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BackgroundEndovascular device effectiveness and safe use rely on closely simulating real-world scenarios during preclinical testing. This study mainly focused on endoscopic evaluation of radial access catheter failure mechanisms tested on human cadaveric models.MethodsA human cadaveric model was created by catheterizing the ascending and descending aorta in a cadaver model consisting of the head, neck, bilateral arms, and torso. An endoscopic camera was inserted through the ascending aorta to evaluate radial access catheter performances. Blood-mimicking fluid was circulated in the cadaver model using an external pump. Bilateral radial access was obtained using 7F slender sheaths. All catheters were tested by a senior neurointerventionist, and during the procedures, all movements of catheters were recorded endoscopically. All recorded videos are evaluated by experienced neurointerventionists to find out possible failure mechanisms of radial access catheters.ResultsWe identified four possible failure mechanisms associated with current-market radial access catheters. These failure mechanisms were simultaneously demonstrated through endoscopic and fluoroscopic imaging. They include insufficient torque transmission, catheter whipping due to torque build-up, scratching atheroma plaques during catheter advancement, catheters getting stuck during advancement by the septum between the brachiocephalic trunk and the left common carotid, and catheters becoming lodged on the edge of the inner vascular layer. All failure mechanisms were documented through endoscopic and fluoroscopic recordings.ConclusionsThe development and optimization of radial access catheters are necessary. Visualizing possible failure mechanisms will contribute to a better understanding of these failure mechanisms and enable the development of more effective catheters.Abstract E-096 Figure 1Disclosures Y. Senol: 6; C; Microvention. M. Asghariahmadabad: 6; C; Microvention. N. Krishnan: None. A. Orscelik: None. L. Savastano: 4; C; Endovascular Horizons. 5; C; Endovascular Engineering, VerAvanti.

IntroductionSubdural hematomas (SDH), especially when recurring, pose a significant challenge in treatment. Middle Meningeal Artery (MMA) embolization has emerged as a promising method for managing chronic cases. Studies suggest its effectiveness in refractory cases with repeated recurrences. However, recurrence may still occur after embolization, necessitating further interventions like craniotomy, re-do ipsilateral MMA embolization of contra-lateral embolization.Case PresentationAn 85-year-old male with a history of recent falls presented to the emergency room for rapidly progressive left-sided weakness. His medical history included remote burr hole for a left-sided subdural hematoma, coronary bypass graft surgery, chronic renal insufficiency, and he was taking ASA. A CT scan revealed a large right-sided subdural hematoma (SDH) with significant mass effect, prompting surgical evacuation followed by transradial MMA embolization with 150–250 microns PVA particles (Contour, Boston Scientific) and coiling of a large meningo-lacrimal artery. Following this procedure, the patient showed neurological improvement and was discharged, with ASA discontinued. Follow-up CT scan at four weeks showed significant recurrent right SDH. Angiography of the right internal maxillary artery revealed complete occlusion of previously embolized right MMA. Angiography of the left MMA revealed multiple distal branches of the frontal and parietal division crossing the midline to supply convexal branches of the contralateral MMA and right sided SDH membranes. This was likely facilitated by patchy, segmental, and predominantly proximal distribution of the embolysate. The left MMA was then embolized with 150–250 microns PVA particles (Contour, Boston Scientific). At two months follow up, the SDH was almost completely resolved in head CT.ConclusionRecurrent SDH after unilateral MMA embolization should prompt evaluation for contralateral MMA anastomosis. Contra-lateral MMA embolization should be considered as a viable treatment option.Disclosures M. Asghariahmadabad: None. Y. Senol: None. A. Orscelik: None. L. Savastano: None.

