Faculty Bibliography

OBJECTIVE:The aim of this study was to develop and demonstrate a postprocedural motion analysis platform capable of objectively quantifying intraoperative surgeon micromovements to facilitate evidence-based self-debriefing in suturing superficial temporal artery-middle cerebral artery microanastomosis. METHODS:The authors analyzed microscope-recorded microanastomoses performed by a cerebrovascular neurosurgeon. Seven suture-placement clips were extracted from operative videos. A computer vision tracking pipeline was implemented in Python using OpenCV to track the needle holder position across the video clips. Four motion metrics were computed for each video clip: absolute error, velocity, acceleration, and jerk. A unified reference distribution was constructed from all clips, and 95th percentile thresholds were defined for each metric. The metrics were displayed as dynamic synchronized plots alongside the corresponding video. Spectral decomposition of the position signal was performed to generate time-frequency representations, and average power in the 6- to 8-Hz band was computed as a quantitative tremor measure. To demonstrate reliable longitudinal performance tracking, the authors applied their platform to 8 recorded procedures between 2023 and 2026 and plotted the mean jerk per suture over time. RESULTS:Reliable tracking was achieved across 92.09% of analyzed footage. Two-dimensional trajectories were reconstructed for a total of 13,183 analyzed frames encompassing 219.82 seconds of suture-placement video (7 clips). Jerk analysis revealed multiple segments exceeding the 95th percentile threshold, flagging moments for surgical review. Time-frequency analysis revealed transient broadband power bursts and 2 persistent spectral bands (6-8 Hz and < 4 Hz). Tremor intensity analysis in the 6- to 8-Hz range revealed temporal tremor fluctuations, a finding undetectable by other metrics. Longitudinal performance tracking was feasible and demonstrated a stable jerk profile, consistent with expert-level performance. CONCLUSIONS:A motion-based postprocedural debriefing platform for the performance of microanastomosis is technically feasible and capable of generating objective, quantitative performance metrics from standard operative video. Unlike prior work focused on expert-novice differentiation, this platform was designed to support individualized self-assessment and reflective practice for surgeons at any experience level. Future work should validate the platform prospectively and correlate motion-based metrics with clinical outcomes.

BACKGROUND AND OBJECTIVES/OBJECTIVE:The Woven Endobridge (WEB) and the Contour Neurovascular System (Contour) are both intrasaccular devices used to treat cerebral aneurysms. We compared outcomes of these 2 devices using data from 2 large registries. METHODS:Data were sourced from the WorldWideWEB Consortium, which included 1363 cases treated with WEB from 2017, and a registry of 277 Contour cases from 10 European centers starting the same year. Patient demographics, aneurysm characteristics, procedural specifics, and outcomes were analyzed. Propensity score matching was applied for comparison. RESULTS:Before matching, the Contour group had more men (37.9% vs 30.8%), more asymptomatic cases (83.4% vs 70.3%), and fewer acute subarachnoid hemorrhage cases (10.8% vs 26.2%). After matching, no significant differences were found in demographics or aneurysm characteristics between groups. The median age was 60 years, and median aneurysm dimensions were comparable. Logistic regression showed no significant differences between WEB and Contour in achieving complete occlusion (odds ratio [OR] = 1.01, 95% CI, 0.67-1.52, P = .971), adequate occlusion (OR = 0.85, 95% CI, 0.41-1.76, P = .665), or achieving modified Rankin Scale 0 to 2 at last follow-up (OR = 0.48, 95% CI, 0.21-1.02, P = .064). Retreatment (OR = 2.23, P = .086), thromboembolic complications (OR = 0.75, P = .452), and adjunctive treatment use (OR = 1.93, P = .141) were also similar. CONCLUSION/CONCLUSIONS:The WEB and Contour demonstrated comparable clinical and angiographic outcomes in this large multicenter study comprised majority small, asymptomatic cerebral aneurysms.

