Torcular dural sinus malformations (tDSMs) with high-flow fistulas pose complex management challenges due to their vascularity and the delicate neuroanatomy involved. This report presents the case of a child with tDSM and hydrocephalus, who underwent 3 staged embolization procedures but required a redo intervention due to residual malformation and venous hypertension. Utilizing the pressure cooker technique (PCT) in a redo setting allowed for high-pressure, targeted embolic delivery with minimized reflux, achieving near-complete occlusion and significant symptom relief. This case highlights PCT’s potential to improve outcomes in multi-stage treatments of high-flow tDSM, reducing reflux and enhancing safety in technically demanding cases.

Torcular dural sinus malformations (tDSMs) with high-flow fistulas pose complex management challenges due to their vascularity and the delicate neuroanatomy involved. This report presents the case of a child with tDSM and hydrocephalus, who underwent 3 staged embolization procedures but required a redo intervention due to residual malformation and venous hypertension. Utilizing the pressure cooker technique (PCT) in a redo setting allowed for high-pressure, targeted embolic delivery with minimized reflux, achieving near-complete occlusion and significant symptom relief. This case highlights PCT’s potential to improve outcomes in multi-stage treatments of high-flow tDSM, reducing reflux and enhancing safety in technically demanding cases.

Torcular dural sinus malformations (tDSMs) with high-flow fistulas pose complex management challenges due to their vascularity and the delicate neuroanatomy involved. This report presents the case of a child with tDSM and hydrocephalus, who underwent 3 staged embolization procedures but required a redo intervention due to residual malformation and venous hypertension. Utilizing the pressure cooker technique (PCT) in a redo setting allowed for high-pressure, targeted embolic delivery with minimized reflux, achieving near-complete occlusion and significant symptom relief. This case highlights PCT’s potential to improve outcomes in multi-stage treatments of high-flow tDSM, reducing reflux and enhancing safety in technically demanding cases.

Torcular dural sinus malformations (tDSMs) with high-flow fistulas pose complex management challenges due to their vascularity and the delicate neuroanatomy involved. This report presents the case of a child with tDSM and hydrocephalus, who underwent 3 staged embolization procedures but required a redo intervention due to residual malformation and venous hypertension. Utilizing the pressure cooker technique (PCT) in a redo setting allowed for high-pressure, targeted embolic delivery with minimized reflux, achieving near-complete occlusion and significant symptom relief. This case highlights PCT’s potential to improve outcomes in multi-stage treatments of high-flow tDSM, reducing reflux and enhancing safety in technically demanding cases.

Torcular dural sinus malformations (tDSMs) with high-flow fistulas pose complex management challenges due to their vascularity and the delicate neuroanatomy involved. This report presents the case of a child with tDSM and hydrocephalus, who underwent 3 staged embolization procedures but required a redo intervention due to residual malformation and venous hypertension. Utilizing the pressure cooker technique (PCT) in a redo setting allowed for high-pressure, targeted embolic delivery with minimized reflux, achieving near-complete occlusion and significant symptom relief. This case highlights PCT’s potential to improve outcomes in multi-stage treatments of high-flow tDSM, reducing reflux and enhancing safety in technically demanding cases.

Background: and Purpose The Save ChildS Study demonstrated that endovascular thrombectomy (EVT) is a safe treatment option for pediatric stroke patients with large vessel occlusions (LVOs) with high recanalization rates. Our aim was to determine the long-term cost, health consequences and cost-effectiveness of EVT in this patient population. Methods: In this retrospective study, a decision-analytic Markov model estimated lifetime costs and quality-adjusted life years (QALYs). Early outcome parameters were based on the entire Save ChildS Study to model the EVT group. As no randomized data exist, the Save ChildS patient subgroup with unsuccessful recanalization was used to model the standard of care group. For modeling of lifetime estimates, pediatric and adult input parameters were obtained from the current literature. The analysis was conducted in a United States setting applying healthcare and societal perspectives. Probabilistic sensitivity analyses were performed. The willingness-to-pay threshold was set to $100,000 per QALY. Results: The model results yielded EVT as the dominant (cost-effective as well as cost-saving) strategy for pediatric stroke patients. The incremental effectiveness for the average age of 11.3 years at first stroke in the Save ChildS Study was determined as an additional 4.02 lifetime QALYs, with lifetime cost-savings that amounted to $169,982 from a healthcare perspective and $254,110 when applying a societal perspective. Acceptability rates for EVT were 96.60% and 96.66% for the healthcare and societal perspectives. Conclusions EVT for pediatric stroke patients with LVOs resulted in added QALY and reduced lifetime costs. Based on the available data in the Save ChildS Study, EVT is very likely to be a cost-effective treatment strategy for childhood stroke.

