Fusiform aneurysms are uncommon compared with their saccular counterparts, yet they remain very challenging to treat and are associated with high rates of rebleeding and morbidity. Lack of a true aneurysm neck renders simple clip reconstruction or coil embolization usually impossible, and more advanced techniques are required, including bypass, stent-assisted coiling, and, more recently, flow diversion. In this article, the authors review posterior circulation fusiform aneurysms, including pathogenesis, natural history, and endovascular treatment, including the role of flow diversion. In addition, the authors propose an algorithm for treatment based on their practice.

Background and Purpose—: Endovascular recanalization treatment for acute ischemic stroke is a complex, time-sensitive intervention. Trip-and-treat is an interhospital service delivery model that has not previously been evaluated in the literature and consists of a shared mobile interventional stroke team that travels to primary stroke centers to provide on-site interventional capability. We compared treatment times between the trip-and-treat model and the traditional drip-and-ship model. Methods—: We performed a retrospective analysis on 86 consecutive eligible patients with acute ischemic stroke secondary to large vessel occlusion who received endovascular treatment at 4 hospitals in Manhattan. Patients were divided into 2 cohorts: trip-and-treat (n=39) and drip-and-ship (n=47). The primary outcome was initial door-to-puncture time, defined as the time between arrival at any hospital and arterial puncture. We also recorded and analyzed the times of last known well, IV-tPA (intravenous tissue-type plasminogen activator) administration, transfer, and reperfusion. Results—: Mean initial door-to-puncture time was 143 minutes for trip-and-treat and 222 minutes for drip-and-ship ( P <0.0001). Although there was a trend in longer puncture-to-recanalization times for trip-and-treat ( P =0.0887), initial door-to-recanalization was nonetheless 79 minutes faster for trip-and-treat ( P <0.0001). There was a trend in improved admission-to-discharge change in National Institutes of Health Stroke Scale for trip-and-treat compared with drip-and-ship ( P =0.0704). Conclusions—: Compared with drip-and-ship, the trip-and-treat model demonstrated shorter treatment times for endovascular therapy in our series. The trip-and-treat model offers a valid alternative to current interhospital stroke transfers in urban environments.

Background Treated aneurysms must be followed over time to ensure durable occlusion, as more than 20% of endovascularly treated aneurysms recur. While digital subtraction angiography (DSA) remains the gold standard, magnetic resonance angiography (MRA) is attractive as a non-invasive follow-up technique. Two different MRA techniques have traditionally been used: time-of-flight (TOF) and contrast-enhanced (CE) MRA. We analysed data from studies comparing MRA techniques with DSA for the follow-up of aneurysms undergoing endovascular treatment. Subgroup analysis of stent-assisted coiling (SAC) and flow diversion (FD) techniques was completed. Methods Comprehensive searches using the Embase, PubMed, and Cochrane databases were performed and updated to November 2018. Pooled sensitivity and specificity were calculated using aneurysm occlusion status as defined by the Raymond–Roy occlusion grading scale. Results The literature search yielded 1579 unique titles. Forty-three studies were included. For TOF-MRA, sensitivity and specificity of all aneurysms undergoing endovascular therapy were 88% and 94%, respectively. For CE-MRA, the sensitivity and specificity were 88% and 96%, respectively. For SAC and FD techniques, sensitivity and specificity of TOF-MRA were 86% and 95%, respectively. CE-MRA had sensitivity and specificity of 90% and 92%. Conclusion MRA is a reliable modality for the follow-up of aneurysms treated using endovascular techniques. While the data are limited, MRA techniques can also be used to reliably follow patients undergoing FD and SAC. However, clinical factors must be used to optimize follow-up regimens for individual patients.

Introduction The endovascular stent-assisted coiling approach for the treatment of cerebral aneurysms is evolving rapidly with the availability of new stent devices. It remains unknown how each type of stent affects the safety and efficacy of the stent-coiling procedure. Methods This study compared the outcomes of endovascular coiling of cerebral aneurysms using Neuroform (NEU), Enterprise (EP), and Low-profile Visualized Intraluminal Support (LVIS) stents. Patient characteristics, treatment details and angiographic results using the Raymond–Roy grade scale (RRGS), and procedural complications were analyzed in our study. Results Our study included 659 patients with 670 cerebral aneurysms treated with stent-assisted coiling (NEU, n=182; EP, n=158; LVIS, n=330) that were retrospectively collected from six academic centers. Patient characteristics included mean age 56.3±12.1 years old, female prevalence 73.9%, and aneurysm rupture on initial presentation of 18.8%. We found differences in complete occlusion on baseline imaging, defined as RRGS I, among the three stents: LVIS 64.4%, 210/326; NEU 56.2%, 95/169; EP 47.6%, 68/143; P=0.008. The difference of complete occlusion on 10.5 months (mean) and 8 months (median) angiographic follow-up remained significant: LVIS 84%, 251/299; NEU 78%, 117/150; EP 67%, 83/123; P=0.004. There were 7% (47/670) intra-procedural complications and 11.5% (73/632) post-procedural-related complications in our cohort. Furthermore, procedure-related complications were higher in the braided-stents vs laser-cut, P=0.002. Conclusions There was a great variability in techniques and choice of stent type for stent-assisted coiling among the participating centers. The type of stent was associated with immediate and long-term angiographic outcomes. Randomized prospective trials comparing the different types of stents are warranted.

Background Clot density (Hounsfield units, HU) and perviousness (post-contrast increase in the HU of clot) are thought to be associated with clot composition. We evaluate whether these imaging characteristics were associated with angiographic outcomes of aspiration and stent retriever thrombectomy in COMPASS: a trial of aspiration thrombectomy versus stent retriever thrombectomy as first-line approach for large vessel occlusion. Methods Clot density and perviousness were measured by two independent operators who were blind to all the final angiographic and clinical outcomes. The association of clot density and perviousness with the Thrombolysis In Cerebral Infarction (TICI) scale after first pass was assessed using univariate and multivariate analysis. Results Among all patients enrolled in COMPASS, 165 were eligible for the post-hoc analysis (81 patients in the aspiration first and 84 in the stent retriever first groups). Overall mean perviousness of clot was significantly higher in patient with mTICI 2b-3 after first pass (28.6±22.9 vs 20.3±19.2, p=0.017). Mean perviousness among patients who achieved TICI 2c/3 versus TICI 2b versus TICI 0-2a in the aspiration first group varied significantly (32.6±26.1, 35.3±24.4, and 17.7±13.1, p=0.013). The association of perviousness with first pass success was not significant in the stent retriever group. Using multivariate analysis, high perviousness (defined as cut-off >27.6) was an independent predictor of TICI 2b-3 (OR 3.82, 95% CI 1.10 to 13.19; p=0.034). Conclusions Clot perviousness is associated with first pass angiographic success in patients treated with the aspiration first approach for thrombectomy.