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Purpose of ReviewIdiopathic intracranial hypertension (IIH) is a disorder characterized by long-standing elevated intracranial pressure (ICP). As the name applies, no uniform cause has been identified. IIH is typically characterized by headaches, pulsatile tinnitus, and visual deterioration.Recent FindingsAnomalies in cerebrospinal fluid (CSF) absorption are implicated in the pathophysiology of IIH. Non-invasive imaging of the brain parenchyma and the cerebral venous sinus has improved, and research has gained a better understanding of the role of cerebral venous sinus stenosis. Both have led to a better delineation of the role of arachnoid granulations (AG) and the glymphatic system in the development of IIH.SummaryIIH may occur as a result of restrictions of CSF absorption from the venous system, and or the congestion and overflow of the glymphatic system. Elucidating these mechanisms will lead to greater understanding of its underlying pathophysiologic mechanisms.

Evaluate the role of venous sinus stenting in the treatment of pulsatile tinnitus among patients with Idiopathic Intracranial Hypertension (IIH) and significant venous sinus stenosis. A written informed consent approved by the Weill Cornell institutional review board was signed and obtained from the study participants. Thirty-seven consecutive patients with IIH and venous sinus stenosis who were treated with venous sinus stenting between Jan.2012-Jan.2016 were prospectively evaluated. Patients without pulsatile tinnitus were excluded. Tinnitus severity was categorized based on \"Tinnitus Handicap Inventory\" (THI) at pre-stent, day-0, 1-month, 3-month, 6-month, 12-month, 18-month and 2-year follow-up. Demographics, body-mass index (BMI), pre and post VSS trans-stenotic pressure gradient were documented. Statistical analysis performed using Pearson's correlation, Chi-square analysis and Fischer's exact test. 29 patients with a mean age of 29.5±8.5 years M:F = 1:28. Median (mean) THI pre and post stenting were: 4 (3.7) and 1 (1) respectively. Median time of tinnitus resolution post VSS was 0-days. There was significant improvement of THI (Δ Mean: 2.7 THI [95% CI: 2.3-3.1 THI], p<0.001) and transverse-distal sigmoid sinus gradient (Δ Mean: -15.3 mm Hg [95% CI: 12.7-18 mm Hg], p<0.001) post-stenting. Mean follow-up duration of 26.4±9.8 months (3-44 months). VSS was feasible in 100% patients with no procedural complications. Three-patients (10%) had recurrent sinus stenosis and tinnitus at mean follow-up of 12 months (6-30 months). Venous sinus stenting is an effective treatment for pulsatile tinnitus in patients with IIH and venous sinus stenosis.

Magnetic resonance venography (MRV) has not been validated in pre-operative planning of the dural venous sinus stenting (VSS) among idiopathic intracranial hypertension (IIH) patients. We aim to prospectively evaluate dural venous sinus measurement in IIH patient population on two-dimensional time-of-flight (2D-TOF) MRV and Three-dimensional contrast-enhanced (3D-CE) MRV acquisitions and compare them against real-time endoluminal measurements with intravascular ultrasound (IVUS), served as the reference. The study has been approved by the Weill Cornell Medicine institutional review board. All patients signed written informed consent approved by IRB. Prospective evaluation of forty-five consecutive IIH patients treated with VSS at our institution were evaluated. Patients with pre-stent magnetic resonance venography (MRV) ≤ 6-months of VSS and intravascular ultrasound (IVUS) during VSS constituted the study population. Maximum diameter (in mm), Area (in cm2) and Perimeter (in cm) were measured at posterior 1/3rd of superior sagittal sinus (SSS), proximal transverse sinus (PTS), proximal sigmoid sinus (PSS) and mid sigmoid sinus (MSS) on 2D-TOF-MRV, 3D-CE-MRV and IVUS. Statistical analysis performed using box and whisker plots, Bland-Altman analysis and paired sample t-test. Twenty (n = 20) patients constituted our study population. The mean age was 30±11 years (7-59 years) and 18 out of 20 were female patients. Mean weight and BMI (range) were 86.3±18.3 kilograms (30.8-107.5 kgs) and 32.9±6.8 kg/M2 (16.4-48.3kg/M2) respectively. The CE-MRV significantly oversized the cerebral venous sinuses compared to TOF-MRV (Dmax: +2.0±1.35 mm, p<0.001; Area: +13.31±10.92 mm2, p<0.001 and Perimeter: +4.79±3.4 mm, p<0.001) and IVUS (Dmax: +1.52±2.16 mm, p<0.001; Area: +10.03±21.5 mm2, p<0.001 and Perimeter: +4.15±3.27 mm, p<0.001). The TOF-MRV sinus measurements were in good agreement with the IVUS measurements with no significant variation (Dmax: +.21±2.23 mm, p = 0.49; Area: +2.51±20.41mm2, p = 0.347 and Perimeter: +.001±1.11 mm, p = 0.991). We report baseline cerebral venous sinus measurements (maximum diameter, area and perimeter) in patients with idiopathic intracranial hypertension. In our experience, TOF-MRV is a reliable representation of endoluminal cerebral venous sinus dimensions, and CE-MRV measurements reflected an overestimation of the endoluminal sinus dimensions when compared against the real time IVUS measurements.

