Elad I. Levy

BACKGROUND AND OBJECTIVES: The Woven Endobridge (WEB) and the Contour Neurovascular System (Contour) are both intrasaccular devices used to treat cerebral aneurysms. We compared outcomes of these 2 devices using data from 2 large registries. METHODS: Data were sourced from the WorldWideWEB Consortium, which included 1363 cases treated with WEB from 2017, and a registry of 277 Contour cases from 10 European centers starting the same year. Patient demographics, aneurysm characteristics, procedural specifics, and outcomes were analyzed. Propensity score matching was applied for comparison. RESULTS: Before matching, the Contour group had more men (37.9% vs 30.8%), more asymptomatic cases (83.4% vs 70.3%), and fewer acute subarachnoid hemorrhage cases (10.8% vs 26.2%). After matching, no significant differences were found in demographics or aneurysm characteristics between groups. The median age was 60 years, and median aneurysm dimensions were comparable. Logistic regression showed no significant differences between WEB and Contour in achieving complete occlusion (odds ratio [OR] = 1.01, 95% CI, 0.67-1.52, P = .971), adequate occlusion (OR = 0.85, 95% CI, 0.41-1.76, P = .665), or achieving modified Rankin Scale 0 to 2 at last follow-up (OR = 0.48, 95% CI, 0.21-1.02, P = .064). Retreatment (OR = 2.23, P = .086), thromboembolic complications (OR = 0.75, P = .452), and adjunctive treatment use (OR = 1.93, P = .141) were also similar. CONCLUSION: The WEB and Contour demonstrated comparable clinical and angiographic outcomes in this large multicenter study comprised majority small, asymptomatic cerebral aneurysms.

Background: Neurointerventionalists performing stent assisted coil embolization for intracranial aneurysms use Neuroform Atlas stents (Stryker) for their low metal coverage, deployment ease, and lower thromboembolic risk, although low profile visualized intraluminal support (LVIS) and LVIS Jr stents (Terumo Neuro) offer better wall apposition and high metal coverage, potentially promoting flow diversion and endothelialization. The next generation LVIS Evolution (LVIS EVO; Terumo Neuro) adds enhanced visibility, improved resheathability, and even higher metal coverage to address earlier limitations of LVIS and LVIS Jr. We evaluated the performance and complications of these devices. Methods: PubMed and Embase were searched from 1 January 2017 to 31 July 2025 to identify studies comparing Atlas assisted coil embolization (AACE) versus LVIS/LVIS Jr assisted coil embolization (LACE), and single arm LVIS EVO assisted coil embolization (LeACE) studies. Meta-analyses were performed to compare baselines, procedural considerations, and occlusion rates. Results: We included five studies comparing 504 patients treated with AACE and 579 patients with LACE, and 12 studies evaluating LeACE (575 patients). Fewer aneurysms were ruptured at presentation in the AACE group than in the LACE (OR 0.09; P<0.01) and LeACE (0.7% vs 15.2%; P<0.01) groups. Comparable technical failure rates were found between AACE and LeACE (1.8% vs 5.4%; P=0.15), contrasting with the superiority of AACE over LACE (OR 0.14; P<0.01). AACE resulted in higher immediate adequate occlusion than LACE (OR 1.62; P=0.02), but comparable with LeACE (83% vs 90.8%; P=0.28). Follow-up complete occlusion rates were similar between AACE and LACE (OR 1.31; P=0.16) and between AACE and LeACE (82.4% vs 81.2%; P=0.86). Conclusions: The superior outcomes of the Atlas over LVIS/LVIS Jr were matched by the LVIS EVO. Thromboembolic complications occurred more frequently with the LVIS EVO.