Background/ObjectiveUnderstanding the prevalence and angioarchitecture of orbital branches of the middle meningeal artery (MMA), such as the meningolacrimal anastomosis (MLA), is critical to safely perform MMA embolizations. The diminutive size of these dural branches have limited the capacity to perform detailed dissection studies, and clinical angiographies likely underdiagnose the prevalence of these branches given the competing arterial flow from the orbit. We conducted a human cadaveric study to quantify the frequency and anatomical parameters of MLA by performing isolated high resolution angiography and DynaCTs of the MMA.MethodsAngiographies and Dyna CT were performed by navigating microcatheters and injecting iodinated contrast in the extracranial MMA in eight (8) human cadaveric specimens. Native and reconstructed images were analyzed for prevalence and morphometric variations.ResultsThe MLA was identified in 15 of 16(93.7%) specimens. Among these, 87.5% had a single ML branch per MMA, while 12.5% had more than one branch. The mean length of the dural segment of the MLA (from the origin at the MMA to the entry into the orbit) was 1.77 ± 0.70 cm. The mean diameter of the MLA was 0.93 ± 0.29 mm, and the MMA diameter at the origine of the MLA measured 2.15 ± 0.51 mm.ConclusionOrbital branches from the MMA are highly prevalent and must be accounted for at the time of selecting embolization agents and devices during MMA embolization.Abstract E-263 Figure 1DisclosuresY. Senol: None. M. Asghariahmadabad: None. A. Liu: None. N. Krishnan: None. P. Kumar: None. A. Orscelik: None. T. Jun: None. L. Savastano: None.

BackgroundIn acute ischemic stroke (AIS), intravenous thrombolysis (IVT) is standard, but some cases require surgical interventions after failed treatments. However, combining IVT or endovascular therapy with surgical embolectomy can increase hemorrhagic complications. Our meta-analysis assesses the use of surgical embolectomy post-unsuccessful thrombectomy in AIS patients.MethodsWe conducted a literature search using PRISMA guidelines using Pubmed, Embase, Scopus, and Web of Science up to April 26, 2023. Statistical analysis was performed using R software to combine prevalence rates and their respective 95% confidence intervals (CI) using a random-fixed model. We evaluated outcomes such as the modified Rankin Scale (mRS - 0–2), successful recanalization and modified treatment in cerebral infarction (mTICI) score ≥2, symptomatic intracranial hemorrhage (sICH), and 90-day mortality.ResultsOur analysis showed that the use of surgical intervention resulted in 48.15% (95% CI: 30.39–66.39) 90-day favorable outcome with (95% CI: 50.70–99.91) successful recanalization rate (mTICI >2) and sICH of 1.84% (95% CI: 0.03–57.30), and mortality rate of 12.31% (95% CI: 3.22–37.19) at 90 days.ConclusionOur analysis shows that surgical embolectomy may be considered a treatment option in stroke patients who failed thrombectomy.Disclosures M. Pakkam: None. A. Orscelik: None. B. Musmar: None. Y. Senol: None. S. Ghozy: None. C. Bilgin: None. R. Kadirvel: None. D. Kallmes: None.

BackgroundMany studies have compared microsurgery with endovascular treatment (EVT) regarding favorable oculomotor nerve palsy (ONP) recovery outcomes in cases associated with posterior communicating artery (PComA) aneurysms. however there is no consensus on the optimum treatment and time course of recovery outcomes of ONP, Thus, this meta-analysis aimed to compare the PComA-associated ONP recovery rates in the short term and long term.MethodsA systematic review and meta-analysis were conducted by searching PubMed, Embase, Scopus, and Web of Science databases. The extracted data included patient demographics, details on treatment modalities and timing, and characteristics of PComA aneurysms ONP caused by unruptured or ruptured aneurysms. The primary outcome was ONP favorable recovery, defined as the resolution of admission symptoms, except for subtle ptosis and mild pupillary asymmetry. We used random effect models to calculate odds ratios (OR) and pool prevalence with their corresponding 95% confidence intervals (CI).ResultsA total of 40 studies met the inclusion criteria. According to the meta-analysis of follow-up results, microsurgery was associated with higher rates of favorable ONP recovery outcomes at 1 month (0.53 vs 0.17, P <0.01), 3 months (0.69 vs 0.33, P<0.01), 6 months (0.79 vs 0.48, P<0.01), and 12 months follow-up (0.90 vs 0.64), after 12 months, comparable recovery outcomes were identified [18 months: (0.87 vs 0.64, P-value = 0.36); ≥24 months: (0.86 vs 0.72 P-Value = 0.26)] and among patients ≥ 60 years, early treatment, ≤ 7 mm aneurysms, ruptured aneurysms, and partial ONP at presentation.ConclusionMicrosurgery demonstrates better recovery of ONP within the first 12 months when compared to EVT. Nevertheless, prolonged follow-up reveals comparable favorable ONP recovery outcomes between microsurgery and EVT over the extended term. These results imply the necessity for tailoring treatment selection by assessing the risks and advantages on an individual basis, considering both short-term and long-term outcomes.Abstract E-057 Figure 1Disclosures R. Abo Kasem: None. H. Matsukawa: None. S. Elawady: None. C. Cunningham: None. A. Orscelik: None. B. Musmar: None. M. Sowlat: None. A. Spiotta: None.

