Interventional Neuroradiology最新文献

BackgroundAt our hospital, we use the flow re-direction endoluminal device (FRED) to treat vertebral artery (VA) aneurysms. Some reports suggest that the treatment efficacy of FRED may be lower in patients with fusiform-type aneurysms. At our hospital, we compared the treatment outcomes of FRED for both fusiform- and saccular-type aneurysms occurring at the posterior inferior cerebellar artery bifurcation.MethodsWe included 29 of 245 patients treated with FRED for VA aneurysms (9 saccular and 20 fusiform) between June 2020 and November 2022. We assessed occlusion rates and background factors, including age, sex, hypertension, diabetes, dyslipidemia, and smoking history. Patients received 100 mg aspirin and 3.75 mg prasugrel for at least 7 days prior to surgery. Non-responders received a loading dose of aspirin or prasugrel before surgery. Follow-up evaluations included magnetic resonance angiography (MRA) at 3 and 9 months and digital subtraction angiography (DSA) at 6 and 12 months. For patients with contradictions to DSA, MRI was used for follow-up if the aneurysm was visible. Additional FRED procedures were considered for patients with poor occlusion evidence at 6 months.ResultsPatients with fusiform type were younger (P = 0.025), and their aneurysms were larger (P = 0.036) and had better obliteration rates (P = 0.007), compared with the saccular type. In the fusiform group, 18 out of 20 cases (90%) achieved good obliteration, whereas only 2 out of 9 cases (34%) in the saccular group did. Multivariate analysis indicated that fusiform aneurysm type was a significant predictor of good obliteration.ConclusionsThe treatment effect of FRED on the fusiform VA aneurysm appears to differ from the outcomes based on the pipeline device, suggesting the potential for achieving favorable results earlier in fusiform cases.

Background and PurposeRapid treatment is a major determinant of outcome in acute ischemic stroke patients with large vessel occlusion. We used patient-level data from the ESCAPE and ESCAPE-NA1 trials to evaluate whether and to what extent workflow interval times have improved over time.MethodsData were derived from the ESCAPE and the ESCAPE-NA1 randomized trials. Workflow interval times and reperfusion quality were summarized using descriptive statistics and compared on a patient level between the two trials using the Wilcoxon rank sum test and Fisher's exact test. The effect of patient baseline characteristics, including patient age, sex and stroke severity as measured by the National Institutes of Health Stroke Scale, on workflow times was determined using linear regression.ResultsAll patients from the ESCAPE trial (n = 315) and the ESCAPE-NA1 trials (n = 1105) were included in the analysis. For endovascular interval times, control patients from the ESCAPE trial were excluded. All in-hospital workflow interval times, including door-to-reperfusion times, were significantly shorter in ESCAPE-NA1 (median 91 min [IQR 69-120] vs. 110 [IQR 89-143], P < .001). These improvements were mainly observed in patients directly presenting to an EVT-capable hospital. Onset-to-randomization times did not differ significantly between the two trials (ESCAPE-NA1: median 188 [122-319] vs. ESCAPE: 174 [119-285], P = .152). There was no effect of procedural sedation use, age, sex, stroke severity or evidence of a learning effect over the duration of each trial.ConclusionWorkflow interval times in endovascular stroke treatment have significantly improved over time, particularly in patients directly presenting to an EVT-capable hospital.

BackgroundCerebral venous thrombosis (CVT) is a rare but important cause of stroke. The superficial venous sinuses, including the superior sagittal sinus, are the most common location of CVT. Thrombosis of the deep venous system occurs less frequently, but can be more clinically severe by causing disturbances of consciousness due to involvement of deep anatomic structures including the thalamus and basal ganglia, leading to a higher incidence of death and disability. While anticoagulation is the standard initial recommended therapy for patients with CVT, endovascular intervention is sometimes proposed to help relieve cerebral venous hypertension.MethodsWe performed a retrospective case series review of a single-center interventional database over a 13-year time period to identify cases of CVT that underwent endovascular therapy and analyzed clinical and radiographic characteristics of these patients.ResultsWe identified 43 patients who underwent endovascular treatment for CVT. Twelve of these cases involved the deep system. Of the 12 patients in our consecutive case series, all 12 experienced recanalization of the deep system following catheter-directed alteplase infusions in the superficial or straight sinuses. On follow-up, these patients clinically did well in spite of initially poor neurologic examinations.ConclusionIn this single-center retrospective case series of 12 patients with deep and superficial venous thrombosis, endovascular treatment with site-directed thrombolytic infusion of the superficial venous sinuses with or without catheterization of the straight sinus resulted in angiographic recanalization of the deep veins and improved radiologic and clinical outcomes in 100% of the patients.