BACKGROUND: The EMBOLISE trial (The Embolization of the Middle Meningeal Artery With Onyx Liquid Embolic System in the Treatment of Subacute and Chronic Subdural Hematoma) demonstrated that middle meningeal artery embolization as an adjunct to surgical drainage reduces recurrence of symptomatic subacute and chronic subdural hematomas. We performed a subgroup analysis of the EMBOLISE surgical cohort to determine how the timing of embolization relative to surgery impacted various outcomes. METHODS: We performed a post hoc subgroup analysis to examine the association of the timing of embolization relative to surgery with the primary end point (hematoma reoperation within 90 days), secondary end points (clinical and radiographic outcomes), and safety end points (serious adverse events, neurological death, all-cause death, and stroke). RESULTS: Middle meningeal artery embolization before surgery (embolization-first group) and middle meningeal artery embolization after surgery (surgery-first group) were performed in 107 and 78 patients, respectively. Demographics and baseline clinical characteristics of the 2 groups were similar. The core laboratory confirmed the procedure to be successful in all patients with similar rates of distal penetration of Onyx into middle meningeal artery branches at the end of the embolization procedure in both groups (49.5% and 48.7%, respectively, P >0.99). Six of 103 patients in the embolization-first group (5.8%) and none in the surgery-first group needed reoperation within 90 days (analysis with observed data, P =0.08). Hematoma volumes at 90 and 180 days were similar except for lower hematoma thickness in the surgery-first group (2.3±3.0 mm versus 4.4±5.6 mm, P =0.03) at 180 days. Clinical and safety outcomes at 30, 90, and 180 days were similar. CONCLUSIONS: Performing surgical drainage before embolization in patients with subacute and chronic subdural hematomas may help minimize treatment failures and enhance hematoma resolution. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT04402632.

Introduction: THUNDER (Acute Ischemic Stroke Study With the Penumbra System Including Thunderbolt Aspiration Tubing) was the first study to evaluate the safety and effectiveness of a proprietary computer assisted vacuum thrombectomy (CAVT) system including modulated aspiration (Penumbra System with Thunderbolt; Penumbra, California, USA) in patients with emergent large vessel occlusion (ELVO). Methods: THUNDER was a single arm, prospective, multicenter study with core laboratory adjudication and oversight by a Clinical Events Committee and Data Safety Monitoring Board. The primary endpoint was post-Thunderbolt successful revascularization (modified Treatment in Cerebral Infarction (mTICI) 2b–3). Secondary endpoints included first pass mTICI 2b–3, post-Thunderbolt mTICI 2c–3, time to revascularization, symptomatic intracranial hemorrhages (sICH), device/procedure related serious adverse events (SAEs) within 24 hours, 90- day modified Rankin Score (mRS) 0–2, and all cause mortality. Results: 216 patients were enrolled across 29 US centers (mean age 64.8 years, 45.4% women, median National Institutes of Health Stroke Scale score 15.0). The predefined performance goal was met, with post-Thunderbolt mTICI 2b–3 revascularization achieved in 87.5% (95% CI 82.3% to 91.6%; P<0.001). First pass mTICI 2b–3 was 64.8%. Post-Thunderbolt mTICI 2c–3 was 70.4%. Median time to revascularization was 20 min. Post-procedure, 83.0% of visualized clots were characterized as ingested. At 90 days, mRS 0–2 was 55.4%. Device/procedure related SAEs occurred in 2.8%, sICH in 0.9%, and the rate of all cause mortality at 90 days was 11.7%. Conclusions: The Thunderbolt system was safe and effective for the treatment of ELVO, achieving high revascularization and clot ingestion rates, short procedure times, and low complication rates. The first pass effect rate was numerically higher than those previously reported for large bore catheters and approximated those of ultra bore/super large bore devices. Trial registration: ClinicalTrials.gov NCT05437055