IntroductionRuptured brain arteriovenous malformations (bAVMs) present complex challenges in neurosurgical management, with timing of microsurgical treatment (MST) being a subject of ongoing debate. This study aims to evaluate the impact of MST timing on clinical outcomes in patients with ruptured bAVMs.MethodsWe conducted a systematic review and meta-analysis following PRISMA guidelines. A comprehensive search of PubMed, Embase, Scopus, and Web of Science databases identified relevant studies. The timing was defined as the duration from the rupture of bAVM to the MST. The patients were divided into four different groups based on MST timing: <48 hours, <1 week, <2 weeks, and <1 month. The primary outcome included favorable outcome defined as a modified Rankin Scale (mRS) score of 0-2 or a Glasgow Outcome Scale (GOS) score of 4-5 in the last clinical follow-up. Secondary outcomes were periprocedural mortality and complete excision.ResultsFifteen studies comprising 1026 patients were included in the meta-analysis. MST time >48 hours group had a significantly higher favorable outcome rate (odds ratio [OR]:9.71, 95% confidence interval [Cl]:3.09-30.57, p<0.01) and a lower mortality rate (OR:0.15, 95% Cl:0.02-0.88, p=0.04) compared to MST timing ≤48 hours group. (Figure 1) After excluding patients who underwent MST with preoperative EVT, MST time >48 hours were associated with a significantly higher favorable outcome rate (OR:9.39, 95% CI: 2.53–34.89, p<0.01). (Figure 2) There were no significant differences in terms of favorable outcomes, mortality, and complete excision when comparing MST times of ≤1 week versus >1 week, ≤2 weeks versus >2 weeks, and ≤1 month versus >1 month.Abstract O-072 Figure 1Abstract O-072 Figure 2ConclusionsOur findings suggest that delaying MST beyond 48 hours with and without preoperative EVT may improve favorable outcomes and reduce mortality rates in patients with ruptured bAVMs.DisclosuresA. Orscelik: None. B. Musmar: None. H. Matsukawa: None. M. Ismail: None. S. Elawady: None. S. Assad: None. C. Cunningham: None. M. Sowlat: None. R. Kasem: None. A. Spiotta: None.

