Significant advances in endovascular neurosurgery tools, devices, and techniques are changing the approach to the management of acute hemorrhagic stroke. The endovascular treatment of intracranial aneurysms emerged in the early 1990s with Guglielmi detachable coils, and since then, it gained rapid popularity that surpassed open surgery. Stent-assisted coiling and balloon remodeling techniques have made the treatment of wide-necked aneurysms more durable. With the introduction of flow diverters and flow disrupters, many aneurysms with complex geometrics can now be reliably managed. Arteriovenous malformations and fistulae can also benefit from endovascular therapy by embolization using n-butyl cyanoacrylate (NBCA), Onyx, polyvinyl alcohol (PVA), and coils. In this article, we describe the role of endovascular treatment for the most common causes of intracerebral and subarachnoid hemorrhages, particularly ruptured aneurysms and vascular malformations.

Background Mechanical thrombectomy (MT) for acute ischemic stroke is generally avoided when the expected infarction is large (defined as an Alberta Stroke Program Early CT Score of <6). Objective To perform a meta-analysis of recent trials comparing MT with best medical management (BMM) for treatment of acute ischemic stroke with large infarction territory, and then to determine the cost-effectiveness associated with those treatments. Methods A meta-analysis of the RESCUE-Japan, SELECT2, and ANGEL-ASPECT trials was conducted using R Studio. Statistical analysis employed the weighted average normal method for calculating mean differences from medians in continuous variables and the risk ratio for categorical variables. TreeAge software was used to construct a cost-effectiveness analysis model comparing MT with BMM in the treatment of ischemic stroke with large infarction territory. Results The meta-analysis showed significantly better functional outcomes, with higher rates of patients achieving a modified Rankin Scale score of 0–3 at 90 days with MT as compared with BMM. In the base-case analysis using a lifetime horizon, MT led to a greater gain in quality-adjusted life-years (QALYs) of 3.46 at a lower cost of US$339 202 in comparison with BMM, which led to the gain of 2.41 QALYs at a cost of US$361 896. The incremental cost-effectiveness ratio was US$−21 660, indicating that MT was the dominant treatment at a willingness-to-pay of US$70 000. Conclusions This study shows that, besides having a better functional outcome at 90-days' follow-up, MT was more cost-effective than BMM, when accounting for healthcare cost associated with treatment outcome.

Introduction: Computed tomography (CT) angiography is commonly utilized to quickly identify vascular injuries caused by blunt cervical trauma. It is often conducted alongside a cervical spine CT, based on established criteria. This study assessed the prevalence of cervical vascular injuries identified via CT angiography (CTA) in patients who had negative findings on cervical CT scans. Materials and methods: A retrospective study was performed on patients who experienced blunt trauma from January 2020 to December 2022 and underwent both cervical CT and CTA. The sample size was determined using the formula: n = (Z^2 * P * (1 - P)) / E^2, assuming a 99% confidence interval, a 2% margin of error, and a proportion of 0.05. Results: A total of 1,165 patients presented with acute blunt trauma to the head and neck during the study period. Out of those, 800 patients (68.7%) had negative cervical CT scans and only 5 patients (0.6%) were found to have vascular injuries on CTA, with an average age of 44.2 years. Regarding the severity of the injuries, three were classified as grade I and two as grade II. On the other hand, of the 365 patients with positive cervical CT, 44 patients (12%) had vascular injury on CTA, including 16 patients (4.5%) with grades III and IV injuries. Conclusion: The findings of this study suggest that CTA in patients with negative cervical CT scans seldom reveals vascular injuries, with no injuries exceeding grade II. This highlights the selective utility of CTA in this patient group.

(1) Background: COVID-19 infection is responsible for the ongoing pandemic and acute cerebrovascular disease (CVD) has been observed in COVID-19 patients. (2) Methods: We conducted a retrospective, observational study of hospitalized adult patients admitted to our hospital with SARS-CoV-2 and acute cerebrovascular disease. All clinical data were reviewed including epidemiology, clinical features, laboratory data, neuroradiological findings, hospital management and course from 32 patients hospitalized for COVID-19 management with acute cerebrovascular disease. (3) Results: Acute CVD with COVID-19 was associated with higher NIH stroke scale on discharge compared to non-COVID-19 CVDs. Seizures complicated the hospital course in 16% of COVID-19 patients with CVD. The majority of the acute CVDs were ischemic (81%) in nature followed by hemorrhagic (22%). Acute CVD with COVID-19 resulted in average hospital stays greater than twice that of the control group (13 days in COVID-19, 5 days in control). Acute CVD with COVID-19 patients had worse clinical outcomes with 31% patient deaths and 6% discharged to hospice. In the control group, 6% of patients died. (4) Conclusions: Acute CVD associated with COVID-19 tends to be more complicated with unique and adverse clinical phenotype, longer hospital admissions, and worse clinical outcomes.

Background: Internal carotid artery dissection (ICD) is a common cause of cerebral ischemia in adults. Medical management has been the standard of care; however, endovascular internal carotid artery (ICA) reconstruction has certain indications. The pipeline^™ embolization device (PED) is a flow-diverting (low porosity), self-expanding, braided platinum and nickel-cobalt chromium alloy stent and is indicated for wide neck or large aneurysms of the ICA from the petrous to the superior hypophyseal segments. The flexible nature of PED stents, with their high wall coverage, makes them amenable as stents for reconstructing arterial dissections diagnosed in the tortuous segments of the extracranial ICA. We present our experience using PEDs for ICA reconstruction in cases of distal cervical or petrous segment dissection or dissecting aneurysms and review the literature on this contemporary indication of flow diverter devices. Methods: This study was a retrospective review of patients with ICD or dissecting aneurysms who underwent endovascular reconstruction at our center using PED stent implants. Patients were selected based on pre-morbid modified Rankin Scores ≤1a and National Institutes of Health Stroke Scale (NIHSS) ≥3 and radiologic data consistent with ICA dissection. Results: Eight patients with a mean age of 55.6 years (range: 31–82 years) and median NIHSS score of 8 (Interquartile range IQR: 2.75–16) who underwent off-label PED surgery were analyzed and are illustrated in this short series. The technical success rate was 100%, with all cases achieving reperfusions of thrombolysis in cerebral infarction grades ≥2b. Conclusion: In our series of patients with distal cervical or petrous segment ICD or dissecting aneurysms, we found the PED to be feasible, safe, and effective in achieving arterial recanalization. Further studies will clarify the role of this technique.

BACKGROUND AND OBJECTIVES: 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: The WEB and Contour demonstrated comparable clinical and angiographic outcomes in this large multicenter study comprised majority small, asymptomatic cerebral aneurysms.