Adel M. Malek

Objective Normal pressure hydrocephalus (NPH) is a neurological condition characterized by impaired gait, cognitive decline, and urinary incontinence. Endovascular shunting using the eShunt Implant diverts cerebrospinal fluid (CSF) from basal cisterns to the internal jugular vein via a transvenous, transfemoral procedure. We report initial eShunt safety data for treatment of NPH through 90 days in a prospective, multicenter, single-arm trial. Methods NPH participants indicated for endovascular shunt placement were included after exhibiting positive gait response to lumbar CSF withdrawal and candidate anatomy. NPH symptoms at baseline and following eShunt Implant placement were assessed using the Timed Up & Go (TUG) test for gait, Montreal Cognitive Assessment (MoCA) for cognition, and Neurogenic Bladder Symptom Score-Short Form (NBSS-SF) for urinary symptoms. The primary endpoint was the rate of device and/or procedure-related serious adverse events (SAE) at 90-day follow-up. Results Sixty-six participants were treated with the eShunt Implant without immediate or delayed cerebral hemorrhage, over-drainage, infection or device-related SAEs. Two procedure-related SAEs (3.0%) occurred, one sigmoid sinus thrombosis and one femoral artery pseudoaneurysm, both resolved without surgical intervention. Matched-pair analysis showed statistically significant improvements in TUG time (37.2%; PConclusions Endovascular shunting for NPH was feasible with a low rate of SAEs typically associated with conventional shunt surgery. An acceptable clinical response through 90 days was observed. These findings suggest further investigation of this minimally invasive, endovascular approach to NPH in a randomized controlled trial comparing to standard of care. Trial registration number ClinicalTrials.gov Identifiers: NCT05250505 and NCT05232838.

Angiography remains the standard imaging modality for evaluating vascular disease and guiding endovascular interventions; however, its limited spatial resolution restricts visualization of vessel wall pathology and therapeutic devices. Over the past decade, intravascular optical coherence tomography (OCT) has emerged as a transformative tool in coronary artery disease. OCT provides three-dimensional, high-resolution imaging of coronary arteries, enabling assessment of vessel wall microstructure, plaque composition, lumen geometry, and stent deployment. This level of detail has advanced the understanding of coronary pathology and contributed to improved outcomes in percutaneous coronary interventions. Major cardiology societies now recommend the use of intravascular imaging, including OCT, for complex coronary interventions with level 1A evidence. OCT is now expanding beyond the coronary vasculature, with growing interest in its potential role in neurointerventional surgery. While limited use of OCT has been reported in the neurovasculature, the characteristics of a coronary OCT device prevent routine use in intracranial arteries. A new generation of intravascular OCT technology has been developed for the tortuous and complex anatomy of cerebral vessels. Early clinical experience has investigated its safety, feasibility, and utility for intracranial vascular imaging. Neuro-dedicated OCT technology could represent a significant advancement in cerebrovascular imaging, offering insights beyond the capabilities of current modalities, with the potential to improve current understanding of neurovascular pathology and refine diagnostic and therapeutic strategies. Successful translation of OCT into neurointervention, however, also requires establishing principles for image interpretation to assess neurovascular disease and therapeutic devices. This article aims to provide guidance for interpreting OCT imaging of intracranial arteries. In addition, it reviews applications of OCT in neurointervention and describes the development of neuro-specific OCT technology.

BACKGROUND: The centroid radii model (CRM)—defined as the distance from aneurysm surface points to the centroid—has shown promise in distinguishing ruptured from unruptured intracranial aneurysms by capturing morphological characteristics. We propose a novel application of radiomics for analyzing CRM texture and patterns, extending radiomics beyond medical imaging‐based analysis. METHODS: Three‐dimensional rotational angiographic volumes from 187 aneurysms (49 ruptured) were analyzed. Aneurysm surfaces were segmented and converted to uniform triangular meshes. Established size and shape metrics (size, height, aspect ratio, height/width, size ratio, and nonsphericity) and CRM values were computed. CRM data were projected onto a unit sphere and mapped to grayscale images for radiomics analysis. Univariate and multivariate analyses were used to evaluate the established features and 93 radiomics features for the accuracy of rupture status discrimination. RESULTS: Ruptured aneurysms exhibited greater CRM texture complexity and heterogeneity, with higher entropy, variance, contrast, and gray‐level nonuniformity. These aneurysms had localized high CRM intensities and widespread low CRM regions, as well as reduced pattern uniformity. All established morphological features were significantly elevated in ruptured aneurysms. Multivariate regression using radiomics features resulted in an area under the curve of 0.86 (specificity 0.81, sensitivity 0.78), compared with conventional features (area under the curve 0.82, specificity 0.75, sensitivity 0.81). CONCLUSION: Radiomics‐based histogram and texture analysis of surface CRM offers strong rupture status discrimination power, which compares favorably with established size and shape features. This novel use of radiomics on surface‐based features provides additional insight into the characteristics of ruptured aneurysms and may have potential utility in risk stratification.