BackgroundMiddle meningeal artery embolization (MMAe) has emerged as an effective intervention for non-acute subdural hematoma (SDH), reducing recurrence rates and minimizing the need for repeated surgical evacuation. However, recurrent or growing SDH after stand-alone or adjuvant MMAe remains a clinical challenge with multifactorial etiologies. This abstract presents cases of failed MMAe, workup done to investigate the underlying failure mechanisms and targeted management strategies.MethodsA retrospective review of 195 patients that underwent MMAe at a major medical center from November 2020 to March 2025 was conducted to identify patients with recurrent SDH after MMA. Data were collected on patient demographics, clinical presentations, imaging findings, treatment approaches, and outcomes. Recurrent SDH was defined as the reaccumulation or acute rebleeding observed on follow-up CT scan after an initial reduction in SDH size following adjunctive MMAe with surgery. In contrast, growing SDH was considered as an increase in SDH size without prior reduction after standalone MMAe. A systematic review of published cases of recurrent SDH post-MMAe was also performed across PubMed, Web of Science, Scopus, and Embase databases, adhering to PRISMA guidelines.ResultsTwenty patients (mean age: 73.2 ± 9.3 years) with recurrent or growing SDH after standalone or adjunctive MMAe were found. Recurrences were observed at a mean interval of 4.7 ± 3.1 weeks post-embolization. The primary recurrence mechanisms and corresponding treatment strategy were: ipsilateral MMA partial recanalization (30%) managed by repeat embolization with polyvinyl alcohol (PVA) particles, Onyx, or coils; dural supply from contralateral MMA (25%) managed by contralateral MMAe; dural supply by deep temporal artery (5%) managed by embolization of this artery; and cerebrospinal fluid (CSF)-venous fistulas (5%) managed by transvenous embolization for CSF-venous fistulas. Rescue craniotomy was performed in two standalone (10%) and four adjunctive MMAe cases (20%), while rescue burr hole evacuation was employed in six standalone (30%) and two adjunctive cases (10%). Among 13 patients (65%) with available follow-up, 10 (50%) achieved complete symptom resolution, while three (15%) showed symptomatic improvement. Follow-up images demonstrated complete or near-complete hematoma resolution in nine patients (45%), stable hematoma size in two patients (10%), and partial resolution in two patients (10%). No further recurrences occurred after final treatment. Two patients (10%) died due to underlying malignancies within 10 days of the last embolization. The systematic review identified eight studies with 10 cases of recurrent SDH after MMAe, demonstrating collateral neovascularization, blood supplies from the deep temporal artery or dural arteriovenous fistula, brain tumors or metastases, and CSF leakage. Successful management involved targeted embolization of alternative vascular supply and surgical evacuation in select cases.ConclusionRecurrent cSDH after MMAe is driven by complex vascular and systemic factors. Addressing MMA recanalization, collateral circulation, and alternative vascular contributors is critical for optimizing outcomes. Bilateral MMAe, aggressive embolization techniques, and targeted treatment of underlying pathologies, such as CSF-venous fistulas, may improve long-term success. Future prospective randomized controlled trials are needed to refine embolization techniques, compare different embolic materials, and explore the potential role of bilateral MMAe in preventing recurrence.DisclosuresA. Orscelik: None. Y. Senol: None. N. Krishnan: None. M. Asghariahmadabad: None. A. Liu: None. P. Kumar: None. J. Tian: None. M. Amans: None. K. Narsinh: None. E. Winkler: None. S. Hetts: None. D. Raper: None. D. Cook: None. L. Savastano: None.

BackgroundThe impact of certain comorbidities on mechanical thrombectomy (MT) outcomes remains largely unexplored. Diabetes mellitus (DM) and admission hyperglycemia have been associated with poor clinical outcomes for patients treated with MT. In this study, we sought to investigate the effects of DM and admission hyperglycemia on MT outcomes.MethodsFollowing PRISMA guidelines, a systematic literature search was conducted in Medline, Embase, Scopus, and Web of Science databases. Data regarding successful recanalization (modified Thrombolysis in Cerebral Infarction [mTICI] ≥2b), functional independence (modified Rankin Scale [mRS] 0–2), excellent outcomes (mRS 0–1), symptomatic intracranial hemorrhage (sICH), and mortality were extracted from the included studies. The pooled odds ratios (ORs) and their corresponding 95% confidence intervals (CIs) were calculated using random effects model.ResultsTwenty-one studies comprising 9708 patients were included. A total of 2311 patients (24%) had a history of DM, and 2026 patients (21%) had admission hyperglycemia. Admission hyperglycemia was associated with significantly lower odds of mTICI ≥2b (OR = 0.7, 95% CI = 0.55–0.89), mRS 0–2 (OR = 0.47, 95% CI = 0.41–0.53), and mRS 0–1 (OR = 0.43, 95% CI = 0.34–0.55) as compared to normoglycemic state. Patients with hyperglycemia had significantly higher rates of sICH (OR = 2.05, 95% CI = 1.66–2.54) and mortality (OR = 1.99, 95% CI = 1.58–2.52) than normoglycemic patients. Diabetes mellitus was associated with significantly high rates of mortality (OR = 1.74, 95% CI = 1.31–2.3) and lower rates of mRS 0–2 (OR = 0.60, 95% CI = 0.48–0.76) in sensitivity analyses.ConclusionOur results indicate that admission blood glucose levels and DM can negatively affect MT outcomes. Further research should focus on optimizing MT outcomes for these patients.DisclosuresC. Bilgin: None. G. Belge Bilgin: None. M. Jabal: None. H. Kobeissi: None. S. Ghozy: None. Y. Senol: None. A. Orscelik: None. R. Kadirvel: None. W. Brinjikji: None. D. Kallmes: None. A. Rabinstein: None.

