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Background Human bone marrow is a source of mesenchymal stem cells (MSCs), other progenitor cells, and factors with anti-inflammatory and regenerative capacity. Though the fraction of MSCs out of the nucleated cells is very small, bone marrow aspirate (BMA) for osteoarthritis (OA) has noteworthy effects. BMA is usually collected from the posterior or anterior iliac crest, and rarely from the proximal tibia. We investigated the clinically beneficial concentration of ex vivo MSCs, derived from BM harvested from the posterior iliac crest and proximal tibia by Marrow Cellution™ Aspiration System, and their phenotypic differences, in comparison to autologous Platelet-Rich Plasma (PRP) treatment prepared with a manual, closed system. Methods A single-center, parallel, randomized controlled study was designed to investigate the efficacy of BMA from the posterior iliac crest compared to BMA from the proximal tibia, against a control group treated with PRP, in knee OA. Thirty patients with knee OA grade I-IV, according to Kellgren-Lawrence (KL), were distributed into each group. Visual Analog Scale (VAS) and Western Ontario & McMaster Universities Arthritis Index (WOMAC) score were used for clinical outcome evaluation. Results Data from an intermediate analysis of 6-months follow-up, involving 15 patients in each arm, showed that the posterior iliac crest was significantly more densely populated with mononuclear cells, than the proximal tibia (p = 0.005). Flow cytometric analysis on ex vivo BMA showed a significantly greater number of MSCs in the BM-derived from the posterior iliac crest when compared with the proximal tibia (p < 0.001), together with a significantly higher number of platelets (PLTs) (p < 0.001). Surprisingly, despite these differences in cells number, the improvement in early pain and function scores, after each treatment, were statistically significant within each of the three arms. BM from the proximal tibia showed the highest ΔWOMAC, while BM from the posterior iliac crest showed the highest ΔVAS; however, these differences were not statistically significant across the three arms (p > 0.05). A better outcome, in terms of ΔVAS, was observed in patients classified as KL I-II, when treated with BMA from crest (p < 0.001) and PRP (p = 0.004). Moreover, the effect of BMA treatment on ΔVAS depends on MSCs % only in the Tibia Arm (r = -0.59, p = 0.021), where we also found a correlation between ΔWOMAC and monocytes (r = 0.75, p = 0.016). Conclusion The results indicate that the iliac crest yields a higher concentration of MSCs compared to the proximal tibia, however both BM, independently of the MSCs concentration, show a beneficial clinical outcome in the treatment of knee OA. Furthermore, BMA is not superior to PRP treatment.

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.

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.

ObjectiveNeurointerventional surgery is witnessing a growth in trans-venous procedures by translating endovascular devices and techniques developed, optimized and used in the arterial system. However, major dural venous sinuses differ from cerebral arteries in their non-circular cross-sectional geometry and in the multiple structures that protrude or cross their lumens. This study employs the ‘live’ cadaver model previously developed and validated in our lab to study the anatomical phenotypes of intraluminal structures with angiography and high-resolution angioscopy.MethodsThe internal jugular veins of six (6) head and neck human cadaveric specimens were catheterized and physiologically pressurized with 0.9% saline and a venous flowrate of 6–9cc/sec was established. Cerebral Venograms were performed by injecting iodinated contrast at the confluence of the major dural sinuses. Then, an angioscope was used to study the anatomical structures in the lumen of transverse/sigmoid sinuses (n=12) and superior sagittal sinuses (n=6). Descriptive statistics were performed to evaluate anatomical structures.ResultsArachnoid granulations and septations were found in all specimens. The majority of arachnoid granulations (50%, n=12) were located in the mid and proximal segments of the transverse sinus (defining ‘proximal’ as towards the torcula), while 33.3% were found in the distal segment. Two specimens (33.3%) only had arachnoid granulations in the superior sagittal sinus. The anterior and middle third of the superior sagittal sinus contained at least two septations and multiple granulations. The average number of septations in the transverse sinus was 2.92 ± 0.79, with the right transverse sinus exhibiting a slightly higher number than the left (3.0 ± 0.89 vs 2.83 ± 0.75, p>0.05) And granulations are commonly found in the proximal transverse sinus, more frequently on the left side compared to the right (100% vs. 80%, p>0.05). Only granulations protruding >50% of the lumen were visible by angiography, while septations were not perceived in angiography.ConclusionThe lumen of major dural venous sinuses frequently harbor crossing septations and protruding granulation, which are typically invisible by angiography. These could interact with devices and impact endovascular procedures.Abstract O-040 Figure 1DisclosuresY. Senol: None. N. Krishnan: None. A. Liu: None. A. Haider: None. M. Amans: 1; C; Department of Defense, NIH, VS3 Medical. 2; C; Stryker, Microvention, VS3 Medical. 3; C; Weil Cornell Medical Center Department. 4; C; VS3 Medical. L. Savastano: None.

