Derrek Schartz

Cerebrospinal fluid-venous fistulas (CVF) cause spontaneous intracranial hypotension (SIH) and can be treated with transvenous embolization (TVE). Although TVE has been shown to result in substantial symptomatic improvement, some patients may require retreatment. The purpose of this study was to clarify the rate, anatomical location, and timing of CVF recurrence/retreatment after TVE. Single center, retrospective cohort of consecutive patients with CVF who were treated with TVE. The rate of retreatment after TVE was determined. In addition, timing of symptom onset and location of recurrent CVF was recorded. One hundred consecutive patients (65% female, mean age 59.3 years) with 105 CVFs treated with TVE were included. Overall, 23% (23/100) of patients required retreatment due to persistence or recurrence of symptoms. Most retreatment patients (74%, 17/23) had persistent or recurrent symptoms within 3 months after TVE. Approximately one third of patients needing retreatment (35%, 8/23) had a CVF at the same site and level as the initial CVF after having been embolized. Approximately one third (30%, 7/23) had a recurrent CVF adjacent to the initial CVF (defined as one level above, one level below, or at the same level but on the contralateral side). The remaining patients (35%, 8/23) had a CVF remote from the original fistula site. Approximately 23% of patients with CVF that are treated with TVE will require retreatment. Symptom recurrence is most common within 3 months after initial treatment. Recurrence can occur due to local treatment failure or development of collateral drainage pathways, but a substantial proportion of patients develop de novo CVFs remote from the initial treatment site. These findings can be used to counsel patients and to manage treatment expectations.

Background: Acute ischemic stroke due to large-vessel or medium-vessel occlusion is often treated with aspiration thrombectomy. Delivery-assist catheters (DAsCs) are a new class of tapered support catheters designed to facilitate navigation of large-bore aspiration catheters through tortuous anatomy. Objective: To perform a meta-analysis to evaluate the procedural efficacy and safety of DAsC-assisted aspiration thrombectomy. Methods: A PRISMA-guided systematic review identified studies using DAsCs during aspiration thrombectomy for large- or medium-vessel occlusions. We extracted data on successful reperfusion; first pass effect (FPE), defined as modified Thrombolysis in Cerebral Infarction (mTICI) ≥2b (FPE≥2b) and mTICI≥2c (FPE≥2); use of adjunctive devices; and symptomatic intracranial hemorrhage (sICH). Pooled event rates with 95% CIs were calculated using a random-effects meta-analysis of proportions. Results: 14 studies were identified with 720 patients. Pooled successful reperfusion was 95% (95% CI 91 to 97%) for final mTICI ≥2b and 71% (95% CI 59% to 81%) for final mTICI ≥2c. FPE ≥2c was achieved in 51% (95% CI 43% to 59%) of cases, while FPE ≥2b was 65% (95% CI 54% to 75%). Adjunctive rescue devices were used in 23% (95% CI 17% to 30%) of procedures. Puncture-to-recanalization time was 26.1 min on average. The rate of sICH was 1% (95% CI 0% to 3%), and 44% (95% CI 39% to 50%) of patients had a 90-day modified Rankin Scale score of 0–2. Conclusions: In pooled analysis, DAsC-assisted aspiration thrombectomy demonstrated high first pass efficacy and low hemorrhagic rates across single-arm studies. This meta-analysis supports DAsCs as a safe adjunct to aspiration thrombectomy. Prospective comparative studies are warranted to evaluate technical performance and safety relative to standard aspiration techniques.

BACKGROUND AND PURPOSE: Post dural puncture headache (PDPH) refractory to conservative measures can be clinically debilitating, and diagnostic evaluation with spinal imaging including CT myelography (CTM) may be performed to localize a CSF leak and guide treatment. The purpose of this study is to determine the diagnostic yield of CTM for detecting a CSF leak in patients with persistent PDPH. MATERIALS AND METHODS: This is a single center, retrospective cohort study of patients referred for CTM between September 2013 to August 2025 to localize and/or identify a CSF leak in patients with PDPH. Brain MRIs were categorized as either positive or negative for findings of intracranial hypotension. CTMs were categorized as either positive or negative for the presence of a CSF leak or arachnoid bleb. The overall rate of CTM positivity in PDPH patients was calculated. Logistic regression analysis was used to investigate variables that were associated with positive CTM. RESULTS: A total of 118 PDPH patients were included in the analysis (81% female, mean age of 40 +/-12 years). Brain MRIs were negative for findings of intracranial hypotension in 92% of cases. Overall, CTM was positive in only 7 cases (5.9%, 7/118). Four were extradural fluid collections consistent with a CSF leak, and 3 were arachnoid blebs at the site of prior dural puncture. In three positive cases where both spine MRI and CTM available, the abnormality was also seen on MRI in two cases. On logistic regression, only a positive brain MRI was independently associated with a significantly higher odds of a positive CTM (OR 12.6 [CI: 1.8 to 90]; P=0.012). CONCLUSIONS: CTM has a low diagnostic yield in patients with PDPH, uncommonly identifying specific leak related findings. Because CTM necessarily involves repeat dural puncture, and given this low yield, it should be used sparingly in patients with refractory PDPH, especially when signs of intracranial hypotension are absent on brain MRI. As some findings on CTM are also seen on spinal MRI, which is noninvasive, further research is needed to compare the yield of MRI and CTM to determine whether and when CTM provides additional diagnostic information in this population. ABBREVIATIONS: CTM＝ CT Myelogram; PDPH＝ Post Dural Puncture Headache; CSF = Cerebrospinal Fluid.