BACKGROUND: Efficient turnover time (TOT) and adherence to first-start time (FST) in operating and angiography suites are critical for optimizing workflow, reducing costs, and maximizing patient satisfaction. Hospitals face challenges in maintaining these metrics due to operational constraints and unexpected emergent cases. Our goal was to compare TOT, FST, and total admission time for elective cases performed in angiography suites at an ambulatory neurosurgery center (ANSC) versus a tertiary hospital (TH). METHODS: We conducted a retrospective analysis of data for patients who underwent elective diagnostic or interventional neuroendovascular procedures at the TH or ANSC from January 2024 through October 2024. TOT was defined as the time between the end of one case and the start of the next. FST was defined as the time the first patient of the day entered the suite. In addition, digital subtraction angiography cases at the ANSC were age- and indication-matched with same-day discharge digital subtraction angiography cases from the TH to compare total admission, preprocedural wait, procedural, and postprocedural times (minutes). RESULTS: A total of 1174 procedures were performed at the TH and 155 at the ANSC. Mean TOT was longer at the TH (30.6 ± 25 minutes) than the ANSC (12 ± 2.8 minutes; P P =0.02). In the matched digital subtraction angiography case-cohort analysis, mean total admission time was significantly longer at the TH (TH: 566 ± 148.9 versus ANSC: 279 ± 66.2 minutes; P P P P <0.001) times. CONCLUSIONS: Data for ANSC procedures demonstrated significantly improved operational efficiency compared with TH procedures, with shorter TOT, earlier FST, and reduced total admission durations for elective digital subtraction angiography cases. These findings support the growing role of ANSCs in optimizing resource utilization and efficiency while maintaining high-quality patient care.

An end-to-end autonomous artificial intelligence–based system was developed and validated at five international stroke centers to enable rapid, standardized quantification of rupture-relevant brain aneurysm and parent artery morphology metrics directly from CT angiography.

Background: The recent focus on improving quality and reducing cost within the US healthcare system has increased care being performed in the outpatient setting. The impact on neurosurgeons’ practice patterns has not yet been fully elucidated. In addition, how this transition may affect neurosurgery resident training is unclear. To better understand these issues, we surveyed neurosurgeons. Methods: A 13-question survey was sent to Council of State Neurosurgical Societies email subscribers. The survey focused on training or practice level, location, practice setting, ambulatory surgical center (ASC) utilization, and types of procedures performed at ASCs. Responses were tabulated. Statistical analysis was performed. Results: Among 11,091 subscribers, 101 responses (0.9%) were recorded. Most of the respondents (57.4%) utilized an ASC in their practice. The commonly performed procedures were microdiscectomy (98.1%), hemilaminectomy (94.2%), battery changes (87.5%), single-level anterior cervical discectomy and fusion (84.6%), single-level lumbar or thoracic laminectomy (80.8%), and peripheral nerve decompression (66.7%). Cranial procedures were seldom performed. Other device-related procedures were common and included vagal nerve stimulation (32.5%), spinal cord stimulation (67.5%), baclofen pump placement (25%), and baclofen pump replacement (27.5%). Only 17.1% of respondents who worked in academia taught residents in an ASC. Conclusion: According to our survey results, most neurosurgeons have incorporated ASCs into their practices in some capacity and most frequently for simple spine procedures, device-related procedures, and peripheral nerve decompression. The limited resident involvement in procedures in the ASC setting, even among attending academic neurosurgeons, suggests an increased need for ASC incorporation in residency training.

Although invasive, digital subtraction angiography (DSA) is considered a relatively safe procedure and remains the gold standard for cerebrovascular imaging. Transient global amnesia (TGA) is a self-limited episode of sudden-onset anterograde amnesia that resolves spontaneously within 24 hours. We report a rare occurrence of TGA after diagnostic DSA. A 62-year-old man presented for an angiogram performed under conscious sedation for the diagnosis of a suspected cavernous internal carotid artery aneurysm. Although the DSA revealed normal anatomy, the patient experienced self-resolving memory impairment immediately after the procedure. To date, only a few such cases have been reported, and this is the first documented instance that occurred at an ambulatory neurosurgery center. This case highlights that rare phenomena, such as transient global amnesia, can occur after cerebral angiography, even with brief radiation exposure and a short procedure duration. Recognizing such events is particularly important as neurosurgical care continues to transition from hospitals to outpatient centers, serving as a key safeguard against the shorter observation periods at these ambulatory facilities.