Rescue stenting (RS) is increasingly used for intracranial artery stenosis-related large vessel occlusion (ICAS-LVO), but optimal patient selection remains uncertain. We investigated the baseline and procedural factors associated with receiving RS and whether they modified the association between RS and clinical outcome.This retrospective multicenter study included patients with middle cerebral artery (MCA) ICAS-LVO treated with mechanical thrombectomy (MT) alone or MT followed by RS. Baseline and procedural characteristics associated with receiving RS were identified using multivariable logistic regression and incorporated into inverse probability of treatment weighting models to assess treatment-effect heterogeneity for the 90-day modified Rankin Scale score.Among 264 patients, 193 received RS and 71 MT alone. MT failure, severe stenosis (> 75%), and higher baseline Alberta Stroke Program Early CT Score (ASPECTS) were independently associated with receiving RS. Both MT failure (interaction OR 0.28, 95% CI 0.10-0.83; p for interaction = 0.02) and severe stenosis (interaction OR 0.13, 95% CI 0.03-0.53; p for interaction = 0.004) significantly modified the association between RS and clinical outcome, whereas baseline ASPECTS did not. Within the MT failure subgroup, a significant interaction between severe stenosis and ASPECTS was observed (interaction OR 0.08, 95% CI 0.02-0.38; p for interaction = 0.002), suggesting a more favorable association between RS and outcome at higher ASPECTS values in patients with severe stenosis.In MCA ICAS-LVO, RS may be associated with more favorable outcomes in patients with MT failure, particularly in the presence of severe residual stenosis and preserved ASPECTS. These findings support a more selective approach to RS and warrant prospective validation.

OBJECTIVES/OBJECTIVE:Small Woven EndoBridge (WEB) devices (≤ 4.5 mm) for the intracranial aneurysm treatment are technically challenging to deploy, with limited efficacy and safety data. This study compared functional, angiographic, and safety outcomes of small WEBs with large (> 4.5 mm) and very large (> 7.5 mm) WEBs. MATERIALS AND METHODS/METHODS:The WorldWideWEB consortium is a retrospective, multicenter collaboration across 30 international institutions including adults with intracranial aneurysms treated with WEB. Patients were stratified into small (≤ 4.5 mm) and large (> 4.5 mm) groups; a subanalysis compared small with very large (> 7.5 mm) devices. Primary outcome was retreatment rate. Secondary outcomes included modified Rankin Scale (mRS), angiographic outcomes periprocedurally and last follow-up (FU), and safety events (intracranial hemorrhage (ICH) and thromboembolic complications (TECs)). RESULTS:Among 1473 patients, 229 (15.5%) received small WEBs. Baseline characteristics were similar. Small WEBs showed lower retreatment (4.3% vs 8.8%, p = 0.04) and higher complete occlusion (periprocedurally: 57.1% vs 36.6%, p < 0.01; FU: 76.2% vs 58.5%, p < 0.01). Median mRS was comparable (1 [1-2] vs 1 [1-2], p = 0.88), as was safety (ICH 2.6% vs 0.9%, p = 0.10; TECs 3.1% vs 3.9%, p = 0.69). Very large WEBs had higher retreatment (16.1%, p < 0.001) and lower complete occlusion (periprocedurally: 32.2%, p < 0.001; FU: 50.5%, p < 0.001), with comparable safety (ICH 0.9%, p = 0.27; TECs 4.5%, p = 0.51). CONCLUSION/CONCLUSIONS:Small WEBs demonstrated lower retreatment, superior anatomic and comparable clinical outcomes compared with large devices, with similar safety profiles. KEY POINTS/CONCLUSIONS:Question Do small Woven EndoBridge devices have comparable efficacy and safety to larger devices for intracranial aneurysm treatment despite technical deployment challenges? Findings Small Woven EndoBridge devices (≤ 4.5 mm) achieved lower retreatment rates and superior angiographic occlusion compared with larger devices, with similar safety and functional outcomes. Clinical relevance These findings support the use of small Woven EndoBridge devices for appropriately sized aneurysms, providing reassurance that deployment challenges do not translate into worse clinical outcomes, while superior anatomic outcomes may encourage their broader adoption in clinical practice.

PURPOSE/OBJECTIVE:Although the Woven EndoBridge (WEB) device is increasingly used for the treatment of wide-neck intracranial aneurysms, including in the acute rupture setting, comparative evidence assessing the impact of rupture status remains limited. This study compared angiographic, safety, and clinical outcomes between ruptured and unruptured intracranial aneurysms treated with WEB. METHODS:We conducted a retrospective analysis of prospectively collected data from the multicenter cohort registry WorldWideWEB, including consecutive adult patients with intracranial aneurysms treated with the WEB. Patients were stratified into groups of ruptured and unruptured aneurysms. Propensity score matching was used to balance baseline characteristics between both groups. Retreatment rate was the primary outcome. Secondary outcomes included mRS, safety events (thromboembolic complications) and angiographic outcomes (periprocedurally and last follow-up). RESULTS:Among 1,220 patients, 342 (28.0%) presented with ruptured aneurysms. Propensity-score-matched analyses revealed no significant difference in thromboembolic complications (11.8% vs. 5.9%, p = 0.056), similar periprocedural adequate occlusion (53.3% vs. 53.8%, p > 0.9), and similar retreatment rates (11.8% (95% CI 7.8-17.6%) vs. 7.1% (95% CI 4.1-12.0%), p = 0.14); however, adequate occlusion at follow-up was lower (82.2% vs. 93.3%, p = 0.002) and functional outcomes were worse (mRS ≥ 2 in 34.1% vs. 21.9%, p = 0.012) among patients with ruptured aneurysms. CONCLUSION/CONCLUSIONS:Ruptured aneurysms demonstrated expected inferior follow-up functional and angiographic outcomes when compared with unruptured aneurysms, but no difference in retreatment rate and procedural safety. These findings support WEB as a safe and effective treatment option for appropriately selected ruptured intracranial aneurysms in routine clinical practice.

