Background: The Surpass Elite (Stryker Neurovascular) is a third-generation flow diverter featuring modified braid architecture with increased braid angle and novel surface charge neutralization treatment. This study presents the first clinical experience with the Surpass Elite globally. Methods: A retrospective analysis of 81 consecutive cases (78 unique patients) treated with the Surpass Elite across four centers by two operators from January to July 2025 was performed. Data collected included patient demographics, aneurysm characteristics, procedural details, technical success, complications, and angiographic/clinical outcomes. Primary endpoints were technical success rate, perioperative safety profile, and aneurysm occlusion rates at approximately 6-month follow-up. Results: The cohort comprised 78 unique patients (76.9% female, mean age 59.2 ± 14.5 years) with 81 aneurysms treated using 112 total devices (mean 1.38 devices per case). Aneurysms were predominantly located in the internal carotid artery (75.3%). Technical success was achieved in 100% of cases regardless of access site. Balloon angioplasty was required in only 13.6% of cases. Among 61 aneurysms with complete angiographic follow-up at a mean of 6 months, complete occlusion (RROC Class I or OKM Grade D) was achieved in 78.7%. In-stent stenosis (< 50%) was observed in only 3.3% of cases with follow-up imaging, suggesting favorable vessel remodeling with minimal intimal hyperplasia. The immediate intraprocedural complication rate was 2.5% (2/81), including one device-related microperforation (complete recovery) and one intraoperative thrombosis (managed successfully intraprocedurally; delayed stroke from subsequent medication noncompliance). Delayed complications within 30 days included one stroke from antiplatelet noncompliance (fatal) and one access-site hematoma (recovered). One delayed adverse event beyond 30 days (delayed right temporal intraparenchymal hemorrhage at 10 months) was observed in a patient on dual antiplatelet therapy plus apixaban and was attributed to cerebral amyloid angiopathy; this event was not considered device- or procedure-related. Overall mortality was 7.4% (6/81): one death (1.2%) was procedure-related (stroke from medication noncompliance), one death occurred within 30 days from post-SAH vasospasm in a ruptured aneurysm case, and four deaths occurred after 30 days (recurrent ICH at 3 weeks, acute respiratory failure with acute on chronic heart failure at 5 months, homicide at approximately 6 months, and one of unknown cause), none of which were device- or procedure-related. Conclusion: This first published clinical experience with Surpass Elite flow diverter demonstrates reliable technical deliverability, favorable early occlusion rates comparable to established flow diverters, and a satisfactory safety profile. The low rates of required balloon angioplasty support the clinical benefit of the modified braid architecture. These preliminary findings support the continued clinical evaluation of the Surpass Elite in larger prospective cohorts.

Idiopathic intracranial hypertension (IIH) and Chiari I malformation (CM-I) are traditionally considered distinct entities, yet accumulating evidence reveals substantial overlap in their clinical presentations and imaging features. Patients with IIH may develop acquired tonsillar herniation mimicking CM-I, while patients with CM-I may harbor unrecognized intracranial hypertension. Failure to identify the primary condition risks unnecessary posterior fossa decompression in patients whose tonsillar descent is pressure-driven, or untreated intracranial hypertension in patients mislabeled as having congenital CM-I. Thus, despite their overlapping presentations, identifying distinct traits in each condition is critical in delivering effective treatment. In this review, we synthesize the neuroimaging features of each condition, identifying their distinct features and their overlap, present illustrative cases spanning the IIH-Chiari diagnostic spectrum, and propose a framework for differentiating the primary pathology to guide management.