Background: Flow diversion (FD) is increasingly used to treat ruptured intracranial aneurysms (rIA); however, antiplatelet (AP) management remains controversial. Intravenous (IV) GPIIb/IIIa inhibitors provide rapid, reversible platelet inhibition and may reduce hemorrhagic risk. We performed a meta-analysis and reported our institutional series to compare IV GPIIb/IIIa and classic AP protocols in FD for rIA. Methods: A systematic search identified studies reporting ischemic and hemorrhagic complications after FD for rIA stratified by AP regimen. Meta-analyses estimated pooled event rates and meta-regression compared outcomes between GPIIb/IIIa and classic AP strategies. We retrospectively reviewed rIA patients treated with FD at our institution. Results: Twenty-six studies were included (387 patients): 167 (43.1%) received GPIIb/IIIa-only protocols and 220 (56.9%) received classic AP (predominantly aspirin and clopidogrel). The hemorrhagic complication rate was 9% (confidence interval (CI): 6%–13%), 5% (CI: 2%–10%) in the GPIIb/IIIa patients, and 12% (CI: 8%–17%) in the classic AP group; meta-regression demonstrated a lower hemorrhagic rate with GPIIb/IIIa ( p = 0.047). The ischemic complication rate was 13% (CI: 9–19%), 11% (CI: 6–18%) in the GPIIb/IIIa group, and 15% (CI: 9%–24%) in the classic AP group ( p = 0.38). Our cohort included seven patients (mean age: 59.1). Six received intra-procedural tirofiban, and one received ticagrelor/aspirin. Hemorrhagic and ischemic complications each occurred in 1/7 (14.3%) patients, two (28.6%) died and four (57.1%) achieved modified Rankin Scale ≤ 2 at 90 days. Conclusions: IV GPIIb/IIIa inhibitors administered at FD deployment for rIA are associated with fewer hemorrhagic complications without increased ischemic events and represent a feasible acute management strategy.

BACKGROUND AND PURPOSE: Cerebrospinal fluid-venous fistulas (CVF) are a common cause of spontaneous intracranial hypotension (SIH) and can be treated with transvenous embolization (TVE). Rebound intracranial hypertension (RIH) is an important periprocedural consideration after TVE and CSF leak closure. The purpose of this study was to determine the incidence and severity of post-procedure RIH among patients with CVFs treated with TVE. MATERIALS AND METHODS: This investigation was a single center, retrospective cohort of consecutive patients treated with TVE for SIH due to a CVF. Patients were included who had early (1-3 days post-TVE procedure) clinical follow-up documenting presence/severity of RIH. RIH was classified as absent, mild (i.e. rated 1-4/10 in severity), moderate (i.e. rated 5-7/10), or severe (i.e. rated 8-10/10). Rate of RIH was then determined. Logistic regression analysis was used to evaluate for clinical predictors of moderate-to-severe RIH and need for eventual therapeutic lumbar puncture (LP). RESULTS: In total, 100 consecutive patients (mean age, 59.4 years old, 63% female) who underwent 105 TVE procedures for 132 CVFs were included. RIH of any severity (mild to severe) occurred in 80% of cases after TVE and was moderate-to-severe in 54% of cases. A therapeutic LP was needed for RIH in 8 cases (7.6%). On multivariate regression, TVE of a single CVF (versus >1 CVF) was independently associated with occurrence of moderate-to-severe RIH (OR: 2.8 [CI: 1.04 to 7.85], p=0.04). Furthermore, higher pre-TVE opening pressure (third tertile, 17-28 cmH2O) was associated with eventual need for therapeutic LP (OR: 5.0 [CI: 1.14 to 25.9], p=0.03). CONCLUSIONS: Early RIH is common after TVE, with symptoms occurring in 80% of all cases. Approximately half of patients will experience moderate-to-severe RIH early after TVE. These findings underscore the value of routine early follow-up after TVE and emphasize the need for proceduralists to be familiar with management strategies for RIH. ABBREVIATIONS: TVE＝ Transvenous embolization; RIH = Rebound intracranial hypertension; CVF = cerebrospinal fluid-venous fistula

