Joshua Seinfeld’s research while affiliated with University of Colorado and other places

Background Barrow Type B indirect carotid-cavernous fistulas (CCF) are arteriovenous shunting lesions between dural branches of the internal carotid artery (ICA) and the cavernous sinus. These lesion are commonly treated with transvenous embolization via the inferior petrosal or superior ophthalmic veins. We describe a 63-year-old female with a Barrow Type B CCF with meningohypophyseal arterial supply from bilateral ICAs. A previous right transvenous treatment attempt at another institution was aborted secondary to intra-procedural iatrogenic arterial ischemic stroke. During attempts at our hospital, we were unable to access the fistulous point through a transvenous approach and the meningohypophyseal artery was not large enough to catheterize for transarterial embolization. The patient was therefore treated with Pipeline flow-diverting stents in each ICA. On follow up, the CCF was radiographically cured and the patient had improvement in ophthalmologic symptoms. Design/Methods A 4.5 mm x 16 mm Pipeline Flex Embolization Device with Shield Technology was deployed from the anterior genu of the cavernous segment of the each ICA into the lacerum segment. Cerebral angiography was performed immediately after placement and at 3 and 9 months post procedure. Neuro-ophthomology monitored follow up intraocular pressures and extraocular movements. Results Immediate postprocedural angiography demonstrated slower shunting into the CCF, which was improved at 3 months. At 9 months there was no residual CCF. While the patient still had retinal hemorrhages in the right eye, there was improvement in intraocular pressures (19 to 15 mmHg) and resolution of extraocular movement restriction and an afferent pupillary defect. Conclusions To our knowledge, this is the first case report to describe the successful deployment of bilateral ICA Pipelines to treat a Barrow Type B CCF. This case suggests an alternative approach to transvenous or transarterial embolization that can be employed in patients with anatomy or previous interventions that preclude standard approaches. • Download figure • Open in new tab • Download powerpoint Abstract E-142 Figure 1 (Left) AP left internal carotid arteriography pre treatment. (Right) AP left internal carotid arteriography post treatment with resolution of the CC fistula Disclosures B. Morel None. E. Lester None. J. Hoffman None. J. Seinfeld None. C. Roark None. Z. Folzenlogen None. D. Case None.

BACKGROUND AND OBJECTIVES: Dual antiplatelet therapy (DAPT) is necessary to minimize the risk of periprocedural thromboembolic complications associated with aneurysm embolization using pipeline embolization device (PED). We aimed to assess the impact of platelet function testing (PFT) on reducing periprocedural thromboembolic complications associated with PED flow diversion in patients receiving aspirin and clopidogrel. METHODS: Patients with unruptured intracranial aneurysms requiring PED flow diversion were identified from 13 centers for retrospective evaluation. Clinical variables including the results of PFT before treatment, periprocedural DAPT regimen, and intracranial complications occurring within 72 h of embolization were identified. Complication rates were compared between PFT and non-PFT groups. Differences between groups were tested for statistical significance using the Wilcoxon rank sum, Fisher exact, or χ2 tests. A P-value <.05 was statistically significant. RESULTS: 580patientsunderwentPEDembolizationwith262patientsdichotomizedtothePFTgroupand318patientstothenon- PFT group. 13.7% of PFT group patients were clopidogrel nonresponders requiring changes in their pre-embolization DAPT regimen. Five percentage of PFT group [2.8%, 8.5%] patients experienced thromboembolic complications vs 1.6% of patients in the non-PFT group [0.6%, 3.8%] (P = .019). Two (15.4%) PFT group patients with thromboembolic complications experienced permanent neurological disability vs 4 (80%) non-PFT group patients. 3.7% of PFT group patients [1.5%, 8.2%] and 3.5% [1.8%, 6.3%] of non-PFT group patients experienced hemorrhagic intracranial complications (P > .9). CONCLUSION: Preprocedural PFT before PED treatment of intracranial aneurysms in patients premedicated with an aspirin and clopidogrel DAPT regimen may not be necessary to significantly reduce the risk of procedure-related intracranial complications.

