Sami Almasri

Purpose: The venous phase of DSA offers inferior spatial resolution of cerebral venous anatomy due to contrast dilution. Likewise, retrograde cerebral venography (RCV) suffers from poor contrast retention due to contrast injection opposing the physiological direction of venous drainage. Therefore, this study aims to investigate the feasibility of balloon-assisted occlusion in improving visualization of cerebral venous anatomy during RCV. Methods: 17 consecutive patients who underwent balloon-assisted RCV between September 2023-June 2025 were included. A 9 F balloon guide catheter was positioned in the internal jugular vein or sigmoid sinus. Venography was performed before and after balloon inflation. Using standardized criteria, three neuroradiologists independently assessed visualization quality of venous structures, anatomical furthest extent of contrast enhancement, and pathology delineation. McNemar’s test was used for paired statistical comparisons between visualization with and without balloon occlusion. Results: Balloon inflation improved rates of “well visualized” pathology from 15.7% to 88.2% ( p < 0.001, OR = 29.04). The most distant structure visualized shifted from the ipsilateral sigmoid sinus without balloon occlusion (visible in 45.1% of cases) to the contralateral sigmoid sinus with balloon occlusion (visible in 72.5% of cases, p < 0.001). With balloon occlusion, homogenous opacification and clear margin delineation of both transverse and sigmoid sinuses showed significant improvements ( p < 0.001 for both). No procedure-related complications were observed in this limited cohort. Conclusion: In this feasibility experience, balloon-assisted occlusion during RCV improved visualization of the posterior and lateral dural venous sinuses and associated pathology. Future well-powered studies are needed to validate our findings and determine the definitive safety of this technique.

Background: The Surpass Elite (Stryker Neurovascular) is a third-generation flow diverter featuring modified braid architecture with increased braid angle and novel surface charge neutralization treatment. This study presents the first clinical experience with the Surpass Elite globally. Methods: A retrospective analysis of 81 consecutive cases (78 unique patients) treated with the Surpass Elite across four centers by two operators from January to July 2025 was performed. Data collected included patient demographics, aneurysm characteristics, procedural details, technical success, complications, and angiographic/clinical outcomes. Primary endpoints were technical success rate, perioperative safety profile, and aneurysm occlusion rates at approximately 6-month follow-up. Results: The cohort comprised 78 unique patients (76.9% female, mean age 59.2 ± 14.5 years) with 81 aneurysms treated using 112 total devices (mean 1.38 devices per case). Aneurysms were predominantly located in the internal carotid artery (75.3%). Technical success was achieved in 100% of cases regardless of access site. Balloon angioplasty was required in only 13.6% of cases. Among 61 aneurysms with complete angiographic follow-up at a mean of 6 months, complete occlusion (RROC Class I or OKM Grade D) was achieved in 78.7%. In-stent stenosis (< 50%) was observed in only 3.3% of cases with follow-up imaging, suggesting favorable vessel remodeling with minimal intimal hyperplasia. The immediate intraprocedural complication rate was 2.5% (2/81), including one device-related microperforation (complete recovery) and one intraoperative thrombosis (managed successfully intraprocedurally; delayed stroke from subsequent medication noncompliance). Delayed complications within 30 days included one stroke from antiplatelet noncompliance (fatal) and one access-site hematoma (recovered). One delayed adverse event beyond 30 days (delayed right temporal intraparenchymal hemorrhage at 10 months) was observed in a patient on dual antiplatelet therapy plus apixaban and was attributed to cerebral amyloid angiopathy; this event was not considered device- or procedure-related. Overall mortality was 7.4% (6/81): one death (1.2%) was procedure-related (stroke from medication noncompliance), one death occurred within 30 days from post-SAH vasospasm in a ruptured aneurysm case, and four deaths occurred after 30 days (recurrent ICH at 3 weeks, acute respiratory failure with acute on chronic heart failure at 5 months, homicide at approximately 6 months, and one of unknown cause), none of which were device- or procedure-related. Conclusion: This first published clinical experience with Surpass Elite flow diverter demonstrates reliable technical deliverability, favorable early occlusion rates comparable to established flow diverters, and a satisfactory safety profile. The low rates of required balloon angioplasty support the clinical benefit of the modified braid architecture. These preliminary findings support the continued clinical evaluation of the Surpass Elite in larger prospective cohorts.

Purpose: Steerable guidewires with deflectable tips enable real-time navigation through complex cerebrovascular anatomy without requiring wire removal and tip reshaping. Despite promising early reports, systematic clinical evaluation remains limited. Methods: We conducted a retrospective analysis of 58 consecutive neurointerventional procedures utilizing steerable guidewires at two centers from September 2024 to August 2025. The cohort comprised 48 cases using the Drivewire 24 (DW24, 0.024-inch diameter) and 10 cases using the Artiria SmartGUIDE (0.014-inch diameter). Primary outcomes included technical success, safety profile, and operator assessment. We also performed a scoping literature review of all published steerable guidewire studies in neurointerventional applications. Results: Technical success in reaching target vessels was achieved in 100% of cases for both systems with no intraoperative or postoperative complications. Mean fluoroscopy time was 32.7 ± 29.5 min for DW24 and 26.1 ± 16.2 min for Artiria procedures. Treatment indications included aneurysm procedures (53.4%), diagnostic angiographies (20.7%), venous sinus stenting (13.8%), middle meningeal artery embolizations (8.6%), and stroke interventions (3.4%). 8.3% of procedures using DW24 were considered higher-risk by the primary operator without steerable capability, including successful navigation of complex posterior circulation anatomy in giant basilar aneurysms and recurrent superior cerebellar artery aneurysms with prior stent constructs. Our limited experience with the Artiria system ( n = 10) revealed operator-noted challenges with shape retention. The scoping review identified only three prior studies encompassing 65 procedures, establishing this as the largest reported experience. Conclusion: Both steerable guidewire systems achieved perfect technical success with excellent safety profiles. Based on our preliminary experience, the DW24 appeared to offer advantages for procedures requiring navigating larger catheters through tortuous anatomy. These findings support selective clinical use of steerable guidewire technology in challenging neurointerventional procedures.