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Philipp Taussky, Ricardo A. Hanel, and Fredric B. Meyer

Incidental findings pose considerable management dilemmas for the treating physician and psychological burden for the respective patient. With an aging population, more patients will be diagnosed with asymptomatic internal carotid artery stenosis. Patients will have to be counseled with regard to treatment options according to their individual risk profile and according to professionals' knowledge of evidence-based data derived from large randomized control trials. Treatment consensus has long been lacking for patients with asymptomatic carotid artery stenosis prior to any randomized controlled trials. Additionally, an individual's risk profile may be hard to assess according to knowledge gained from randomized controlled trials. Moreover, while earlier studies compared carotid endarterectomy and medical therapy, in the past years, a new therapeutic modality, carotid artery angioplasty and stenting, has emerged as a possible alternative. This has been evaluated in a recent randomized controlled trial, the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST), which compared carotid endarterectomy with angioplasty and stenting in both symptomatic and asymptomatic patients. The following review summarizes current knowledge of the natural history, diagnosis, and treatment strategies to counsel patients with asymptomatic carotid artery stenosis.

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Sean Sullivan, Pedro Aguilar-Salinas, Roberta Santos, Alexandra D. Beier, and Ricardo A. Hanel

The use of simulators has been described in a variety of fields as a training tool to gain technical skills through repeating and rehearsing procedures in a safe environment. In cerebrovascular surgery, simulation of skull base approaches has been used for decades. The use of simulation in neurointervention to acquire and enhance skills before treating a patient is a newer concept, but its utilization has been limited due to the lack of good models and deficient haptics. The advent of 3D printing technology and the development of new training models has changed this landscape. The prevalence of aneurysms in the pediatric population is much lower than in adults, and concepts and tools sometimes have to be adapted from one population to another. Neuroendovascular rehearsal is a valid strategy for the treatment of complex aneurysms, especially for the pediatric population. The authors present the case of an 8-year-old boy with a fusiform intracranial aneurysm and documented progressive growth, who was successfully treated after the authors rehearsed the placement of a flow diverter using a patient-specific 3D-printed replicator system model.

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Areej Tariq, Pedro Aguilar-Salinas, Ricardo A. Hanel, Neeraj Naval, and Mohamad Chmayssani

Intracranial pressure (ICP) monitoring has been widely accepted in the management of traumatic brain injury. However, its use in other pathologies that affect ICP has not been advocated as strongly, especially in CNS infections. Despite the most aggressive and novel antimicrobial therapies for meningitis, the mortality rate associated with this disease is far from satisfactory. Although intracranial hypertension and subsequent death have long been known to complicate meningitis, no specific guidelines targeting ICP monitoring are available. A review of the literature was performed to understand the pathophysiology of elevated ICP in meningitis, diagnostic challenges, and clinical outcomes in the use of ICP monitoring.

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Elad I. Levy, Robert D. Ecker, James J. Thompson, Peter A. Rosella, Ricardo A. Hanel, Lee R. Guterman, and L. Nelson Hopkins

Recent advances in carotid artery (CA) stent placement procedures have propelled this technology into the forefront of treatment options for both symptomatic and asymptomatic patients with CA stenosis. Until recently, endarterectomy was the only surgical option for patients with CA occlusive disease. For high-risk surgical candidates, periprocedural stroke rates remained unacceptable and were significantly higher than those associated with the natural history of the disease. Advances in stent technology and improvements in antiplatelet and antithrombotic regimens, in conjunction with distal protection devices, have significantly lowered the risk of periprocedural complications for high-risk surgical candidates requiring CA revascularization. In this paper the authors review data gleaned from the important recent CA stent trials and address questions concerning the safety, efficacy, and durability of stent-assisted angioplasty for extracranial CA occlusive disease. Additionally, they review the role of noninvasive imaging modalities for the diagnosis and surveillance of CA disease in these high-risk patients.

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Robert D. Ecker, Ricardo A. Hanel, Elad I. Levy, and L. Nelson Hopkins

✓The authors report the successful staged stenting and coil embolization of a large vertebral artery–posterior inferior cerebellar artery (VA-PICA) aneurysm using the contralateral VA for access. A 67-year-old woman presented with a large ruptured VA-PICA aneurysm. Initial attempts to stent the wide-necked aneurysm from the ipsilateral side failed, so coil embolization of the dome was performed. During a second endovascular session, the aneurysm neck was successfully stented from the contralateral VA into the PICA. Six weeks later, coils were inserted into the aneurysm from the ipsilateral side. The coil result was stable at the 3-month follow-up examination.

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Yiemeng Hoi, Hui Meng, Scott H. Woodward, Bernard R. Bendok, Ricardo A. Hanel, Lee R. Guterman, and L. Nelson Hopkins

Object. Few researchers have quantified the role of arterial geometry in the pathogenesis of saccular cerebral aneurysms. The authors investigated the effects of parent artery geometry on aneurysm hemodynamics and assessed the implications relative to aneurysm growth and treatment effectiveness.