Background Proximal arterial control is critical for safe and effective microsurgical clipping of ophthalmic segment aneurysms (OSAs). Traditionally, this is achieved via neck dissection and temporary clamping of the cervical internal carotid artery (ICA). Advances in endovascular technology have introduced temporary balloon occlusion (TBO) as a potentially less invasive alternative. This study aims to assess the utility of TBO during microsurgical clipping of OSAs. Methods A retrospective review was conducted of all patients at a single institution who underwent microsurgical OSA clipping with planned TBO. Patient demographics, presentation, aneurysm morphology, occlusion outcomes, complications, recurrence, and functional outcomes based on modified Rankin score (mRS) at follow-up were evaluated. Patients who underwent balloon inflation for proximal control (+ TBO) were compared with those who did not (-TBO). Results A total of 34 patients with 35 OSAs were included. A temporary balloon guide catheter was successfully navigated to the cervical carotid in all cases. TBO was performed in 19 patients (20 aneurysms) during aneurysm clipping. Aneurysm sizes ranged from 2.8 to 18.0 mm (mean: 6.7 mm), with neck sizes ranging from 1.6 to 8.1 mm (mean: 4.2 mm). The + TBO group had a significantly higher proportion of wide-necked aneurysms (> 4 mm) compared to the -TBO group (55.0% vs. 26.7%; p = 0.008) and more frequently required anterior clinoidectomy (84.2% vs. 46.7%; p = 0.020). Complete or near-complete (< 2 mm remnant) aneurysm occlusion was achieved in all cases. There was one complication (2.9%) with permanent sequela and median mRS at follow-up was 0. There were no significant differences in complication rates or functional outcomes between the + TBO and -TBO groups. Conclusion Endovascular-assisted TBO is a safe and effective minimally invasive alternative to open neck dissection for achieving proximal control during OSA clipping. TBO may be particularly advantageous for managing wide-neck aneurysms.

BackgroundThe River stent is the first stent specifically designed for intracranial venous sinuses. We report the 1-year results of the River trial, performed to obtain Humanitarian Device Exemption approval of the River stent in the United States (US).MethodsThe River trial was a prospective, open-label, multicenter, single-arm trial which enrolled 39 subjects at 5 US centers. Eligible patients had clinical diagnosis of idiopathic intracranial hypertension (IIH) with severe headaches or visual field loss and had failed medical therapy. The primary safety endpoint was the 1-year rate of major adverse events compared with cerebrospinal fluid (CSF) shunting using historical controls. The primary benefit endpoint was a composite at 1 year of clinical improvement and absence of venous sinus stenosis. Secondary endpoints included improvement in pulsatile tinnitus, visual symptoms, quality of life (QOL) scores, and medications.ResultsAll procedures were technically successful. There was one serious adverse event, a gastrointestinal hemorrhage observed 2 months after the procedure while the patient was still on dual antiplatelet therapy. The primary safety endpoint was met with a rate of major adverse event of 5.4% versus 51.7% for CSF shunts. The primary benefit endpoint was achieved in 60% of trial participants. Additional improvements were also observed in opening CSF pressure, headaches, papilledema, pulsatile tinnitus, visual symptoms, and QOL scores. Post hoc analysis demonstrated that subjects with minimal or absent papilledema at baseline showed similar improvement compared with subjects with papilledema at baseline, in terms of headaches, pulsatile tinnitus, and QOL.ConclusionsThe River study 1- year results establish safety and suggest efficacy for venous sinus stenting in IIH subjects who have failed medical therapy.