Background: and Purpose In the ESCAPE-NA1 (Efficacy and Safety of Nerinetide for the Treatment of Acute Ischaemic Stroke) trial, treatment with nerinetide was associated with improved outcomes in patients who did not receive intravenous alteplase. We compared the effect of nerinetide on clinical outcomes in patients without concurrent intravenous alteplase treatment within different patient subgroups. Methods: ESCAPE-NA1 was a multicenter randomized trial in which acute stroke patients with baseline Alberta Stroke Program Early CT Score (ASPECTS) >4 undergoing endovascular treatment (EVT) were randomized to intravenous nerinetide or placebo. The primary outcome was independence (modified Rankin Scale [mRS] score 0–2) at 90 days. We assessed baseline, clinical, and imaging variables as predictors of outcome and for evidence of treatment effect modification. We constructed two multivariable models using variables known prior to randomization and variables known immediately post-EVT procedure to provide adjusted estimates of effect. We assessed for evidence of treatment effect modification using multiplicative interaction terms within each model. Results: Four hundred forty-six patients were included in the analysis. Clinical outcomes were better in patients randomized to the nerinetide arm (mRS 0–2: 59.4% vs. 49.8%). There was possible treatment effect modification by ASPECTS score; patients with ASPECTS 8–10 showed a larger treatment effect compared to those with lower ASPECTS score. Younger age, lower NIHSS score, lower baseline serum glucose, absence of atrial fibrillation at baseline, higher ASPECTS score, middle cerebral artery (vs. internal carotid artery) occlusion, use of conscious or no sedation (vs. general anesthesia), and faster treatment were all predictors of favorable outcome. Conclusion Patients in the nerinetide arm who were not treated with concurrent alteplase showed improved clinical outcomes and the treatment effect was larger among patients with favorable ASPECTS profiles.

Background: and Purpose In the ESCAPE-NA1 (Efficacy and Safety of Nerinetide for the Treatment of Acute Ischaemic Stroke) trial, treatment with nerinetide was associated with improved outcomes in patients who did not receive intravenous alteplase. We compared the effect of nerinetide on clinical outcomes in patients without concurrent intravenous alteplase treatment within different patient subgroups. Methods: ESCAPE-NA1 was a multicenter randomized trial in which acute stroke patients with baseline Alberta Stroke Program Early CT Score (ASPECTS) >4 undergoing endovascular treatment (EVT) were randomized to intravenous nerinetide or placebo. The primary outcome was independence (modified Rankin Scale [mRS] score 0–2) at 90 days. We assessed baseline, clinical, and imaging variables as predictors of outcome and for evidence of treatment effect modification. We constructed two multivariable models using variables known prior to randomization and variables known immediately post-EVT procedure to provide adjusted estimates of effect. We assessed for evidence of treatment effect modification using multiplicative interaction terms within each model. Results: Four hundred forty-six patients were included in the analysis. Clinical outcomes were better in patients randomized to the nerinetide arm (mRS 0–2: 59.4% vs. 49.8%). There was possible treatment effect modification by ASPECTS score; patients with ASPECTS 8–10 showed a larger treatment effect compared to those with lower ASPECTS score. Younger age, lower NIHSS score, lower baseline serum glucose, absence of atrial fibrillation at baseline, higher ASPECTS score, middle cerebral artery (vs. internal carotid artery) occlusion, use of conscious or no sedation (vs. general anesthesia), and faster treatment were all predictors of favorable outcome. Conclusion Patients in the nerinetide arm who were not treated with concurrent alteplase showed improved clinical outcomes and the treatment effect was larger among patients with favorable ASPECTS profiles.

Background: and Purpose In the ESCAPE-NA1 (Efficacy and Safety of Nerinetide for the Treatment of Acute Ischaemic Stroke) trial, treatment with nerinetide was associated with improved outcomes in patients who did not receive intravenous alteplase. We compared the effect of nerinetide on clinical outcomes in patients without concurrent intravenous alteplase treatment within different patient subgroups. Methods: ESCAPE-NA1 was a multicenter randomized trial in which acute stroke patients with baseline Alberta Stroke Program Early CT Score (ASPECTS) >4 undergoing endovascular treatment (EVT) were randomized to intravenous nerinetide or placebo. The primary outcome was independence (modified Rankin Scale [mRS] score 0–2) at 90 days. We assessed baseline, clinical, and imaging variables as predictors of outcome and for evidence of treatment effect modification. We constructed two multivariable models using variables known prior to randomization and variables known immediately post-EVT procedure to provide adjusted estimates of effect. We assessed for evidence of treatment effect modification using multiplicative interaction terms within each model. Results: Four hundred forty-six patients were included in the analysis. Clinical outcomes were better in patients randomized to the nerinetide arm (mRS 0–2: 59.4% vs. 49.8%). There was possible treatment effect modification by ASPECTS score; patients with ASPECTS 8–10 showed a larger treatment effect compared to those with lower ASPECTS score. Younger age, lower NIHSS score, lower baseline serum glucose, absence of atrial fibrillation at baseline, higher ASPECTS score, middle cerebral artery (vs. internal carotid artery) occlusion, use of conscious or no sedation (vs. general anesthesia), and faster treatment were all predictors of favorable outcome. Conclusion Patients in the nerinetide arm who were not treated with concurrent alteplase showed improved clinical outcomes and the treatment effect was larger among patients with favorable ASPECTS profiles.