IntroductionThe two-step management that combines surgical evacuation of non-acute subdural hematoma (SDH) for rapid brain decompression and middle meningeal artery embolization (MMAe) to prevent re-bleeding as a surgical adjunct is becoming a dominant treatment paradigm of symptomatic SDH. However, this approach requires two different interventions with their associated risks, prolonged ICU and hospital stay and drastically increases medical care costs. A technology was developed for MMAe and endovascular drainage of non-acute SDH. We report the procedural results of the first cohort of consecutive patients treated with this system.MethodsA prospective, single-arm, first-in-human study (EMBODRAIN Study) was conducted to evaluate the safety and feasibility of endovascular drainage of non-acute SDH and MMAe using a purpose-built technology (Endovascular Horizons, Inc) for transvascular access to the intracranial intradural space.ResultsTen (10) consecutive patients (8 males (80%), average age 73.6 years) underwent MMAe and endovascular drainage of SDH. Radiographically, the cohort included sub-acute (n=2), chronic (n=2), acute-on-chronic (n=3), and trabeculated SDH type (n=3). Acute clinical success (defined as MMAe and transvascular drainage of the SDH with no conversion to open surgical drainage) and acute technical success (defined as ability to create a leak-proof transvascular passageway and access the subdural space with a microcatheter, drain the SDH and occlude the MMA) was achieved in all cases (10/10). No Serious Adverse Events (SAE) including death, life-threatening illness or injury, persistent or significant disability or incapacity, or the need for medical or surgical intervention to prevent permanent impairment to a body structure or function were recorded at 30-days. No patient required open surgical drainage. The SDH volume at baseline was an average of 188.1 mL and decreased immediately post-procedurally to an average of 65.5 mL (>65% volumetric reduction). The SDH thickness at baseline was an average of 23.4 mm, and decreased post-procedurally to an average of 14.4 mm. The midline shift at baseline was an average of 9.7 mm and decreased post-procedurally to an average of 4.2 mm. Post-procedural flat panel CT and head CT at 72-hours did not demonstrate interval hemorrhage in any of the cases. The average Modified Rankin Scale Score and Markwalder grade decreased from 2.7 and 1.9 , respectively at presentation to 1.3 and 0.7, respectively at 72hrs post-intervention. There were no recurrence or progression requiring surgery, and no deterioration in neurological function.ConclusionsMMAe and transvascular drainage of a broad range of symptomatic non-acute SDH in a single, fully endovascular procedure is feasible and is associated to rapid radiographic and clinical improvement.DisclosuresP. Lylyk: None. P. Lylyk: None. I. Lylyk: None. C. Bleise: None. N. Perez: None. E. Scrivano: None. J. Lundquist: None. D. Andrist: 5; C; CTO Endovascular Horizons. L. Savastano: 4; C; Founder, Endovascular Horizons. 6; C; Inventor (Royalties agreement).

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.

IntroductionSymptomatic non-stenotic carotid disease (SyNC) is an underrecognized etiology of cryptogenic ischemic stroke. Maximal medical therapy has limited efficacy against SyNC patients with certain plaque features. Endovascular treatment of SyNC in conjunction with multimodal imaging technologies is an unexplored frontier. We present a brief report of a case of SyNC that was endovascularly treated and guided by optical coherence tomography (OCT).Materials and MethodsA 74-year-old male with history of remote cryptogenic cerebellar stroke presented with self-limited episodes of dysarthria and left hemifield visual loss. Based on his clinical history and clinical examination, a diagnosis of stroke with cardioembolic or unstable atherosclerotic disease origin was made, and imaging was ordered accordingly.ResultsBrain magnetic resonance (MR) imaging showed multifocal subacute and chronic right hemispheric infarcts. MR and CT angiography of the neck demonstrated <50% stenosis of the right ICA due to a partially calcified, possibly ulcerated plaque with intraplaque hemorrhage. Baseline OCT images demonstrated a large excavation within an ulcerated ICA plaque and thrombus. Patient was then treated with a carotid artery stenting under flow arrest. Post-stenting OCT confirmed the collapse of the intraplaque lumen by outward radial displacement of the fibrous cap and excellent stent wall apposition without atheroma protrusion.ConclusionSyNC is increasingly being recognized as a potential etiology in cryptogenic ischemic strokes. Plaques can be evaluated through imaging modalities such as OCT providing insight towards targeted therapy for patients.Disclosures S. Madhani: None. S. Oushy: None. N. Borg: None. E. Scharf: None. L. Savastano: None.