BACKGROUND:Venous anatomical variants are common and generally considered normal. However, growing recognition of cerebral venous disorders (CVD) in neurological disease has prompted renewed interest in venous architecture, especially with increasing use of the internal jugular vein (IJV) as a target for outflow augmentation. Establishing baseline data on venous stenosis prevalence in an unselected population is critical for future research. This study aimed to assess the prevalence of IJV stenoses in patients undergoing neck CT angiography for unrelated indications. METHODS:We conducted a multicenter, retrospective study analyzing the venous anatomy of patients who underwent CT angiography for unrelated conditions, primarily large vessel occlusion. Stenosis was graded based on the percentage of lumen narrowing with a NASCET-style methodology, and the relationship between IJV stenosis severity and suboccipital collateral drainage was evaluated. Consecutive CT angiograms of patient were queried to map anatomical features. RESULTS:68% of the 679 total patients exhibited some degree of IJV stenosis. Severe unilateral stenosis (≥51%) was present in approximately 21% of patients, while complete or near-complete occlusion was uncommon at 8%. Bilateral high-grade stenosis was noted in 18% of patients for >50% stenosis and in only 2% of patients for >75% stenosis. A greater degree of stenosis correlated with increased suboccipital collateral vein diameter (p = 0.0025). CONCLUSION/CONCLUSIONS:IJV stenosis is common on CT angiography performed for non-venous indications with a correlation between the degree of stenosis and suboccipital collateral vein diameter. The clinical significance of these findings and its possible contribution to CVD requires further prospective investigation.

PURPOSE/OBJECTIVE:Rescue stenting (RS) can achieve durable recanalization in cases of acute large vessel occlusion due to underlying intracranial artery stenosis (ICAS), but its clinical effects may be influenced by procedural factors. This study aimed to evaluate whether the severity of stenosis affects the outcomes after RS. METHODS:In this multicenter retrospective study, patients with acute middle cerebral artery occlusion and underlying ICAS were divided into two groups based on the treatment they received: mechanical thrombectomy (MT) + RS (n = 172) or MT-only (n = 131). Inverse probability of treatment weighting was used to balance baseline characteristics. We systematically evaluated stenosis thresholds from 40% to 90% to identify the optimal cutoff that best differentiated treatment effects on the 90-day modified Rankin Scale (mRS) score and safety outcomes, including symptomatic intracranial hemorrhage (sICH). RESULTS:A stenosis severity of 75% was identified as the optimal cutoff for effect modification. While RS improved recanalization rates overall, its effect on the 90-day mRS score was beneficial only in patients with > 75% stenosis compared to MT-only (Average Treatment Effect (ATE) -0.98, 95% CI -1.73 to -0.22; p = 0.01). In contrast, it showed a detrimental effect in those with < 75% stenosis (ATE 1.08, 95% CI 0.32 to 1.83; p = 0.005). Furthermore, RS increased the rate of sICH regardless of ICAS severity. CONCLUSIONS:The clinical benefit of RS is contingent on the underlying stenosis severity, providing favorable outcomes in patients with high-grade stenoses only. ICAS severity should also be considered for treatment decisions, though these findings require validation in prospective controlled studies.

