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Alexander G. Chartrain, Ahmed J. Awad, Justin R. Mascitelli, Hazem Shoirah, Thomas J. Oxley, Rui Feng, Matthew Gallitto, Reade De Leacy, Johanna T. Fifi, and Christopher P. Kellner

Endovascular thrombectomy device improvements in recent years have served a pivotal role in improving the success and safety of the thrombectomy procedure. As the intervention gains widespread use, developers have focused on maximizing the reperfusion rates and reducing procedural complications associated with these devices. This has led to a boom in device development. This review will cover novel and emerging technologies developed for endovascular thrombectomy.

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Ahmed J. Awad, Justin R. Mascitelli, Reham R. Haroun, Reade A. De Leacy, Johanna T. Fifi, and J Mocco

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.

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Srinivasan Paramasivam, Johanna T. Fifi, Rafael A. Ortiz, Yasunari Niimi, and Alejandro Berenstein

The authors present a rare case of arteriovenous fistula (AVF) of the basal vein of Rosenthal draining into a dilated vein of Galen managed by transarterial endovascular embolization. A male infant born at full term following a normal pregnancy and delivery with congestive heart failure, on investigation with MR imaging and MR angiography was found to have a basal vein of Rosenthal fistula with a dilated vein of Galen. His congestive heart failure was treated medically, and the AVF was managed electively at 10 months of age with successful transarterial endovascular embolization. The authors discuss the embryological aspects related to the pathological entity and the various clinical presentations, investigations, and management options. Management is primarily endovascular embolization; microsurgery is performed for a few selected cases, and radiosurgery has a limited role in older patients. Endovascular embolization is a safe and effective way to manage this malformation, with an excellent outcome if the AVF is eliminated by proper embolization at the fistulous point.

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Justin R. Mascitelli, Michael T. Lawton, Benjamin K. Hendricks, Trevor A. Hardigan, James S. Yoon, Kurt A. Yaeger, Christopher P. Kellner, Reade A. De Leacy, Johanna T. Fifi, Joshua B. Bederson, Felipe C. Albuquerque, Andrew F. Ducruet, Lee A. Birnbaum, Jean Louis R. Caron, Pavel Rodriguez, and J Mocco

OBJECTIVE

Randomized controlled trials have demonstrated the superiority of endovascular therapy (EVT) compared to microsurgery (MS) for ruptured aneurysms suitable for treatment or when therapy is broadly offered to all presenting aneurysms; however, wide neck aneurysms (WNAs) are a challenging subset that require more advanced techniques and warrant further investigation. Herein, the authors sought to investigate a prospective, multicenter WNA registry using rigorous outcome assessments and compare EVT and MS using propensity score analysis (PSA).

METHODS

Untreated, ruptured, saccular WNAs were included in the analysis. A WNA was defined as having a neck ≥ 4 mm or a dome/neck ratio (DNR) < 2. The primary outcome was the modified Rankin Scale (mRS) score at 1 year posttreatment, as assessed by blinded research nurses (good outcome: mRS scores 0–2) and compared using PSA.

RESULTS

The analysis included 87 ruptured aneurysms: 55 in the EVT cohort and 32 in the MS cohort. Demographics were similar in the two cohorts, including Hunt and Hess grade (p = 0.144) and modified Fisher grade (p = 0.475). WNA type inclusion criteria were similar in the two cohorts, with the most common type having a DNR < 2 (EVT 60.0% vs MS 62.5%). More anterior communicating artery aneurysms (27.3% vs 18.8%) and posterior circulation aneurysms (18.2% vs 0.0%) were treated with EVT, whereas more middle cerebral artery aneurysms were treated with MS (34.4% vs 18.2%, p = 0.025). Within the EVT cohort, 43.6% underwent stand-alone coiling, 50.9% balloon-assisted coiling, 3.6% stent-assisted coiling, and 1.8% flow diversion. The 1-year mRS score was assessed in 81 patients (93.1%), and the primary outcome demonstrated no increased risk for a poor outcome with MS compared to EVT (OR 0.43, 95% CI 0.13–1.45, p = 0.177). The durability of MS was higher, as evidenced by retreatment rates of 12.7% and 0% for EVT and MS, respectively (p = 0.04).

CONCLUSIONS

EVT and MS had similar clinical outcomes at 1 year following ruptured WNA treatment. Because of their challenging anatomy, WNAs may represent a population in which EVT’s previously demonstrated superiority for ruptured aneurysm treatment is less relevant. Further investigation into the treatment of ruptured WNAs is warranted.