Moyamoya arteriopathy is a condition where chronic, progressive stenosis of large intracranial arteries, primarily of the anterior circulation, results in ischemia and the growth of small, abnormal collateral vessels. There is increasing evidence that infectious pathologies, such as COVID-19, may serve as a sort of trigger, or “second hit," for the development of moyamoya arteriopathy. In this article, we present the case of a 13-year-old female with Down syndrome and unilateral moyamoya arteriopathy who developed contralateral internal carotid artery (ICA) dissection and thrombus in the setting of a positive COVID-19 test and subsequently developed rapidly progressive contralateral ICA and bilateral anterior cerebral artery (ACA) moyamoya-like stenosis. The rapidly progressive contralateral ICA and bilateral ACA moyamoya-like stenosis are likely multifactorial in nature. The contralateral ICA may have had a predisposition for injury and stenosis due to the preexisting moyamoya arteriopathy, making stenosis more likely after COVID-19-induced vascular inflammation and injury as well as after a possible thrombectomy-associated injury. Based on this presentation, patients with moyamoya arteriopathy may be at risk for rapid progression of their moyamoya pathology when exposed to catalysts, including infection, such as COVID-19, and vascular injury, such as thrombectomy-induced injury. In these circumstances, high suspicion and close monitoring are essential for addressing ischemia related to the stenosis before permanent injury.

Background Blister aneurysms are high-risk intracranial vascular lesions. Definitive treatment of these lesions has been challenging. Severe disability or mortality rates are as high as 55% when these lesions are treated with open surgery. Recent data show that flow diversion is a safe and effective alternative treatment for blister aneurysms. Rerupture of the functionally unsecured lesion remains a concern as flow diversion does not immediately exclude the aneurysm from the circulation. Methods A retrospective review was performed of any patients with ruptured blister aneurysms treated with a pipeline embolization device between 2010 and 2020 at the University of Colorado. Results In this paper, we present the results of the intensive care management of ruptured intracranial blister aneurysms after flow-diverting stent placement. Conclusion Despite the need for dual antiplatelet therapy and the delayed occlusion of blister aneurysms treated with flow diversion, we did not find an increase in periprocedural complications.

A single center had a collaborative, multidisciplinary review to determine how to best implement new acute ischemic stroke trials involving large vessel occlusions. A flow diagram process map was created for clinical decision support. Patients were divided into four groups based upon size of infarct and timing of presentation. The process map, available in the electronic health record (EHR) for clinicians to reference, guides the selection of patients for endovascular therapy with neuroimaging. In addition, the process map offers guidance for discussions with families and patients experiencing large vessel occlusions with both small and large core infarcts. This manuscript describes the process of creating the process map through a multidisciplinary review and discussion, with points of controversy and how these were addressed.

BACKGROUND AND OBJECTIVES Stereotactic radiosurgery (SRS) is an effective treatment modality used by neurosurgeons to treat cerebral arteriovenous malformations (AVMs), particularly for treating AVMs <10 cm ³ . Current strategies include single-staged, dose-staged, and volume-staged SRS, all of which demonstrate varying effectiveness for treating large-volume AVMs (>10 cm ³ ). We introduce a novel refinement called time-dosed SRS for the treatment of large-volume AVMs or AVMs located in eloquent areas. This study aims to detail treatment parameters, outcomes, and complications associated with time-dosed SRS in our early experience study. METHODS We retrospectively reviewed all patients treated using time-dosed SRS at our institution. Data, including AVM location, history of hemorrhage, history of intervention, AVM volume, Spetzler-Martin grade, presence of residual disease, and occurrence of postprocedural complications, were collected. RESULTS Sixteen patients were included. The median total AVM volumes treated were 9.64 cm ³ (0.92-46.2 cm ³ ) and 13.2 cm ³ (3.0-42.2 cm ³ ) in adults and children, respectively. The median margin doses for adults and children at each of the 3 stages were 10 Gy, 10 Gy (8-10 Gy) and 9 Gy (8-10 Gy), and 10 Gy, 10 Gy (9-10 Gy), and 10 Gy (8-10 Gy), respectively. The median total dose delivered was 29 Gy (27-30 Gy) in adults and 30 Gy (28-30 Gy) in children. The median radiological follow-up length was 35 months (9-62 months) in adults and 31 months (4-72 months) in pediatric patients. Complete obliteration was confirmed by cerebral angiogram in 6 adult patients and 1 pediatric patient. One adult patient and 2 pediatric patients suffered radiation-related toxicity. No patients suffered postprocedural hemorrhage. CONCLUSION Time-dosed SRS seems to be effective for treating large AVMs or those in highly eloquent areas, with a low rate of complications.