Background Middle meningeal artery (MMA) embolization is increasingly utilized in the treatment of chronic subdural hematoma (cSDH); however, supply cost variation between embolization agents remains unclear. We hypothesized that nBCA might be associated with lower costs, given the ability to use a single vial and treat multiple pedicles. Objective To compare the supply costs of MMA embolizations using ethylene vinyl-alcohol copolymer-based Onyx (Onyx), n-butyl cyanoacrylate-based TRUFILL (nBCA), and/or coils. Methods This retrospective study analyzed 100 consecutive MMA embolizations performed at a single institution before March 2025. The supplies (including catheters and embolic agents) used in each embolization, along with procedure time, laterality, and number of pedicles embolized, were documented. Radiographic and clinical patient outcomes were evaluated. Results Of the 100 procedures: 63 used nBCA, 26 Onyx, 2 coils, 2 nBCA and coils, and 7 Onyx and coils. Supply costs ranged from approximately $5000 to $18 000. Onyx was significantly less expensive than nBCA in supply cost per patient ($7910 vs $10 241; P0.05), functional outcomes (modified Rankin Scale; P=0.813), or complete cSDH resolution (P=0.149) between embolic techniques. Conclusions There is significant variation in supply cost associated with different MMA embolization techniques. In our institutional experience, Onyx was associated with the lowest supply cost per patient, hemisphere, and pedicle. Complication rates and functional status did not significantly differ across techniques.

Background: Delivery assist catheters are a new class of devices designed to better navigate tortuous segments and reach the clot interface in mechanical thrombectomy. The RED 72 aspiration catheter with SENDit technology is one such example. SENDit is a novel tapered obturator used instead of a microcatheter to bring up the RED 72. It was designed to speed materials setup and overcome “ledge” effect. This case series aims to assess the safety, efficacy, and associated materials costs of SENDit in a postmarket study. Methods: This was a single-institution retrospective case series of endovascular thrombectomy for anterior circulation large vessel occlusions affecting the internal carotid artery, M1, or M2 treated with SENDit between August 2023 and May 2024. Demographic, clinical, and cost variables were collected. Results: Median time from groin puncture to first pass was 14.0 min, and median time from groin puncture to recanalization was 25.0 min. Modified first-pass effect (mTICI ≥2b) was achieved in 51.4% of cases. The final recanalization mTICI ≥2b rate was 91.9%. A stentriever was required for 10.8% of cases. The rate of functional independence (mRS 0–2) at 3 months follow-up was 43.8%. The average materials cost per case was $7517.40 ± $2795.25; 10.8% of patients experienced access site complications. There was no artery dissection, and the rate of symptomatic intracerebral hemorrhage was 5.4%. Conclusion: In this case series, SENDit achieved a high rate of first pass effect, rapid recanalization, and low stentriever use and materials cost. It is safe given the low rate of procedural complications and favorable clinical outcomes. Delivery assist catheters are a promising alternative to stentrievers.

Objective: Post-dural puncture headache (PDPH) is potential complication after procedures with dural puncture. This study analyzes how patient and procedural factors are related to the development of PDPH. Methods: Demographic and procedural data were extracted from the electronic medical record in patients undergoing a dural puncture procedure from 1/1/2020 to 12/31/2020. Procedural variables were extracted from procedure reports including spinal level, number of punctures, any reported complications, needle type, and gauge. Fisher-exact test, with a subgroup analysis, and multivariable logistic regression were used to analyze the association of variables with the development of a PDPH. Results: A total of 1237 procedures with 1005 patients were identified. The mean age was 56.9 ± 16.4 years, mean BMI was 31.0 ± 7.8 kg/m ² , and 534 (53.1%) identified as female. Seventy-four (7.3%) patients developed a PDPH with mean onset of 1.9 ± 1.9 days post-procedure. The likelihood of PDPH was significantly positively associated with both patient characteristics such as female sex (OR = 2.657, 95%CI [1.529,4.617], p < .001), BMI above 25 kg/m ² (OR = 2.609, 95%CI [1.177,5.786], p = .015), and history of chronic tension headaches (OR = 2.943, 95%CI [1.688,5.130], p < .0003), as well as procedural characteristics such as decreasing gauge (OR = 1.124, 95%CI [1.111,1.136], p < .0001), higher opening pressure (mean difference = −6.288 ± 2.119. p = .005). Conclusions: This retrospective study of fluoroscopy-guided dural puncture procedures shows that the incidence of PDPH is associated with several patient and procedural characteristics.