BackgroundTransradial access for interventional procedures has become increasingly favored over the transfemoral approach. However, radial artery spasm (RAS) and radial artery occlusion (RAO) pose challenges to this approach.AimsThis study aims to conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing hydrophilic coated (HC) introducer sheaths with non-coated (NC) introducer sheaths during transradial procedures. The impact on RAS, RAO, periprocedural pain, and complications is evaluated.MethodsPubMed, Embase, and the Cochrane Library were searched for RCTs utilizing HC sheaths in their intervention arm and NC sheaths in the control arm for patients undergoing transradial procedures. Outcomes included incidence of RAS, RAO, pain or discomfort during the procedure, procedure duration, pseudoaneurysm, and hematoma. RevMan 5.4 software was used to analyze pooled risk ratios and mean differences with 95% confidence intervals.ResultsEight RCTs were included in this study. HC sheaths significantly reduced the risk of RAS and periprocedural pain or discomfort compared to NC sheaths (RR = 0.38, 95% CI [0.24, 0.60], I²= 19% and RR = 0.47, 95% CI [0.37, 0.59], I²= 1%, respectively). The use of HC sheaths had no significant effect on the risk of RAO, hematoma, or pseudoaneurysm.ConclusionThe use of HC sheaths can enhance the overall patient and operator experience by reducing the risk of RAS and pain during transradial procedures, with no significant effect on RAO, hematoma, or pseudoaneurysm. This study provides evidence supporting the superiority of HC introducer sheaths over NC sheaths during transradial interventions.

Acute ischemic stroke occurs when a blood clot obstructs cerebral blood flow, leading to ischemia and potentially irreversible brain damage. While large vessel occlusions are known for their catastrophic effects, medium vessel occlusions (MeVOs) also contribute significantly to stroke-related disability. These occlusions, which occur in smaller, mid-sized vessels, can result in substantial neurological deficits depending on their location and the availability of collateral circulation. The detection of MeVOs poses unique diagnostic challenges, as their subtle presentations are often overlooked in standard imaging. Timely and accurate identification is critical for initiating appropriate therapies, including intravenous thrombolysis, endovascular thrombectomy, and secondary prevention measures. This editorial takes you on a visual journey through the world of MeVOs, exploring their locations, challenging cases, and the diverse techniques used to identify them. With detailed illustrations, it demonstrates how to recognize these occlusions on both advanced and conventional imaging, including guidance on spotting them on digital subtraction angiography. Finally, it delves into how these strokes are treated, offering a comprehensive and engaging look at the unique challenges and solutions in MeVO management.

In their recently published INR study, Qureshi et al. present their results on intra-arterial lidocaine administration in the middle meningeal artery for the short-term treatment of subarachnoid hemorrhage (SAH)-related headaches. The authors demonstrate that their proposed intra-arterial treatment consistently alleviates headaches in patients with SAH. The purpose of this commentary is to commend the authors on their paper and the notable results they have achieved. It is always pleasant to encounter studies that not only make it to the "Latest Online" section of neurointerventional journals but also push the boundaries, advancing our understanding and care for patients in the most meaningful ways. There is no doubt that our field has witnessed remarkable progress and an expanding spectrum of interventions that endovascular neuroservices can offer. Several therapeutic approaches have emerged from similarly constructive articles, including intra-arterial chemotherapy for malignant cerebral tumors, innovative treatments for cerebrospinal fluid-venous fistulas, hydrocephalus, and chronic subdural hematomas, as well as the implantation of brain-computer interface devices.

Introduction: Flow diverting stents (FDS) are routinely used to reconstruct the arteries of the head and neck. When placed into the mobile cervical internal carotid artery (cICA) segment, the FDS runs the risk of post-procedure stent migration and proximal intimal hyperplasia reaction from physiologic movement of the neck. We report our experience using a novel proximal anchoring technique during endovascular flow reconstruction of complex petrocervical dissections to prevent this potentially deleterious result.

Methods: We reviewed a prospectively maintained IRB-approved institutional database of the senior authors to identify cases of FDS treatment in the mobile petrocervical segments which had the proximal FDS "anchored" with a nitinol stent.