Background The Pipeline Vantage 027 flow diverter became available a year ago in the United States. We report an observational study of its safety and early angiographic response in the treatment of internal carotid artery (ICA) aneurysms. Methods All patients treated with the Vantage 027 for ICA aneurysms from April to November 2024 at a single center were included. Intraprocedural contrast-enhanced cone-beam CT was used to evaluate vessel wall apposition. A novel proximal ledge deformity is defined as delayed elevation of one stent edge into the lumen while the opposite edge remains wall-apposed. Results Twenty-four aneurysms (mean size 4.2±2.7 mm) in 20 patients underwent Vantage 027 embolization. Clinical follow-up at 6 months revealed no major/minor stroke and a single reversible ischemic attack following dual anti-platelet therapy (DAPT) non-compliance. Follow-up angiography in all patients revealed complete occlusion in 19/24 aneurysms at a median of 3.5 months (79%). Severe ≥50% stenosis was noted in 7/20 (35%) with distal fishmouth deformity in 12/20 (60%); both fishmouthing (p=0.003) and severe stenosis (p=0.04) were associated with younger age. We also observed a proximal ledge in 5/20 (25%) with luminal caliber compromise. Conclusions Although Vantage 027 ICA aneurysm embolization resulted in early robust aneurysm involution, it was associated with an age-dependent fishmouthing braid deformity and a proximal ledge deformity possibly requiring extended DAPT. These results encourage further analysis of the vascular response to Vantage 027 and similar stents.

Background: Larger “macrowires” may facilitate microcatheter-free delivery of large-bore aspiration catheters (ACs) for intracranial endovascular mechanical thrombectomy. We examined the safety and efficacy of the Aristotle Colossus Guidewire for this use. Methods: In this retrospective analysis of prospective data from 12 institutions, we identified anterior circulation endovascular mechanical thrombectomy cases involving the Aristotle Colossus guidewire over a 12-month period. The primary efficacy endpoint was successful delivery of the AC to the site without the use of adjunct devices. Multivariable logistic regression was performed with clinically relevant covariables. Results: In 122 patients (median age 74 years (interquartile range (IQR) 63–82)), most intracranial occlusions were in the M1 segment of the middle cerebral artery (95/122, 78.0%). The primary endpoint of microcatheter-free AC delivery was met in 87.7% (107/122) of patients; 93/122 (76.2%) patients underwent microcatheter-free delivery with successful reperfusion via contact aspiration (modified thrombolysis in cerebral infarction grade ≥ 2B). The median number of passes was 1 (IQR 1–2). Multivariable regression demonstrated that severe internal carotid artery tortuosity or cervical loop presence (odds ratio (OR): 0.09, 95% confidence interval (CI): 0.01–0.54, p = 0.01) and presence of intracranial atherosclerotic disease (OR: 0.15, 95% CI: 0.03–0.83, p = 0.03) were significantly associated with lower odds of successful AC delivery over the guidewire. Intraprocedural vasospasm occurred in 4.9% (6/122) of cases; there were no reports of vessel dissection or perforation. Conclusions: We demonstrate the favorable performance of the Aristotle Colossus guidewire for anterior circulation ischemic stroke intervention. The macrowire appears to safely facilitate navigation of the neurovasculature by large-bore ACs without the need for microcatheter and/or stentriever.

Background Hydrocephalus is commonly treated using invasive surgical shunt placement with associated morbidity and frequent revision in children. The eShunt System, an endovascular miniature transdural shunt implanted via the inferior petrosal sinus (IPS), has shown promise in adults, but its pediatric application remains undefined because of limited data on IPS and cerebellopontine angle cistern (CPAC) morphometry. Materials and methods Consecutive patients from two pediatric hospitals with high-resolution brain MRI were retrospectively analyzed. IPS and CPAC measurements were evaluated against adult anatomical criteria for safe implantation (IPS size ≥2 mm, IPS angle Results One hundred patients were included: 20 toddlers (1–2 years), 24 preschool age (3–5), 27 school age (6–11), and 29 adolescents (12–18). Median IPS size was 2.8 mm (2.4–3.3 mm) and 2.8 (2.5–3.4 mm) while median CPAC depth was 7.6 mm (5.6–9.0 mm) and 6.8 mm (5.5–8.5 mm) for the right and left side, respectively. While younger age was associated with smaller IPS diameter (PConclusion A majority of patients over 1 year of age met IPS and CPA anatomical criteria for placement of the eShunt System.