Danielle Golub

Introduction: Stenting is increasingly used for neurovascular atherosclerotic lesions, but standardized techniques and dedicated devices remain lacking. Objective: To report outcomes and technical considerations of off-label use of the coronary Onyx drug-eluting stents (DES) for intra- and extracranial neurovascular atherosclerotic lesions. Methods: We retrospectively reviewed all patients who underwent Onyx DES placement for neurovascular atherosclerotic lesions at our institution between January 2018 and September 2024. Demographics, clinical presentation and follow-up, angiographic findings, procedural details, and complications were collected. Outcomes included procedural success, periprocedural stroke, and in-stent restenosis (ISR) requiring reintervention. Results: 84 Onyx DES were deployed in 63 patients (33% female). Procedural success was achieved in all cases. Stent locations included the basilar artery (21.4%), middle cerebral artery (20%), cervical internal carotid artery (ICA) (2.4%), petrous ICA (4.8%), cavernous ICA (8.3%), supraclinoid ICA (10.7%), V1 (10.7%), V3 (1.2%), and V4 (19%). Three patients (4.8%) developed iatrogenic carotid-cavernous fistulae, all successfully treated. Postprocedural stroke rate was 4.8%. During a mean follow-up of 20.6 months, three patients (4.8%) required angioplasty for ISR. Independent predictors of complications included posterior circulation stenting (OR 13.8, p = .005), smaller stent diameter (OR 0.17, p = .03), and higher stent number (OR 14.7, p < .0001). Conclusion: Onyx DES demonstrated excellent navigability, high technical success, and favorable long-term outcomes in patients with neurovascular atherosclerotic lesions. Together with growing comparative evidence, these findings suggest newer-generation DES may overcome limitations of earlier stent systems and merit further prospective evaluation.

Background: Glomus jugular tumors (GJTs), a subset of paragangliomas, are highly vascularized neoplasms arising in the jugular foramen, typically affecting middle-aged women. Although benign, GJTs often present with critical cranial neuropathies such as hearing loss, swallowing disturbances, and facial weakness and can cause venous outflow obstruction from jugular vein compression. In symptomatic cases, early intervention is warranted and involves surgical resection. Approaches include transmastoid approach, juxtacondylar approach, infratemporal approaches, transotic approach, extreme lateral infrajugular transtubercular exposure (ELITE), or a combination thereof. Due to the highly vascularized nature of these tumors and the relative fragility of nearby cranial nerves, significant bleeding and neurological deficits can occur as a consequence of resection. Intraoperative bleeding, however, can be reduced with preoperative embolization. Case Description: We present the case of a 57-year-old woman with a right-sided GJT extending into the jugular foramen and compressing the facial nerve. Given her progressive symptoms, we felt that radiosurgery was not an ideal treatment. The goals of the procedure were to decompress the facial nerve and achieve maximal safe tumor resection. We utilized the ELITE approach with tailored mastoidectomy, allowing anterolateral access to the tumor. The mastoidectomy allows skeletonization of the sigmoid sinus and jugular bulb as well as the fallopian canal housing the facial nerve. To minimize postoperative cranial nerve palsies, neuromonitoring was used to limit facial nerve manipulation, and an intrabulbar dissection approach was employed to avoid iatrogenic injury to other neurovascular structures. The patient consented to the procedure and the publication of her images. Conclusion: This case highlights a surgical approach that prioritizes both tumor resection and cranial nerve protection and offers insights into strategies for optimizing outcomes in GJT management. Furthermore, this case underscores the importance of tailored, precise techniques to minimize surgical morbidity for patients with these challenging lesions.

BACKGROUND: The Woven EndoBridge (WEB) embolization system is an endovascularly deployed intrasaccular device that promotes occlusion in cerebrovascular aneurysms through intra-aneurysmal thrombosis. While the safety and efficacy of the WEB device have been well described in the literature, the treatment of recurrent aneurysms after WEB embolization via microsurgical clipping requires further study. OBSERVATIONS: A 71-year-old female patient with an incidentally discovered anterior communicating artery aneurysm underwent WEB embolization with complete aneurysm occlusion observed on immediate postintervention angiography. Catheter angiography both 9 and 18 months after embolization revealed aneurysm recanalization. Given the aneurysm’s wide neck and irregular dome, the patient underwent an uncomplicated left pterional craniotomy for microsurgical clipping of the recurrent aneurysm 21 months after initial WEB embolization. Intraoperative angiography confirmed complete aneurysm occlusion. Follow-up catheter angiography 12 months later demonstrated persistent aneurysm occlusion with preservation of parent and adjacent vessels. LESSONS: The compressibility of the WEB device with aneurysm clips and the device’s tendency to remain intrasaccular after clipping make microsurgical clipping a favorable treatment option for aneurysmal recurrence after WEB embolization in appropriate surgical candidates. Further dedicated studies evaluating outcomes after microsurgical clipping for recurrent or residual aneurysms after WEB embolization are warranted. https://thejns.org/doi/10.3171/CASE25340

