. In this case, dual volume cone beam CT imaging (versus the traditional single volume technique), combined with post-processing tools on a modern workstation, enabled clear resolution of critical angioarchitectural features of the dAVF leading to a targeted cure. This technique has the potential to vastly improve dAVFs resolution in the context of partial treatment, a challenging and not uncommon diagnostic and treatment challenge.

IntroductionFlow diversion with the pipeline embolization device (PED) is an effective endovascular treatment. However, the metal surface's thrombogenicity and need for dual antiplatelet therapy (DAPT) are notable limitations. Few prior studies have reported specifically on flow diverters' safety in patients with hemoglobinopathies, a population at increased risk of thrombotic and hemorrhagic complications.MethodsNatural language processing queried our institution's medical records for intracranial embolization procedures from 2014 to 2024, screening for "hemoglobinopathy," "thalassemia," and "sickle cell." Patient charts were retrospectively reviewed.ResultsSixteen procedures in 14 patients were identified in which a mean 2.0 PEDs per patient were used. Most patients were female (71.4%). Median age was 48.8 years. Five patients had sickle cell disease, two had sickle cell trait, two had sickle cell or hemoglobin C trait and alpha thalassemia minor, and five had alpha thalassemia minor. The 14 patients were treated for 20 aneurysms; four treatments covered two distinct aneurysms. Median dome size per treatment was 4.0 mm. Of the 16 aneurysm treatments, five (31.2%) treated an irregular aneurysm. Most (56.2%) treatments used multiple PEDs. All patients were discharged on DAPT after verifying effect with P2Y12 assays. Follow-up DSA, CTA, or MRA was obtained in 12/14 (85.7%) patients at a median 1.6 years. Complete occlusion was achieved in all aneurysms. Clinical follow-up was obtained in all patients at a median 2.2 years. There were no thromboembolic or hemorrhagic complications, neurological deficits, or mortalities.ConclusionPipeline embolization can safely and effectively treat patients with hemoglobinopathies.

INTRODUCTION/BACKGROUND:While revascularization rates have improved for mechanical thrombectomy (MT) in acute ischemic stroke, advancements in aspiration pumps have been limited. The ALGO Smart Pump (Von Vascular, Sunrise, FL) is a small on-field, operator-driven pump offering two aspiration modes: Adaptive Pulsatile Aspiration (APA™) Mode and a continuous 'Static' mode. This study evaluates the performance of the ALGO Smart Pump's Static Mode compared to a commercially available aspiration pump. METHODS:Operators performed aspiration thrombectomy in a flow model with ALGO and the Penumbra ENGINE (Penumbra, Alameda, CA) using medium (ID.036-.057") to large (ID.068-.071) bore aspiration catheters. Primary endpoint was complete clot ingestion (CCI), defined as the full ingestion of the clot within the catheter or pump's canister, without any clot at the catheter tip or evidence of embolization to new territories (ENT). Secondary endpoints included first pass recanalization, ENT and total aspiration time. RESULTS:When comparing all catheters, ALGO Smart Pump achieved CCI in 154 of 180 thrombectomies (85.6 %) compared to Penumbra ENGINE achieving CCI in 136 of 180 thrombectomies (75.6 %). The CCI rate between pump types across all catheters was statistically significant (p = 0.008), favoring ALGO pump. There was no difference between pump type on aspiration time. CONCLUSION/CONCLUSIONS:The ALGO Smart Pump may represent an alternative in MT, with potential higher effectiveness compared to existing available aspiration pumps with additional user-friendly benefits including a sterile, smaller, on-field apparatus.