Methods. The hemodynamics of three-dimensional saccular aneurysms arising from the lateral wall of arteries with varying arterial curves (starting with a straight vessel model) and neck sizes were studied using a computational fluid dynamics analysis. The effects of these geometric parameters on hemodynamic parameters, including flow velocity, aneurysm wall shear stress (WSS), and area of elevated WSS during the cardiac cycle (time-dependent impact zone), were quantified. Unlike simulations involving aneurysms located on straight arteries, blood flow inertia (centrifugal effects) rather than viscous diffusion was the predominant force driving blood into aneurysm sacs on curved arteries. As the degree of arterial curvature increased, flow impingement on the distal side of the neck intensified, leading to elevations in the WSS and enlargement of the impact zone at the distal side of the aneurysm neck.

Conclusions. Based on these simulations the authors postulate that lateral saccular aneurysms located on more curved arteries are subjected to higher hemodynamic stresses. Saccular aneurysms with wider necks have larger impact zones. The large impact zone at the distal side of the aneurysm neck correlates well with other findings, implicating this zone as the most likely site of aneurysm growth or regrowth of treated lesions. To protect against high hemodynamic stresses, protection of the distal side of the aneurysm neck from flow impingement is critical.

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Ramon Navarro, Benjamin L. Brown, Alexandra Beier, Nathan Ranalli, Philipp Aldana, and Ricardo A. Hanel

Pediatric intracranial aneurysms are exceedingly rare and account for less than 5% of all intracranial aneurysms. Open surgery to treat such aneurysms has been shown to be more durable than endovascular techniques, and durability of treatment is particularly important in the pediatric population. Over the past 2 decades, however, a marked shift in aneurysm treatment from open surgery toward endovascular procedures has occurred for adults.

The authors describe their early experience in treating 3 unruptured pediatric brain aneurysms using the Pipeline embolization device (PED). The first patient, a girl with Majewski osteodysplastic primordial dwarfism Type II who was harboring multiple intracranial aneurysms, underwent two flow diversion procedures for a vertebrobasilar aneurysm and a supraclinoid internal carotid artery aneurysm. The second patient underwent PED placement on a previously coiled but enlarging posterior communicating artery aneurysm. All procedures were uneventful, with no postsurgical complications, and led to complete angiographic obliteration of the aneurysms. To the authors' knowledge, this is the first series of flow diversion procedures in children reported in the medical literature.

While flow diversion is a new and relatively untested technology in children, outcomes in adults have been promising. For challenging lesions in the pediatric population, flow diversion may have a valuable role as a well-tolerated, safe treatment with durable results. Many issues remain to be addressed, such as the durability of flow diverters over a very long follow-up and vessel response to growth in the presence of an endoluminal device.

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Ricardo A. Hanel, Alan S. Boulos, Eric G. Sauvageau, Elad I. Levy, Lee R. Guterman, and L. Nelson Hopkins

Vertebrobasilar nonsaccular aneurysms represent a small subset of intracranial aneurysms and usually are among the most challenging to be treated. The aim of this article was to review the literature and summarize the experience in the treatment of these lesions with endovascular approaches. The method of stent implantation as it is performed at the authors' institution, including options available for vertebral artery access, is described. Practitioners involved in the treatment of these lesions should be aware of the potential application of intravascular stent placement as well as the associated postprocedure risks and potential complications.

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Stanley H. Kim, Adnan I. Qureshi, Elad I. Levy, Ricardo A. Hanel, Amir M. Siddiqui, and L. Nelson Hopkins

✓ The authors report a case of emergency carotid artery (CA) stent placement for a symptomatic acute CA occlusion following carotid endarterectomy (CEA). This 43-year-old man underwent a right-sided CEA for an asymptomatic 80% CA stenosis detected using duplex ultrasound testing. The patient experienced hypotension and possibly a myocardial infarction intraoperatively and a left hemiplegia immediately postoperatively. He was referred to the authors' institution for consideration of emergency coronary intervention and evaluation of stroke. A computerized tomography scan of the head demonstrated subtle early ischemic changes in the right posterior parietal region. Cerebral angiography revealed occlusion of the right common CA (CCA) at the CA bifurcation. Two coronary stents (Magic Wall; Boston Scientific Scimed, Maple Grove, MN) were placed in tandem in the right CCA and internal CA (ICA), overlapping at the proximal cervical ICA. Complete recanalization of the CA was achieved, and the patient made a clinically significant recovery. Diagnostic angiography can provide important information about CA and intracranial circulation that will aid in the evaluation of postoperative stroke after CEA. Stent placement should be considered as an alternative method of treatment for acute CA occlusion or dissection following CEA.