Background: Venous sinus stenting (VSS) is an established treatment for idiopathic intracranial hypertension (IIH), and pulsatile tinnitus (PT), but optimal patient selection remains a challenge. Current protocols rely on catheter angiography and manometry-based pressure gradients, which can be operator-dependent and subject to measurement variability. Intravascular ultrasound (IVUS) offers real-time, cross-sectional visualization of venous anatomy, potentially providing more consistent and objective assessments of stenosis severity. Methods: We conducted a retrospective study of 31 patients undergoing venography with IVUS over an eight-month period for suspected venous sinus stenosis. The point of maximal stenosis severity was measured using both angiography and IVUS, and findings were compared to intravascular pressure gradients. A pressure difference or gradient of ≥8 mmHg in IIH and ≥4 mmHg in PT across the stenosis was considered clinically significant based on prior prospective trial criteria. Results: Patients included those with IIH (41.9%) or PT (58.1%). Mean maximal stenosis was 51.2% by angiography and 65.2% by IVUS. The agreement between different reviewers measuring angiographic stenosis was low ( r ²=.19), and IVUS-based stenosis correlated more strongly with pressure gradients than angiographic estimates ( r = .78 vs. .46, p = .044). An IVUS-measured stenosis ≥53.2% predicted a clinically significant pressure gradient (≥8 mmHg) with 100% sensitivity and 66.7% specificity. No IVUS-related complications occurred. Conclusion: IVUS is a safe and promising adjunct to conventional venography for assessing venous sinus stenosis, with stronger correlation to physiologic pressure gradients than angiographic estimates. These findings suggest that IVUS may enhance patient selection for venous sinus stenting by more accurately identifying candidates likely to benefit from intervention, potentially increasing treatment eligibility and intervention rates. By refining diagnostic accuracy, IVUS may also contribute to improved long-term symptom relief. Nonetheless, given the retrospective, single-center design and limited sample size, larger prospective studies are warranted to validate these findings and assess their impact on clinical outcomes.

OBJECTIVE: Although well-established in moyamoya disease (MMD), the role of direct superficial temporal artery (STA) to middle cerebral artery (MCA) bypass in non-MMD (N-MMD) cerebrovascular steno-occlusive syndromes remains controversial. Nonetheless, the recurrent stroke risk in patients with N-MMD, despite best medical management, remains exceedingly high—especially for those suffering from hypoperfusion-related ischemia. The study objective was to determine the relative safety and efficacy profiles of direct STA-MCA bypass surgery for MMD and N-MMD patients in a large contemporary cohort. METHODS: The authors conducted a retrospective review of all direct STA-MCA bypass cases performed between 2014 and 2023 at a high-volume center, which yielded 139 cases. Cases were excluded if they involved double-barrel bypass, an interposition graft, or if the surgical indication was not cerebral hypoperfusion. Direct bypass graft patency was serially assessed on follow-up vessel imaging. RESULTS: Of the 139 included cases, 88 (63.3%) were MMD and 51 (36.7%) were N-MMD cases. The mean patient age was 49.2 years and 60.4% were female. The mean follow-up duration was 18.5 months. The perioperative stroke risk within 30 days of revascularization was 6.5% for the overall cohort, with no significant difference (p = 0.725) observed between MMD (5.7%) and N-MMD (7.8%) cases. The overall postoperative ipsilateral hemispheric and MCA distribution stroke rates at last follow-up were 11.5% and 9.4%, respectively. Despite a greater medical comorbidity burden, N-MMD cases demonstrated comparable rates of direct bypass graft occlusion (21.6% N-MMD vs 28.4% MMD, p = 0.426), MCA-distribution ischemic stroke (11.8% N-MMD vs 7.9% MMD, p = 0.549), and ipsilateral ischemic stroke (15.7% N-MMD vs 9.1% MMD, p = 0.276) to patients with MMD at last follow-up. Higher preoperative total hemispheric flow on noninvasive optimal vessel analysis (NOVA) imaging was the only variable associated with prolonged direct bypass graft patency (hazard ratio [HR] 0.39, p = 0.036). Postoperative stroke-free survival was improved by performing dural synangiosis (HR 0.31, p = 0.033) and, in multivariate analysis, was reduced with direct bypass graft occlusion (HR 4.58, p = 0.009) and a preoperative diffusion-weighted imaging–Alberta Stroke Program Early CT Score (DWI-ASPECTS) < 8 (HR 3.90, p = 0.024). CONCLUSIONS: This robust cohort of MMD and N-MMD STA-MCA bypass cases highlights the safety and efficacy of a technically sound direct bypass across all subtypes of cerebrovascular steno-occlusive disease. Careful attention to preoperative MRI parameters, including hemispheric flow rates on NOVA imaging, may improve surgical risk stratification. Further examination of the benefits of adjunctive indirect bypass or dural synangiosis, especially for patients with N-MMD, remains warranted.