Purpose Pre-clinical evidence suggests bevacizumab (BV) depletes the GBM peri-vascular cancer-stem cell niche. This phase I/II study assesses the safety and efficacy of repeated doses of superselective intra-arterial cerebral infusion (SIACI) of BV after blood–brain barrier disruption (BBBD). Methods Date of surgery was day 0. Evaluated patients received repeated SIACI bevacizumab (15 mg/kg) with BBBD at days 30 ± 7, 120 ± 7, and 210 ± 7 along with 6 weeks of standard chemoradiation. Response assessment in neuro-oncology criteria and the Kaplan–Meier product-limit method was used to evaluate progression free and overall survival (PFS and OS, respectively). Results Twenty-three patients with a median age of 60.5 years (SD = 12.6; 24.7–78.3) were included. Isocitrate dehydrogenase mutation was found in 1/23 (4%) patients. MGMT status was available for 11/23 patients (7 unmethylated; 3 methylated; 1 inconclusive). Median tumor volume was 24.0 cm3 (SD = 31.1, 1.7–48.3 cm 3 ). Median PFS was 11.5 months (95% CI 7.7–25.9) with 6, 12, 24 and 60 month PFS estimated to be 91.3% (95% CI 69.5–97.8), 47.4% (26.3–65.9), 32.5% (14.4–52.2) and 5.4% (0.4–21.8), respectively. Median OS was 23.1 months (95% CI 12.2–36.9) with 12, 24, and 36 month OS as 77.3% (95% CI 53.6–89.9), 45.0% (22.3–65.3) and 32.1% (12.5–53.8), respectively. Conclusions Repeated dosing of IA BV after BBBD offers an encouraging outcome in terms of PFS and OS. Phase III trials are warranted to determine whether repeated IA BV combined with Stupp protocol is superior to Stupp protocol alone for newly diagnosed GBM.

Purpose Subdural hematoma (SDH) is quickly becoming the most common neurosurgical pathology due to the aging population. Middle meningeal artery embolization (MMAE) has recently emerged as an effective adjunct to surgical SDH evacuation by decreasing recurrence risk. MMAE has also shown promise as a standalone SDH intervention, but clinical and radiographic predictors of successful MMAE remain ill-defined. Methods Retrospective chart review from 2020 to 2023 at a single center identified all MMAE cases performed as primary SDH treatment. Cases were classified by hematoma internal architecture as homogeneous, separated, laminar, or trabecular. SDH maximal thickness was assessed on all follow-up imaging and any recurrences or expansions requiring surgery were denoted as treatment failures. Results 164 standalone MMAE cases were reviewed. Most cases were in male patients (75.0%) with a mean age of 73.2 years. The overall MMAE treatment failure rate was 6.7% with a 4.9% periprocedural complication rate. The cases with trabecular and laminar collections were slightly larger than those with homogeneous and separated collections (16.2 mm vs. 14.2 mm, p  = 0.008 * ), but other baseline characteristics were similar. The MMAE failure rate was significantly lower in the laminar and trabecular subgroup (1.2%) compared to the homogeneous and separated subgroup (12.4%) ( p  = 0.005 * ). Homogeneous and separated internal hematoma architecture was the only predictor of MMAE failure in multivariate analysis (OR 10.5, p  = 0.027 * ) and was also associated with delayed SDH resorption (ANOVA: F = 4.8, p  = 0.0025 * ). Conclusions Standalone MMAE is an effective, safe, and durable treatment for non-acute SDHs, and is especially effective for SDHs with more membranous internal architecture.