Data on the use of Woven EndoBridge (WEB) devices in the treatment of narrow-neck intracranial aneurysms (NNA) are limited. We compared the efficacy and safety of single-layer (SL) and single-layer spherical (SLS) WEB devices in treating NNA. We conducted a multicenter retrospective analysis of adult patients with NNA (neck ≤ 4 mm and width-to-neck ratio ≥ 2) treated with SL or SLS WEB devices between January 2011 and December 2022. Patients with fusiform or blister aneurysms, adjunctive treatments, or devices other than SL or SLS were excluded. Propensity score matching was used to adjust for confounding variables. Outcomes included procedural complications, angiographic occlusion rates using the Raymond Roy classification, major device compaction, need for retreatment, and functional outcomes assessed by the modified Rankin Scale (mRS). After matching, resulting in 101 patients in each group, baseline characteristics were well-balanced. Thromboembolic complications occurred in 2.0% of the SLS group and 5.9% of the SL group (P = 0.28). Hemorrhagic complications occurred in 1.0% of the SLS group and 6.4% of the SL group (P = 0.062). Adequate occlusion rates (Raymond Roy grades I and II) were similar between groups (96% in SLS vs. 91% in SL; P = 0.20). Major device compaction was significantly less frequent in the SLS group compared to the SL group (0% vs. 7.6%; P = 0.024). The need for retreatment trended to be lower in the SLS group (1.1% vs. 6.6% in SL; P = 0.12). Functional outcomes (mRS 0–1) at last follow-up were comparable (82% in SLS vs. 86% in SL; P = 0.41). In the treatment of narrow-neck intracranial aneurysms, the SLS WEB device was associated with significantly lower rates of major device compaction compared to the SL device. Reduced compaction may lead to a lower need for retreatment. Overall imaging outcomes and safety profiles were similar between the two devices.

BACKGROUND:Flow diverters (FDs) are increasingly used for cerebral aneurysms, including distal anterior cerebral artery (DACA) aneurysms, but comparative data between devices in this challenging location are limited. OBJECTIVE:To compare the safety and efficacy of Pipeline, Silk Vista Baby (SVB), and FRED Jr. FDs for unruptured DACA aneurysms and identify predictors of complete occlusion. METHODS:We retrospectively analyzed 166 patients treated with FDs at 39 centers in 14 countries (2018–2022) from the CRETA registry. Outcomes included aneurysm occlusion (O’Kelly–Marotta [OKM] scale), complications, retreatment, modified Rankin Scale (mRS) scores, and independent predictors of complete occlusion using multivariable Cox regression. RESULTS:Aneurysms were predominantly saccular and located on the pericallosal artery. Complete occlusion (OKM D) was achieved in 73%, and neck remnants (OKM C) in 12%, with no differences across devices. Ischemic complications occurred in 11% (mostly asymptomatic), hemorrhagic complications in 5%, and in-stent stenosis in 17%. Retreatment was performed in 1.3%. At last follow-up, 98% had mRS ≤ 2. Independent predictors of complete occlusion were female sex (HR 1.85), asymptomatic presentation (HR 1.79), smaller aneurysm neck (HR 0.83/mm), radial access (HR 2.20), and aspirin plus ticagrelor therapy (HR 1.84); device type was not predictive. CONCLUSION:Pipeline, SVB, and FRED Jr. FDs show similar safety and efficacy for unruptured DACA aneurysms. Complete occlusion is influenced by clinical and procedural factors, supporting individualized device selection.

OBJECTIVE:The cause of perimesencephalic subarachnoid hemorrhage (pmSAH) is unclear but has historically been attributed to a venous source. The authors hypothesized that high-resolution cone-beam CT (CBCT) during angiography could better identify pmSAH etiology. METHODS:All patients with pmSAH treated at the authors' institution between January 2023 and December 2024 were retrospectively analyzed. Patients were excluded if CBCT was not performed as part of the digital subtraction angiography (DSA), if CBCT source data were not available for review, or if the images were deemed to be low quality. All images were reviewed by 2 neuroangiographers with extensive neurovascular imaging experience and discussed until consensus agreement. Data were recorded as counts and percentages. RESULTS:Among 152 patients who presented with spontaneous SAH in 2023-2024, 22 had a pmSAH defined according to the Rinkel criteria. These 22 patients had a catheter angiogram performed on 1 of 2 biplane machines. Thirteen of those patients had high-quality CBCT data available for review, 8 (61%) of whom were found to harbor a basilar perforator focal outpouching consistent with a site of rupture. All patients with pmSAH, including the 8 found to have a basilar perforator aneurysm, achieved an excellent neurological recovery with resolution of the basilar perforator finding on follow-up DSA with CBCT and without experiencing a re-rupture event or clinically significant vasospasm. CONCLUSIONS:In the setting of pmSAH, high-resolution CBCT acquired as part of catheter angiography frequently identifies a basilar perforator pseudoaneurysm. Conservative management was associated with excellent outcomes in this series. The authors propose that in the setting of pmSAH, a high suspicion of an arterial etiology should be considered until proven otherwise.