Background Prolactinomas represent the most common pituitary adenoma subtype, the majority of which are microprolactinomas. Dopamine agonists (DAs) remain the first-line intervention for microprolactinomas, however, many patients either cannot tolerate DAs or require lifelong therapy to maintain hormonal control. As endoscopic endonasal surgery (EES) continues to revolutionize the surgical management of sellar lesions, we sought to reassess the feasibility and efficacy of early surgical resection for microprolactinoma. Methods Retrospective chart review from 2010 to 2021 of adults who underwent EES for microprolactinoma was performed across three medical centers. Surgical failure was defined as a need to restart DAs, a serum prolactin level greater than 30ng/mL at last follow-up, tumor recurrence, or a need for reoperation. Results A total of 56 patients were identified with a mean age of 32.9 years and an average of 26.4 months of follow-up. The majority had been on DAs preoperatively (98.2%). The most common surgical indications were DA intolerance (73.2%), tumor unresponsiveness (19.6%), and desire for pregnancy (7.1%). Gross total resection was achieved in 51 (91.1%) cases. The overall surgical remission rate was approximately 70% with failures observed in 17 (30.4%) patients. Multivariate logistic regression identified subtotal resection as the only independent predictor of surgical failure (p = 0.038*). The most common postoperative complication was transient arginine vasopressin deficiency (AVP-D) (21.4%). There were no cases of permanent AVP-D, new visual deficits, or cerebrospinal fluid leak. Conclusions With a surgical remission rate of nearly 70%, EES represents a safe and viable alternative strategy to long-term DA treatment for microprolactinomas.

Purpose Subdural hematoma (SDH) is quickly becoming the most common neurosurgical pathology due to the aging population. Middle meningeal artery embolization (MMAE) has recently emerged as an effective adjunct to surgical SDH evacuation by decreasing recurrence risk. MMAE has also shown promise as a standalone SDH intervention, but clinical and radiographic predictors of successful MMAE remain ill-defined. Methods Retrospective chart review from 2020 to 2023 at a single center identified all MMAE cases performed as primary SDH treatment. Cases were classified by hematoma internal architecture as homogeneous, separated, laminar, or trabecular. SDH maximal thickness was assessed on all follow-up imaging and any recurrences or expansions requiring surgery were denoted as treatment failures. Results 164 standalone MMAE cases were reviewed. Most cases were in male patients (75.0%) with a mean age of 73.2 years. The overall MMAE treatment failure rate was 6.7% with a 4.9% periprocedural complication rate. The cases with trabecular and laminar collections were slightly larger than those with homogeneous and separated collections (16.2 mm vs. 14.2 mm, p = 0.008*), but other baseline characteristics were similar. The MMAE failure rate was significantly lower in the laminar and trabecular subgroup (1.2%) compared to the homogeneous and separated subgroup (12.4%) (p = 0.005*). Homogeneous and separated internal hematoma architecture was the only predictor of MMAE failure in multivariate analysis (OR 10.5, p = 0.027*) and was also associated with delayed SDH resorption (ANOVA: F = 4.8, p = 0.0025*). Conclusions Standalone MMAE is an effective, safe, and durable treatment for non-acute SDHs, and is especially effective for SDHs with more membranous internal architecture.

Background: The endovascular treatment of complex intracranial aneurysms, such as wide-neck aneurysms (WNAs), remains a challenge. More established endovascular techniques, which include balloon-assisted coiling, stent-assisted coiling, and flow diversion, all have their drawbacks. Intrasaccular flow disruptor devices have emerged as a useful tool for the neurointerventionalist. Methods: Here, we discuss landmark studies and provide a comprehensive, narrative review of the Woven EndoBridge (WEB; Microvention, Alisa Viejo, CA, USA), Artisse (Medtronic, Irvine, CA, USA), Contour (Stryker, Kalamazoo, MI, USA), Saccular Endovascular Aneurysm Lattice Embolization System (SEAL; Galaxy Therapeutics Inc, Milpitas, CA, USA), Medina (Medtronic, Irvine, CA, USA), and Trenza (Stryker, Kalamazoo, MI, USA) devices. Results: Intrasaccular devices have proven to be effective in treating complex aneurysms like WNAs. Conclusions: Intrasaccular flow disruptors have emerged as a new class of effective endovascular therapy, and results of ongoing clinical studies for the newer devices (e.g., SEAL and Trenza) are much anticipated.