Purpose: The venous phase of DSA offers inferior spatial resolution of cerebral venous anatomy due to contrast dilution. Likewise, retrograde cerebral venography (RCV) suffers from poor contrast retention due to contrast injection opposing the physiological direction of venous drainage. Therefore, this study aims to investigate the feasibility of balloon-assisted occlusion in improving visualization of cerebral venous anatomy during RCV. Methods: 17 consecutive patients who underwent balloon-assisted RCV between September 2023-June 2025 were included. A 9 F balloon guide catheter was positioned in the internal jugular vein or sigmoid sinus. Venography was performed before and after balloon inflation. Using standardized criteria, three neuroradiologists independently assessed visualization quality of venous structures, anatomical furthest extent of contrast enhancement, and pathology delineation. McNemar’s test was used for paired statistical comparisons between visualization with and without balloon occlusion. Results: Balloon inflation improved rates of “well visualized” pathology from 15.7% to 88.2% ( p < 0.001, OR = 29.04). The most distant structure visualized shifted from the ipsilateral sigmoid sinus without balloon occlusion (visible in 45.1% of cases) to the contralateral sigmoid sinus with balloon occlusion (visible in 72.5% of cases, p < 0.001). With balloon occlusion, homogenous opacification and clear margin delineation of both transverse and sigmoid sinuses showed significant improvements ( p < 0.001 for both). No procedure-related complications were observed in this limited cohort. Conclusion: In this feasibility experience, balloon-assisted occlusion during RCV improved visualization of the posterior and lateral dural venous sinuses and associated pathology. Future well-powered studies are needed to validate our findings and determine the definitive safety of this technique.

Purpose: Non-geometric wide-neck bifurcation aneurysms (WNBAs) present with treatment challenges of unfavorable neck morphology at bifurcation sites combined with irregular saccular geometry. While microsurgical clipping remains the traditional standard treatment, unsuitable candidates often require endovascular alternatives. We developed the WEVO technique, combining a volumetrically matched Woven EndoBridge (WEB) placement with a LVIS EVO braided stent deployment to achieve device stabilization and neck reconstruction with enhanced metal coverage. Methods: We conducted a retrospective review of 21 patients treated for non-geometric WNBAs. Patient demographics, aneurysm characteristics, procedural parameters, and clinical outcomes were analyzed. The LVIS EVO stent was deployed using a “shouldering” technique to compress stent cells across the aneurysm neck. All patients received dual antiplatelet therapy. Aneurysm occlusion was assessed using the WEB Occlusion Scale (WOS) at 3 to 6 months and at 12 months. Results: Median age was 71 (IQR: 64–76); 71% were female. All aneurysms were unruptured with median volume 81.4 mm ³ (IQR: 46.0-147.1). Most common locations included middle cerebral artery (33%) and basilar artery (33%). Upper extremity arterial access was used in all cases. Immediate contrast stasis was achieved in all patients. One patient developed transient intra-procedural stent thrombus that resolved with intra-arterial tirofiban. No other complications occurred. At 3 to 6‑month follow-up ( n = 16), adequate occlusion (WOS Grade A or AB) was achieved in 87%. At 12-month follow-up ( n = 11), adequate occlusion was maintained in all patients. Conclusion: The WEVO technique provides a safe and effective endovascular treatment option for non-geometric WNBAs by combining intrasaccular flow disruption with neck scaffolding and increased metal coverage.

Background and purpose: Preservation of perforator arteries during cerebrovascular interventions remains challenging due to their submillimeter caliber and variable anatomy. High-resolution cone-beam computed tomography (HR-CBCT) offers improved resolution compared with conventional CT angiography (CTA), yet its utility for perforator assessment has not been systematically evaluated. This study assessed HR-CBCT for visualization of intracranial perforators in both preoperative and intraoperative contexts. Methods: Imaging from 20 patients who underwent aneurysm clipping, arteriovenous malformation resection, or dural arteriovenous fistula treatment between July 2022 and November 2024 was reviewed. Three imaging modalities were evaluated: preoperative CTA, preoperative HR-CBCT, and intraoperative HR-CBCT. Five perforator arteries—the recurrent artery of Heubner, anterior choroidal artery, lateral lenticulostriate arteries, basilar artery perforators, and posterior cerebral artery perforators—were independently scored by four neuroradiologists using a three-point visibility scale (3 = visible, 2 = not visible due to limited field of view, 1 = not visible due to resolution). Reader confidence was recorded, and statistical analysis was performed using R. Results: Perforator visualization was significantly higher with both preoperative and intraoperative HR-CBCT compared with CTA. On preoperative imaging, confidence was significantly higher for anterior choroidal and lateral lenticulostriate arteries ( p < 0.001), but not for the recurrent artery of Heubner ( p = 0.102). Intraoperative scans showed no significant reduction in visibility. Effective dose did not differ between CTA and HR-CBCT ( p = 0.700). Conclusions: Preoperative and intraoperative HR-CBCT provide superior perforator visualization compared with CTA, with intraoperative imaging closely matching preoperative performance.