Results: The proximal anchoring technique was successfully performed in the mobile cervical segment in a total of 31 cases over the study period. Each case involved a complex ICA dissection with 68% (n = 21) having an accompanying pseudoaneurysm. Fifty-two percent (n = 16) were female. Surpass Streamline and Evolve FDS were utilized in all cases. An average of 2.2 ± 0.1 FDS devices were utilized (range 2-4 FDS), with each case utilizing a laser-cut nitinol carotid stent as the proximal anchor. The average stent diameter was 5.64 ± 0.2 mm (range 4-8 mm) and length of 30.1 ± 1.5 mm (range 20-60 mm). On last follow-up angiography, there were no instances of stent migration or proximal neointimal hyperplasia.

Conclusion: Utilization of the proximal anchoring technique on FDS constructs in the mobile cICA may provide additional protection from post-procedure stent migration and intimal reaction attributed to patient neck movement resulting in augmentation of successful healing.

Background: The Flow Re-Direction Endoluminal Device X (FRED X) offers several benefits over other flow-diverter devices including an antithrombotic coating, optimized in-vessel stability, and increased flexibility for easier device placement. We present a to-date experience of the safety and utility of the FRED X device in the repair of posterior and anterior circulation aneurysms.

Methods: A retrospective review was conducted on all endovascular procedures that utilized the FRED X device at our center from May 2022 to November 2023.

Results: 77 patients (72.7% women, mean age 58.9), underwent a total of 85 procedures using the FRED X device. Indications included treatment of incidentally discovered aneurysms, acute dissections, aneurysm rupture, repair of residual filling following prior intervention, and use of FRED X for recanalization of non-aneurysmal extracranial stroke. 31.3% of the aneurysms were in the posterior circulation, 68.7% were in the anterior circulation. 9.4% of patients presented with SAH due to acute aneurysm rupture. Patients treated with FRED X were separated into OFF-Label (40.0%) or ON-label (60.0%) indications. Occlusion rate at 6-month follow-up were 72.2% in the OFF-label group, 66.7% in the ON-label group, and 68.4% overall. Rate of major periprocedural complications was 1.2% and the cumulative rate of postprocedural complication at follow-up was 5.3%.

Conclusion: This study shows that FRED X treatment of intracranial aneurysms is safe in both OFF-label and ON-label indications. Continued follow-up of our patient population will further establish the safety, efficacy, and long-term stability of this device.

Background: Idiopathic intracranial hypertension (IIH) is strongly associated with spontaneous skull-base cerebrospinal fluid (CSF) leaks. Venous sinus stenting (VSS) has proven effective for the treatment of IIH. Hence, its role in spontaneous skull-base CSF leaks is being explored actively.

Methods: We performed a systematic literature search across EMBASE, MEDLINE, Scopus, The Cochrane Library, and Google Scholar to identify studies reporting the use of VSS for spontaneous skull-base CSF leaks. Studies with pediatric patients, non-English articles, and nonspontaneous leaks were excluded. Failure of treatment (persistence / recurrence of CSF leak) was regarded as the primary outcome.

Results: Eight studies with 62 patients undergoing VSS for spontaneous skull-base CSF leaks were included. Mean age of the patients was 51.9 years; 87.5% were females. Obesity was highly prevalent, with a mean body mass index of 33.9 kg/m² (4 studies). IIH was noted in 74.6% patients (7 studies). Twenty-six patients (41.9%) underwent VSS alone whereas 36 patients (58.1%) underwent surgical repair + VSS. Seven patients (11.3%) had a failure of treatment. Three failures from one study could not be definitively ascribed to either of the groups. Hence, the estimated failure rate for VSS alone ranged from 18.6% (95% CI [0.02 - 0.46]) to 26.4% (95% CI [0.11 - 0.46]), whereas that for surgical repair + VSS ranged from 5.5% (95% CI [0.00 - 0.16]) to 12.2% (95% CI [0.01 - 0.32]). Furthermore, the estimated rate for resolution of concomitant IIH-related symptoms was 88.7% (95% CI [0.75 - 0.98%]). Majority of the studies did not report any serious complications or mortality related to VSS.

Conclusion: VSS has a potential role in the management of spontaneous skull-base CSF leaks. Its exact indications as a standalone treatment versus as an adjuvant to surgical repair, and the predictors for successful treatment remain to be defined.