Objective: Endoluminal flow diversion reduces blood flow into intracranial aneurysms, promoting thrombosis. Postprocedural dual antiplatelet therapy (DAPT) is necessary for the prevention of thromboembolic complications. The purpose of this study is to therefore assess the impact that the type and duration of DAPT has on aneurysm occlusion rates and iatrogenic complications after flow diversion. Methods: A retrospective review of a multicenter aneurysm database was performed from 2012 to 2020 to identify unruptured intracranial aneurysms treated with single device flow diversion and ≥12-month follow-up. Clinical and radiologic data were analyzed with aneurysm occlusion as a function of DAPT duration serving as a primary outcome measure. Results: Two hundred five patients underwent flow diversion with a single pipeline embolization device with 12.7% of treated aneurysms remaining nonoccluded during the study period. There were no significant differences in aneurysm morphology or type of DAPT used between occluded and nonoccluded groups. Nonoccluded aneurysms received a longer mean duration of DAPT (9.4 vs 7.1 months, P = 0.016) with a significant effect of DAPT duration on the observed aneurysm occlusion rate (F(2, 202) = 4.2, P = 0.016). There was no significant difference in the rate of complications, including delayed ischemic strokes, observed between patients receiving short (≤6 months) and prolonged duration (>6 months) DAPT (7.9% vs 9.3%, P = 0.76). Conclusions: After flow diversion, an abbreviated duration of DAPT lasting 6 months may be most appropriate before transitioning to low-dose aspirin monotherapy to promote timely aneurysm occlusion while minimizing thromboembolic complications.

Objective Ruptured blister, dissecting, and iatrogenic pseudoaneurysms are rare pathologies that pose significant challenges from a treatment standpoint. Endovascular treatment via flow diversion represents an increasingly popular option; however, drawbacks include the requirement for dual antiplatelet therapy and the potential for thromboembolic complications, particularly acutely in the ruptured setting. The Pipeline Flex Embolization device with Shield technology (PED-Shield) offers a reduced material thrombogenicity via coating with phosphorylcholine, which may aid in the treatment of ruptured internal carotid artery pseudoaneurysms. Methods The authors conducted a multi-institution, retrospective case series to determine the safety and efficacy of PED-Shield in the treatment of ruptured blister, dissecting, and iatrogenic pseudoaneurysms of the internal carotid artery. Clinical, radiographic, treatment, and outcomes data were collected. Results Thirty-three patients were included in the final analysis. Seventeen underwent placement of a single device and 16 underwent placement of two devices. Adjunctive coiling was conducted in two cases. Four patients were maintained on aspirin alone and all others were treated with long-term dual antiplatelet therapy. No thromboembolic complications occurred. Among patients with 3-month follow-up, 93.8% had an modified Rankin Scale score of 0-2. Overall complete occlusion at follow-up was observed in 82.6% of patients. Among patients treated with multiple telescoping devices, complete occlusion was observed in 90.9% of cases, while those treated with a single device demonstrated complete occlusion in 72.7% of cases. Extremely early complete occlusion (observed in less than one month post-operatively) was observed in five patients. Of the five patients, four underwent placement of multiple telescoping devices, while the remaining one was treated with a single device. Conclusions PED-Shield represents a new option for treatment of ruptured blister, dissecting, and iatrogenic pseudoaneurysms of the internal carotid artery, and the presented work represents the largest series to date describing treatment of this pathology with PED-Shield. The reduced material thrombogenicity appears to improve the safety of the PED-Shield device, as our series demonstrated no thromboembolic complications, even among patients treated with only single antiplatelet therapy. The efficacy of the PED-Shield reported in this series, particularly with placement of two devices, demonstrates its potential as a first-line treatment option for these pathologies. Disclosures M. Bounajem None. E. Joyce None. J. Scoville None. J. Seinfeld 2; C; Medtronic. J. Hoffman None. J. Grossberg 1; C; GRA, EMFC, Neurosurgery Catalyst. 4; C; Cognition. V. Waiters None. A. White None. J. Nerva 4; C; Midwest Interventional Systems Inc, Synchron LLC, Bendit Technologies Ltd, Borvo Medical. J. Burkhardt 2; C; Microvention, Cerenovus, Stryker, Medtronic, Longeviti Neuro Solutions, Q`Apel Medical. D. Tonetti None. K. El Naamani None. M. Gooch 2; C; Stryker. P. Jabbour 1; C; Medtronic. S. Tjoumakaris 6; C; Microvention. S. Ortega Gutierrez 6; C; Stryker, Medtronic, Microvention. M. Levitt 1; C; Medtronic, Stryker. 2; C; Metis Innovative, Aeaean Advisers, Stereotaxis. 6; C; Prioprio, Hyperion Surgical, Synchron, Fluid Biomed, Cerebrotech. M. Lang None. W. Ares None. S. Desai None. J. Mascitelli 2; C; Stryker. C. Kilburg 6; C; Medtronic, Cerenovus. K. Budohoski None. W. Couldwell None. B. Gross 2; C; Medtronic, Microvention, Stryker. R. Grandhi 6; C; Medtronic, Cerenovus, Balt.