PurposeRapid revascularization in stroke thrombectomy is associated with improved outcomes in patients with acute ischemic stroke due to intracranial large vessel occlusion (LVO). Higher first-pass effect rate (FPE)— removal of all intracranial thrombus on the first attempt—may translate into a lower risk of morbidity and mortality. We examined the FPE rate retrospectively in stroke thrombectomies performed at UCSF, and we examined possible predictors of FPE.MethodsClinical history and laboratory data were collected from 221 stroke thrombectomy patients at UCSF. Information on the use of BGC, aspiration catheters, and stentrievers was recorded. Endovascular success was evaluated using metrics such as first-pass recanalization, eventual recanalization, the number of device passes, procedure times, and immediate complications like vascular dissection or perforation. Success rates were defined as achieving modified-FPE (mTICI 2b-3) after a single-pass approach, as well as final successful (mTICI 2b-3) and complete (mTICI 2c-3) reperfusion rates. Times from groin puncture to first angiogram and final revascularization were recorded. Data was analyzed using R software, with univariate tests (Chi-square, student’s t-test) performed on potential FPE predictors.ResultsThe FPE rate, defined by complete reperfusion (mTICI 2c-3), was 51.58% (114/221). The overall successful reperfusion rate, defined as mTICI 2b-3, was 61.08% (135/221). Univariate analyses were conducted to assess the impact of potential factors on the FPE. Chi-square analysis on the location of occlusion showed a statistically significant relationship (p<0.01) between occlusion site and FPE success in thrombectomies, with certain locations, such as M1, demonstrating higher FPE success rates than others. Other factors showed no significant differences between the FPE group and the non-FPE group.ConclusionsThe results suggest that the FPE and modified FPE rate in stroke thrombectomies performed at UCSF, is higher than rates reported in other studies. Achieving FPE is important in endovascular stroke therapy, as it has been associated with better clinical outcomes, including reduced mortality in patients with acute ischemic stroke due to intracranial LVO.There is a statistically significant relationship (p<0.01) between occlusion site and FPE success in thrombectomies; patients with more proximal occlusions were more likely to have successful thrombectomy. Other univariate analyses did not identify any significant predictors of FPE among the variables assessed, including patient sex, age, type of stentriever, use of contact aspiration, use of balloon, and administration of TNK or tPA.Abstract E-227 Table 1Procedural factors between FPE vs. non-FPE with p-valuesAbstract E-227 Figure 1Forest plot of odds ratios for occlusion site, stentriever, IV lytics[Figure omitted. See PDF]DisclosuresA. So: None. P. Rowley: None. D. Cooke: None. M. Amans: None. L. Savastano: None. K. Narsinh: None. E. Winkler: None. D. Raper: None. S. Hetts: None.

Introduction/PurposeParaspinal venous embolization is emerging as a highly efficacious minimally invasive novel treatment for patients with cerebrospinal fluid venous (CSF-venous) fistulas. We sought to describe the technical nuances of transvenous embolization in our series of 35 treatments.Materials and MethodsRetrospective review of all patients undergoing endovascular paraspinal venous embolization of CSF-venous fistulas at two sites of single institution. Procedural details including venous access site, venous navigation, site of embolization, equipment and embolization material used, procedural technical outcome, and complications were reviewed.Results35 paraspinal vein embolization were performed in 33 patients with CSF-venous fistulas confirmed by digital subtraction myelography in all cases. All procedures had technical success in paraspinal vein embolization without immediate complication. Treatment targets ranged from C7 to L2. Venous access site was from right common femoral vein (27/35, 77%), left common femoral vein (5/35, 14%), cubital vein (3/35, 9%), and jugular vein (1/35, 3%). Venous navigation to the paraspinal vein including transit through azygous/hemiazygous (24/35, 68%), vertebral (6/35, 17%), and supreme intercostal (3/35, 9%) veins. Embolization with combination of Onyx 34 and/or 18 was used for all cases using DMSO-compatible catheters (Headway Duo or Echelon-10) or balloon-catheter (Scepter XC/C).ConclusionParaspinal venous embolization is a highly efficacious novel minimally invasive treatment for CSF-venous fistulas. Our review of procedures highlights important venous anatomy and technical nuances of transvenous navigation required for successful paraspinal venous embolization.Disclosures T. Huynh: None. D. Miller: None. H. Cloft: None. L. Savastano: None. W. Brinjikji: 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.