BackgroundCerebral vasospasm is a leading cause of delayed cerebral ischemia following subarachnoid hemorrhage (SAH), often resulting in high morbidity and mortality. While balloon angioplasty (BA) and intra-arterial calcium channel blockers (IA CCBs) are utilized for vasospasm management, their efficacy and safety remain unclear.MethodsWe systematically searched PubMed, Scopus, and Web of Science for studies reporting on BA or IA CCB treatment for cerebral vasospasm up to October 2024, following PRISMA guidelines.ResultsSeventy studies met the inclusion criteria. BA was associated with a clinical improvement rate of 65.03% and favorable outcomes in 51.00% of patients. Hemorrhagic complications occurred in 1.55%, ischemic complications in 4.91%, and the mortality rate was 19.76%. Radiological improvement was achieved in 93.46% of BA cases, with a retreatment rate of 11.19%. Nimodipine showed clinical improvement in 55.79% of cases and favorable outcomes in 57.39%, with a 16.10% rate of ischemic complications and a mortality rate of 14.03%. Nicardipine had the highest rates of clinical improvement (73.50%) and favorable outcomes (85.29%), with a mortality rate of 5.76%. Verapamil showed clinical improvement in 44.37% of cases and a mortality rate of 17.40%. Retreatment rates were 26.16% for nimodipine, 46.00% for nicardipine, and 45.01% for verapamil.ConclusionBA and IA CCBs are both effective in treating cerebral vasospasm. BA provides high radiological improvement but is associated with high complication and mortality rates. IA CCBs, particularly nicardipine, offer good clinical and radiological outcomes with lower complication rates but require more frequent retreatments. Further randomized trials are needed to optimize treatment strategies.DisclosuresB. Musmar: None. A. Orscelik: None. J. El Khoury: None. N. Adeeb: None. S. Tjoumakaris: None. M. Gooch: None. C. Notarianni: None. B. Guthikonda: None. J. Morcos: None. R. Rosenwasser: None. P. Jabbour: None.

BackgroundAneurysmal subarachnoid hemorrhage (aSAH) often leads to cerebral vasospasm, a serious complication associated with delayed cerebral ischemia (DCI) and increased morbidity. For vasospasm management, both balloon angioplasty (BA) and intra-arterial (IA) calcium channel blockers (CCBs) are commonly used, although their combined efficacy and safety compared to monotherapy remain unclear.MethodsWe conducted a systematic review and meta-analysis in accordance with Cochrane and PRISMA guidelines. Studies were included if they investigated patients with vasospasm post-aSAH treated with both BA and IA CCBs. Outcomes of interest were clinical improvement, favorable outcomes, hemorrhagic and ischemic complications, and retreatment rates. A random-effects model was used to analyze pooled prevalence rates and odds ratios (ORs) with 95% confidence intervals (CIs).ResultsEight studies met inclusion criteria, comprising patients treated with BA, IA nimodipine, or IA verapamil. Combined BA with IA nimodipine significantly improved clinical outcomes compared to BA alone (OR: 0.07, 95% CI: 0.01–0.68, p = 0.02) without increasing hemorrhagic or ischemic risks. However, ischemic complications were higher with combined therapy than IA nimodipine alone (OR: 0.04, 95% CI: 0.01–0.40, p < 0.01). Combined therapy reduced retreatment rates compared to IA verapamil monotherapy (OR: 3.18, 95% CI: 1.15–8.79, p = 0.03).ConclusionOur analysis indicates that combined BA and IA CCBs may improve clinical outcomes for aSAH patients with vasospasm without increasing complications. Further randomized studies are necessary to confirm these findings and establish standardized guidelines for combined therapy use.DisclosuresB. Musmar: None. A. Orscelik: None. J. Roy: None. S. Hage: None. N. Adeeb: None. S. Tjoumakaris: None. M. Gooch: None. C. Notarianni: None. B. Guthikonda: None. J. Morcos: None. R. Rosenwasser: None. P. Jabbour: None.