Interventional Neuroradiology最新文献

Background: Pretreatment CT perfusion (CTP) marker relative cerebral blood volume (rCBV) < 42% lesion volume has recently shown to predict poor collateral status and poor 90-day functional outcome. However, there is a paucity of studies assessing its association with hemorrhagic transformation (HT). Here, we aim to assess the relationship between rCBV < 42% lesion volume with HT.

Methods: In this retrospective study, we included patients with acute ischemic stroke secondary to large vessel occlusion (AIS-LVO) of anterior circulation who had successful recanalization from two comprehensive stroke centers between 9/1/2017 and 10/01/2023. Successful recanalization was defined as modified treatment in cerebral infarction (mTICI) 2b or greater. Logistic regression analysis and ROC analysis were used to assess the relationship between rCBV <42% and HT.

Results: In total, 150 patients (median age: 69 years, 58.7% female) met our inclusion criteria. On multivariable logistic regression analysis, taking into account age, sex, hypertension, hyperlipidemia, diabetes, prior stroke or transient ischemic attack, admission National Institute of Health stroke scale (NIHSS), Alberta Stroke Program Early CT Score (ASPECTS), and intravenous thrombolysis, rCBV <34% (aOR:1.01, P < .05), rCBV <38% (aOR:1.01, P < .05) and rCBV <42% (aOR:1.01, P < .05) lesion volumes were independently associated with HT. On ROC analysis rCBV < 42% (AUC = 0.61, P < .05) performed slightly better than rCBV < 38% (AUC = 0.59, P < .05) and rCBV < 34% (AUC = 0.59, P < .05) in predicting HT.

Conclusion: The rCBV <42% lesion volume is independently associated with HT in AIS-LVO patients who underwent successful recanalization.

Background and purpose: Mechanical thrombectomy (MT) has become the standard of care for treatment of acute ischemic stroke secondary to large vessel occlusion up to 24 h from the last known normal time. With ADAPT and SOLUMBRA techniques, classically, a large bore aspiration catheter is delivered over a microcatheter and microwire crossing the clot to perform thrombectomy. Recently, a novel macrowire (Colossus 035 in.) has been introduced as a potential alternative to the use of microwire-microcatheter to allow the delivery of the aspiration catheter (ID = 0.070 in. up to 0.088 in.) over a macrowire alone.

Objective: To test the feasibility of delivering an aspiration catheter to clot interface over a macrowire alone.

Materials and methods: A retrospective evaluation of prospectively maintained Macrowire for Intracranial Thrombectomy (MINT) Registry where this novel technique was utilized for thrombectomy. Consecutive patients undergoing MT using the MINT technique were included. We collected baseline demographics, imaging and clinical characteristics, rate of procedural success, conversion to traditional MT, and complications.

Results: Fifty consecutive patients were recruited during the initial 4 months of the larger study duration. The aspiration catheter was able to be advanced to the clot interface successfully in 46/50 (92%) using the MINT technique. Median time from vascular access to the first pass was 11.30 min (IQR = 7.45-14.30 min) and successful thrombectomy was 14 min (IQR = 10-22.15). The modified first-pass effect with this procedure was 71%. One vasospasm was reported as a procedural complication.

Conclusions: MINT is safe and feasible for large vessel occlusion recanalization based on our initial clinical experience in this multicenter study.

Mechanical thrombectomy has become the cornerstone to achieve reperfusion in large vessel occlusion causing acute ischemic stroke. Since the advent of intracranial thrombectomy, the procedural setup has been to deliver aspiration catheter over microwire and microcatheter to the intracranial occlusion (ADAPT) or to deliver the stent-retriever through the microcatheter (SOLUMBRA) to perform thrombectomy.¹ In both these techniques the quintessential aspect is crossing the clot/thrombus, which increases the chances of clot fragmentation or disruption.² We demonstrate delivering an ultra-large bore (Sofia 0.088, Microvention, Aliso Viejo, CA, USA) to the intracranial occlusion over a macrowire (Aristotle Colossus OD: 0.035' × 200 cm, Scientia Vascular, UT, USA) alone with no use of microcatheter or microwire. The utilization of macrowire to perform thrombectomy provides enough support to guide the large or ultra large bore catheter to the clot interface without the need to cross the clot. As this technique involves no crossing of clot it prevents clot disruption and distal embolization. There are other possible benefits which are under study in MINT Registry³ and include making thrombectomy more time and cost efficient.

Migraine is a common neurological disorder that primarily affects young adults. Despite the availability of multiple therapeutic options for patients with intractable migraine, a significant proportion of these patients remain refractory to treatment, highlighting the importance for novel therapies. In this study, we comprehensively assessed the role of the middle meningeal artery (MMA) in the management of intractable migraine. Although the exact pathophysiology of migraine remains a subject of debate, the neurovascular theory of migraine has gained attention recently following multiple studies assessing the role of the MMA in migraine pathophysiology. In addition, the successful utilization of lidocaine both through intravenous injection and directly into the MMA, as well as favorable results observed in the form of headache relief following MMA embolization (MMAE) in patients with chronic subdural hematoma, has further substantiated the neurovascular theory hypothesis. In this study, we evaluated the current evidence, potential trends, role of other injection medications, as well as risks and limitations of MMAE in the management of patients with refractory migraine. Intractable migraine is a complex condition that often requires multimodal management. MMAE has emerged as a promising, novel therapeutic technique that may help reduce pain and minimize the need for additional treatments. However, further prospective and randomized trials are still necessary for further validation.