Abstract BACKGROUND: Neuroform stent-assisted coil embolization facilitates the endovascular treatment of wide-necked intracranial aneurysms. However, the safety and efficacy of its long-term use have not been fully elucidated. OBJECTIVE: To retrospectively examine the long-term results of Neuroform stent usage in conjunction with coil embolization in wide-necked intracranial aneurysms. METHODS: Between November 2002 and December 2010, 79 patients harboring wide-necked intracranial aneurysms were treated with use of the Neuroform stent. The stenting procedure failed in 2 patients. Therefore, 77 patients harboring 79 intracranial aneurysms were included for analysis. Patient and aneurysm characteristics, progression of aneurysm occlusion, and occurrence of complications were analyzed. Follow-up imaging included digital subtraction angiography (DSA) or magnetic resonance angiography (MRA). Kaplan-Meier analysis, as well as univariate analysis were performed to determine the progression of aneurysm occlusion and to examine the predictive factors for complete aneurysm occlusion, respectively. RESULTS: Overall, complete aneurysm occlusion was observed in 42.4% of the cases immediately after treatment and progressed to 96.5% at 7-year follow-up. The mean angiographic follow-up time was 25.8 months (range, 0–84 months). Eleven aneurysms (14%) were re-treated. Sixty-eight patients (88.3%) had favorable clinical outcome with a modified Rankin Scale (mRS) ⩽ 1, 3 patients (3.9%) had an mRS of 2, and 5 patients (6.5%) did not have a clinical follow-up. The mean clinical follow-up time was 45.4 months (range, 3–92 months). One patient (1.3%) died of a procedure-related hemorrhage. CONCLUSION: Neuroform stent-assisted coil embolization of wide-necked intracranial aneurysms prevents hemorrhage and provides a high rate of aneurysm occlusion at long-term follow-up.

Background This report addresses the feasibility of virtual injection software based on contrast-enhanced cone-beam CTs (CBCTs) in the context of cerebrovascular lesion embolization. Intracranial arteriovenous malformation (AVM), dural arteriovenous fistula (AVF) and mycotic aneurysm embolization cases with CBCTs performed between 2013 and 2020 were retrospectively reviewed. Cerebrovascular lesions were reviewed by 2 neurointerventionalists using a dedicated virtual injection software (EmboASSIST, GE Healthcare; Chicago, IL). Points of Interest (POIs) surrounding the vascular lesions were first identified. The software then automatically displayed POI-associated vascular traces from vessel roots to selected POIs. Vascular segments and reason for POI identification were recorded. Using 2D multiplanar reconstructions from CBCTs, the accuracy of vascular traces was assessed. Clinical utility metrics were recorded on a 3-point Likert scale from 1 (no benefit) to 3 (very beneficial). Results Nine cases (7 AVM, 1 AVF, 1 mycotic aneurysm) were reviewed, with 26 POIs selected. Three POIs were in 2nd order segments, 8 POIs in 3rd order segments and 15 POIs in 4th order segments of their respective arteries. The reviewers rated all 26 POI traces – involving a total of 90 vascular segments – as accurate. The average utility score across the 8 questions were 2.7 and 2.8 respectively from each reviewer, acknowledging the software’s potential benefit in cerebrovascular embolization procedural planning. Conclusion The operators considered CBCT-based virtual injection software clinically useful and accurate in guiding and planning cerebrovascular lesion embolization in this retrospective review. Future prospective studies in larger cohorts are warranted for validation of this modality.

In this article, a detailed description of the normal arterial supply and venous drainage of the spinal cord is provided, and the role of catheter angiography and MR angiography in depicting the vascular anatomy of the spinal cord is discussed.