Introduction Cerebral venous thrombosis (CVT) accounts for a small percentage of all strokes. While the superior sagittal sinus is the most common location, a subset of CVT involves the deep venous system - the internal cerebral veins, vein of Galen, basal vein of Rosenthal, and thalamostriate veins. Deep CVT can cause thalamic and basal ganglia edema, hemorrhage, and strokes, resulting in disorders of consciousness and subsequent death or dependency. While anticoagulation is the mainstay therapy for CVT, patients with worsening neurologic examinations, strokes, or intracerebral hemorrhage (ICH) may benefit from endovascular therapy and recanalization of the affected vessels. This is complicated in the deep veins by difficult catheterization due to small, fragile vessels. We hypothesize that endovascular treatment of the superficial venous sinuses or the straight sinus alone, without catheterization of deep veins, can result in apparent recanalization of the deep venous sinuses resulting in improved radiologic and clinical outcomes. Materials/Methods We queried our interventional radiology (IR) database from January 1, 2010 - February 23, 2021 for patients with CVT. This returned a total of 5599 patient encounters containing the search terms, of which 43 had undergone endovascular treatment for CVT. 31 of these patients had venous thrombosis in the superficial sinuses only, while 12 patients had venous thrombosis involving the deep venous system. Results The 12 patients whose CVT involved deep veins and who underwent endovascular intervention had the following demographics.View this table: • View inline • View popup Abstract O-035 Table 1 All 12 patients underwent intervention due to clinical and/or radiographic worsening despite adequate heparin infusions. 4 patients underwent catheterization of the straight sinus. All other interventions were in the superficial venous sinuses only. All 12 patients with deep venous involvement ultimately had recanalization of the deep system. Modified Rankin scale at discharge was an average of 2.2 (range 0-5). Conclusions Although deep venous involvement of CVT is uncommon, these patients are at risk of quickly becoming critically ill with an elevated rate of death or dependency. Although these patients may develop stroke, hemorrhage, or neurologic decline prompting consideration of endovascular therapy, the deep cerebral venous system is not easily accessible with catheters due to small lumens and risk of perforation. It has been proposed that deep cerebral veins may have a higher chance of recanalization if venous thrombus burden is reduced in other parts of the dural venous sinuses. Current literature has not fully explored the association between endovascular treatment of the superficial dural venous sinuses and deep venous flow. Our study shows that endovascular recanalization of the superficial venous sinuses and/or straight sinus can subsequently result in recanalization of the deep veins and improve radiologic and clinical outcomes. Prospective trials are still needed to provide further evidence of safety and efficacy. Disclosures B. Morel None. J. Hoffman None. Z. Folzenlogen None. C. Roark None. J. Seinfeld None. D. Case None.