Background: Dissecting intracranial aneurysms (DIAs) have been treated through endovascular reconstructive manners, such as flow diverters (FDs) and stent-assisted coiling (SAC). Notably, no robust evidence has compared both approaches. Hence, the authors conducted a meta-analysis to compare their outcomes.

Methods: PubMed, Embase and Web of Science were searched for studies employing SAC and FD treatment for DIAs. The following outcomes were considered for extraction: procedure-related mortality, total mortality, postoperative and follow-up complete aneurysm occlusion, complications, good clinical outcomes, recurrence, and retreatment. Odds ratio (OR) with random effects was employed for statistical comparison.

Results: The meta-analysis included 10 studies. A total of 195 and 222 patients were included in the FD and the SAC group, respectively. Stent-assisted coiling had higher postoperative complete aneurysm occlusion rates (OR 0.03; 95% CI 0.01-0.08). Flow diverter retreatment rate was lower, but without statistical significance (OR 0.35; 95% CI 0.11-1.10). No significant differences were found in follow-up complete aneurysm occlusion (OR 1.18; 95% CI 0.35-3.99); total mortality (OR 0.44; 95% CI 0.09-2.08); intraoperative complications (OR 0.30; 95% CI 0.06-1.45); postoperative complication (OR 0.77; 95% CI 0.35-1.70); good clinical outcomes (OR 0.97; 95% CI 0.43-2.20); and recurrence (OR 0.38; 95% CI 0.13-1.10) between the two groups.

Conclusion: Stent-assisted coiling shows higher postoperative complete aneurysmal occlusion rates, but both techniques achieve similar rates in angiographic follow-up. Flow diverter has lower, but not statistically significant, retreatment rates than SAC. Both techniques have similar complication rates. Future randomized, multicenter, and prospective studies with larger sample sizes are needed for more conclusive findings.

Introduction: Middle meningeal artery embolization (MMAe) is increasingly utilized as a primary or secondary treatment for chronic subdural hematoma (cSDH) and is usually performed with liquid embolics or particles. Outcomes after MMAe with coiling as a standalone treatment, or an adjunct to other agents, have not been reviewed.

Methods: A systematic review of the literature was performed to identify all original research that included patients who underwent standalone or adjunctive coiling for MMAe. The primary outcome was the need for rescue treatment defined as any unplanned reintervention for recurrent or residual cSDH.

Results: A total of 10 studies comprising 346 patients (mean age 73 years, 39% female) who underwent MMAe with coils were included. The majority of embolizations were with coils and particles (n = 176), followed by standalone coiling (137) and coiling with liquid embolics (120). The pooled rate of rescue treatment after embolization was 9.4% (95% CI 6.4-13.6, I²= 0). The pooled complication rate was 2.6% (95% CI 1.3-5.1, I²= 0). In the subgroup analysis of four studies reporting results after standalone coiling, the pooled rescue treatment rate was 8.2% (95% CI 4.0-15.9, I²= 0) and there were no complications.

Conclusion: MMAe with coils is safe and potentially effective, but additional studies evaluating long-term clinical and radiographic results after standalone coiling are needed.

Background: Iatrogenic cervical artery dissection (CeAD) results from various procedures including interventional angiographic procedures and diagnostic angiography. Iatrogenic CeAD is rare, resulting in limited literature on management and outcomes. This observational cohort study investigates approaches and outcomes of iatrogenic CeAD after endovascular interventions.

Methods: We conducted a retrospective review for patients who underwent endovascular intervention with resulting iatrogenic CeAD at Mayo Clinic, Rochester, MN, from 1998 to 2021. Pertinent patient factors were extracted and descriptive statistics generated.

Results: Between 1998 and 2021, 21,191 patients underwent catheter-based cerebral angiography. Thirty-two had iatrogenic CeADs (23 women; median age 59 [range 40.5-92.9]). Common comorbidities included hypertension (62.5%), smoking (56.3%), and hyperlipidemia (46.9%). Nine (28.1%) had dissection with diagnostic angiograms, 6 (18.8%) endovascular thrombectomy, 15 (46.9%) intracranial aneurysm treatment/coiling, and 2 (6.3%) intracranial angioplasty with/without stenting. All dissections were diagnosed by cerebral angiography during the same session as initial interventions. Four (12.5%) underwent hyperacute stenting. Thirty (93.7%) were placed on antithrombotic therapy with aspirin alone (34.4%) or dual-antiplatelet therapy with aspirin and clopidogrel (37.5%). Median duration of acute treatment was three months. Follow-up imaging showed excellent radiological course.

