Basilar artery fenestration aneurysms are rare and complex lesions. Endovascular treatment appears to be safe and efficient. The detailed understanding of the aneurysm morphology and its relation to the fenestration is strongly recommended to treatment planning. Further studies are necessary to validate the utility of the proposed classification and treatment strategy.

In this study, in comparison with the use of coils alone, the association of transvenous embolization with liquid embolic agents for DCCF treatment resulted in higher rates of complete occlusion without increasing complication rates. The clinical outcome at the 6-month follow-up showed significant improvement in ocular symptoms over cranial nerve palsy regression, which was independent of the embolic agent chosen for treatment.

OBJECTIVE Ruptured intracranial aneurysms (RIAs) can be managed surgically or endovascularly. In this study, the authors aimed to measure the interobserver agreement in selecting the best management option for various patients with an RIA. METHODS The authors constructed an electronic portfolio of 42 cases of RIA in which an angiographic image along with a brief clinical vignette for each patient were displayed. Undisclosed to the responders was that the RIAs had been categorized as International Subarachnoid Aneurysm Trial (ISAT) (small, anterior-circulation, non-middle cerebral artery location, n = 18) and non-ISAT (n = 22) aneurysms; the non-ISAT group also included 2 basilar apex aneurysms for which a high number of endovascular choices was expected. The portfolio was sent to 132 clinicians who manage patients with RIAs and circulated to members of an American surgical association. Judges were asked to choose between surgical and endovascular management, to indicate their level of confidence in the choice of treatment on a quantitative 0-10 scale, and to determine whether they would include the patient in a randomized trial in which both treatments are compared. Eleven clinicians were asked to respond twice at least 1 month apart. Responses were analyzed using kappa statistics. RESULTS Eighty-five clinicians (58 cerebrovascular surgeons, 21 interventional neuroradiologists, and 6 interventional neurologists) answered the questionnaire. Overall, endovascular management was chosen more frequently (n = 2136 [59.8%] of 3570 answers). The proportions of decisions to clip were significantly higher for non-ISAT (50.8%) than for ISAT (26.2%) aneurysms (p = 0.0003). Interjudge agreement was only fair (kappa 0.210, 95% CI 0.158-0.276) for all cases and judges, despite high confidence levels (mean score> 8 for all cases). Agreement was no better within subgroups of clinicians with the same specialty, years of experience, or location of practice or across capability groups (ability to clip or coil, or both). When agreement was defined as > 80% of responders choosing the same option, agreement occurred for only 7 of 40 cases, all of which were ISAT aneurysms, for which coiling was preferred. CONCLUSIONS Agreement between clinicians regarding the best management option was infrequent but centered around coiling for some ISAT aneurysms. Surgical clipping was chosen more frequently for non-ISAT aneurysms than for ISAT aneurysms. Patients with such an aneurysm might be candidates for inclusion in randomized trials.

Conclusions: The number of entry tears detected on the first computed tomography angiography (CTA) study following acute type B aortic dissection is a significant predictor of subsequent aortic growth. Summary: Patients with uncomplicated acute type B aortic dissection treated conservatively by antihypertensive treatment have in-hospital mortality rates between 1% and 10%. Favorable initial outcomes, however, are mitigated by medium-term and long-term problems related to the aorta, such as aneurysm growth and rupture. These delayed problems result in survival rates of 56% to 92% at 1 year and 48% to 82% at 5 years (Tsai TT et al, N Engl J Med 2007;357:349-59). It is thought that impaired outflow of the false lumen or increased inflow to the false lumen can lead to an increase in mean and diastolic pressure in the false lumen. Acutely, this may lead to true lumen collapse and malperfusion and, on a more long-term basis, elevated pressure in the false lumen with increased aortic growth and risk for aortic rupture. The authors sought to determine whether the number of entry tears detected between the true and false lumen might help predict which patients with acute type B aortic dissection are at increased risk for late aortic dilation. The authors evaluated acute type B aortic dissection patients with uncomplicated dissection. Patients with a CTA obtained at clinical presentation and another CTA at least 90 days after medical treatment were included from the years 2005 to 2010. Aortic diameters were measured at five levels on the base line CTA and on last available CTA with annual aortic growth rates calculated. The number of entry tears between the true and false lumen were also determined. Number of entry tears and the location of entry tears in the aorta were then compared with aortic growth rates. There were 60 patients with 243 dissected segments. Mean growth rates during follow-up (median, 23.2 months, range, 3-132 months) were higher in patients with one entry tear (5.6 6 8.9 mm) than those with two (2.1 6 1.7 mm; P ¼ .001) and three entry tears (mean, 2.2 6 4.1; P ¼ .010). Distance of the primary entry tear from the left subclavian artery did not have an effect on aortic growth rate (median, 38 mm; interquartile range, 24-137 mm; P ¼ .434). Comment: The data are somewhat limited by the fact that in the clinical setting, imaging of acute aortic dissections may vary with respect to the cardiac cycle, configuration of the aortic lumen, and changes of the flap during systole and diastole. Dynamic CT scanning rather than static scanning used in this study may have also identified additional entry tears. The aortic dissection process is complex and in some respects the data may argue for more routine use of dynamic CT imaging in patients with acute type B aortic dissection. It is only through improved understanding of the dissection process that better selection of patients with acute type B aortic dissection for immediate intervention will be determined.

BACKGROUND The safety and efficacy of the first generation of the Pipeline Embolization Device (PED; Medtronic Inc) have been proven in large case series. Ischemic events are one of the most common complications following treatment of aneurysms with flow diverters. The new PED Flex with Shield technology (PED Shield; Medtronic Inc) was introduced to minimize the rate of complications. OBJECTIVE To evaluate the outcomes of patients harboring aneurysms treated with the PED Shield. METHODS This was an observational, prospective, single-arm multicenter study of patients treated with the PED Shield. The primary safety endpoint was the absence of major neurological complications and death. The secondary effectiveness endpoint was angiographic occlusion at 6 and 12 mo. Technical complications were also reported. RESULTS Between November 2017 and December 2018, 151 patients from 7 centers with 182 aneurysms were enrolled. The mean aneurysm size was 7.0 mm; 27 (14.8%) aneurysms were large, and 7 (3.8%) were giant. In 141 of 151 patients (93.4%), the primary endpoint was reached. The overall rate of periprocedural complications was 7.3%. Of the aneurysms, 79.7% met the study's secondary endpoint of complete occlusion at 6 mo and 85.3% at 12 mo. CONCLUSION The PED Shield is a safe and effective treatment for intracranial aneurysms. The results regarding total occlusion and ischemic complications did not differ from those obtained in case series using previous versions of the PED. Long-term follow-up and comparative studies are required to provide stronger conclusions regarding the reduced thrombogenicity of this device.