Conclusions: Iatrogenic CeAD with endovascular interventions is rare and typically benign. Most are managed medically without complications or long-term negative outcomes. Oral single or dual-antiplatelet therapies are preferred compared to previous studies which emphasize intravenous anticoagulation. The duration of acute therapy varied from three months to lifelong. Key factors influencing clinical decision-making may include occlusion rate, pseudoaneurysm formation, intracranial extension, distal collateral circulation, and resultant ischemia.

Background: Flow diverting stents (FDS) are an established endovascular treatment for intracranial aneurysms but are reported to have varying rates of adequate occlusion and thromboembolic complications. This study reports clinical safety and efficacy results of the FRED and FRED Jr FDS in clinical practice in the UK at 6 months and 1 year.

Methods: The FRED-UK study is a single arm, multicentre, prospective, observational study conducted in the UK. Safety was reviewed by evaluating morbidity (modified Rankin Score ≤2) and mortality. Efficacy was assessed as adequate occlusion of the treated aneurysm. A clinical event committee and core laboratory independently assessed clinical and anatomical results.

Results: Seven neurointerventional centers treated 61 patients, 57 of which met the full inclusion and exclusion criteria. Of these, 75.4% were treated with FRED and 24.6% with FRED Jr. The aneurysms were located on the cavernous or supraclinoid internal carotid artery (ICA) in 75.4%, on the anterior cerebral artery (ACA) or anterior communicating artery (Acom) in 21.1%, and on the middle cerebral artery (MCA) in 3.5%. 57.9% of aneurysms were small (<10 mm), 40.4% were large (10-24 mm) and 1.8% were giant (≥25 mm). All-cause morbidity and mortality were 0% at 6 and 12 months, and adequate occlusion was 86.7% at 12 months in the per protocol population.

Conclusions: The FRED and FRED Jr devices are safe and efficacious in the treatment of intracranial aneurysms.

Background: Spontaneous skull base cerebrospinal fluid leaks (CSFLs) are associated with increased intracranial pressure in idiopathic intracranial hypertension (IIH) and hypothesized to relate to skull base erosions due to increased CSF pressure. Given the increasing recognition of internal jugular venous stenosis (IJVS) as a cause of intracranial hypertension (IH), we evaluated the relationship between spinal CSFL and venous causes of IH.

Methods: The spinal CSFL database at a single institution was assessed to identify 12 consecutive spontaneous, non-traumatic spinal CSFL patients with CTV data. Exclusion criteria included documented IIH and iatrogenic CSFL. Demographics, clinical parameters, imaging characteristics, and IJV manometry results were recorded. Internal jugular venous stenosis was graded as: none (0-10%), mild (10-50%), moderate (50-80%), severe (>80-99%), and occluded (100%). Twelve consecutive patients who presented with cerebrovascular accidents without CSFL, matched by age and sex, were similarly analyzed as a control group. STROBE guidelines were used in reporting results.

Results: All CSFL patients had IJVS (83.3% bilateral, 33.3% severe) compared to 41.7% of the control group (33.3% bilateral, 16.7% severe-occluded); p = 0.04. All CSFL patients with available venogram manometry data had at least unilateral IJV gradients. Most patients presented with modified Rankin score (mRS) of 1 (66.7%), but in those with higher mRS, medical and/or surgical interventions were associated with decreased morbidity.

Conclusion: Spontaneous spinal CSFL was associated with IJVS in patients not meeting IIH criteria. Persistently high CSF pressure resulting in CSFL may cause opening pressure to be falsely normal or low. Internal jugular venous stenosis may be a viable target in recurrent CSFL management and improve morbidity.

Background: The majority of studies on parasagittal dural arteriovenous fistulas (DAVFs) have been limited to case reports or case series, and they are frequently reported alongside true superior sagittal sinus (SSS) DAVFs. Because of the selective bias present in the reporting of dispersed small numbers of parasagittal DAVFs, the results of each study may influence the findings. As a result, we present a large sequential cohort of parasagittal DAVFs from our institution spanning a 20-year period.

Methods: This study was a retrospective analysis involving 80 patients with parasagittal DAVFs who were hospitalized at a single medical center from 2002 to 2022. We explore their clinical manifestations, angioarchitecture, clinical and radiographic outcomes.

Results: We identified 80 patients with 85 parasagittal DAVFs. The cohort consisted of 69 men and 11 women, with a M ± SD age of 50.5 ± 11.1 years. Seventy-six patients underwent trans-arterial embolization (TAE), two underwent surgery, and two received conservative treatment. Immediate complete occlusion was achieved in 74 cases (94.9%). Fifty (96.2%) patients were cured, with no recurrence detected on final follow-up imaging. One patient died 6 months after the final subtotal occlusion, while the other patients experienced improvement or resolution of clinical symptoms following treatment.

Conclusions: These lesions carry a high risk of hemorrhage and nonhemorrhagic neurological deficits. In our series, TAE achieved a high cure rate for these lesions, with no major complications reported.