Interventional Neuroradiology最新文献

BackgroundData on off-label use of flow diverter for ruptured distal anterior cerebral artery aneurysms (rDACAAs) are limited. The purpose of the present study is to evaluate the efficacy and safety of flow diversion for rDACAAs in a large multicenter cohort.MethodsA retrospective observational study on consecutive patients who were treated with flow diversion for rDACAAs at 8 centers in 4 countries was performed. Primary outcome was the occlusion rate of the target aneurysm at the last radiological follow-up. Secondary outcomes included good clinical outcome, retreatment, technical success, procedure-related complications, radiological outcome of the covered branches and mortality rate.ResultsA total of 21 patients with 21 rDACAAs were treated between January 2017 and December 2024. Thirteen patients were women (61.9%) and the median age was 54 years (IQR 46-66). The most common etiology was saccular (71.4%), followed by dissecting (23.8%) and mycotic (4.8%). In all patients a single stent was successful deployed. Median imaging follow-up was 9 (7-12) months. At last follow-up adequate occlusion was 95.2%. Symptomatic thromboembolic or hemorrhagic complications occurred in 9.5% of patients. Seventeen patients (81%) had good clinical outcome (mRS 0-2) with mortality rate of 9.5%. In-stent stenosis occurred in one case that was conservatively managed without major concerns.ConclusionsFlow diversion is feasible as a potential treatment strategy for acutely ruptured aneurysms arising from distal anterior cerebral artery. Flow diverter may represent a valid option whenever other treatments are considered challenging or high risk.

PurposePresented here is a strategy of sequential lateral decubitus digital subtraction myelography (LDDSM) followed closely by lateral decubitus CT (LDCT) to facilitate cerebrospinal fluid (CSF)-venous fistula (CVF) localization.Materials and MethodsThis is a retrospective analysis of patients referred to our institution for evaluation of CSF leak. Patients with Type 1 and Type 2 leaks, and those not displaying MR brain stigmata of intracranial hypotension were excluded. All patients underwent consecutive LDDSM and LDCT. If the CVF was not localized on the first LDDSM-LDCT pair the patient returned for contralateral examinations. Images were reviewed for CVF and for accumulation of contrast within the renal pelvises expressed as a renal pelvis contrast score (RPCS) in Hounsfield units (HU).ResultsTwenty-two patients were included in this study. In 21 of 22 patients (95%) a CVF was identified yielding an RPCS for the LDDSM-LDCT pair ipsilateral to the CVF ranging from 71 to 423 with an average of 146 HU. An RPCS of the negative side LDDSM-LDCT pair contralateral to a CVF was available in 8 patients and averaged 51 HU. In 4 patients the initial bilateral LDDSM-LDCT pairs did not reveal the location of the CVF however in 3 of these 4 cases the CVF was revealed on a third LDDSM repeated ipsilateral to the higher RPCS.ConclusionThe strategy of sequential LDDSM-LDCT coupled with evaluation of renal accumulation of contrast agent appears to improve the rate of CVF localization and warrants further evaluation.

PurposeFlow re-direction endoluminal device (FRED) is a novel dual-layer flow-diverting stent to treat cerebral aneurysms with high obliteration rates, however, it induces inevitable metal-related artifacts. We compared silent magnetic resonance angiography (MRA), a new MRA method using ultra-short time of echo and arterial spin-labeling, with conventional time-of-flight (TOF)-MRA for imaging aneurysms treated using FRED.MethodsBetween May 2020 and September 2022, 16 patients with unruptured internal carotid aneurysms treated using FRED simultaneously underwent silent MRA and TOF-MRA after treatment, with 36 follow-up sessions in total. Two observers independently graded the quality of intra-aneurysmal flow and stented parent arteries under both types of MRA from 1 (not visible) to 4 (nearly equal to digital subtraction angiography [DSA]), with reference to DSA images as a standard criterion.ResultsThe mean scores for intra-aneurysmal flow and stented parent arteries were significantly better for silent MRA (3.93  ±  0.21 and 3.82  ±  0.32, respectively) than for TOF-MRA (2.08  ±  0.99 and 1.92  ±  0.79, respectively) (P < 0.01). Intermodality agreements for intra-aneurysmal flow and stented parent arteries were 0.87 and 0.90, respectively.ConclusionSilent MRA is superior to TOF-MRA for assessing patients treated with FRED, with potential as an alternative imaging modality to DSA.

Over the last 10 years, there has been a rise in neurointerventional case complexity, device variety and physician distractions. Even among experienced physicians, this trend challenges our memory and concentration, making it more difficult to remember safety principles and their implications. Checklists are regarded by some as a redundant exercise that wastes time, or as an attack on physician autonomy. However, given the increasing case and disease complexity along with the number of distractions, it is even more important now to have a compelling reminder of safety principles that preserve habits that are susceptible to being overlooked because they seem mundane. Most hospitals have mandated a pre-procedure neurointerventional time-out checklist, but often it ends up being done in a cursory fashion for the primary purpose of 'checking off boxes'. There may be value in iterating the checklist to further emphasize safety and communication. The Federation Assembly of the World Federation of Interventional and Therapeutic Neuroradiology (WFITN) decided to construct a checklist for neurointerventional cases based on a review of the literature and insights from an expert panel.

IntroductionIntracranial aneurysms (IA) are a focal dilatation of the vessel wall, the rupture of these, causes subarachnoid hemorrhage. Until now, endovascular management is the ideal treatment, providing the interventionist a range of options among which the stent and coils embolization stands out because of its occlusion rate. This study presents the results of a retrospective cohort comparing the effectiveness, morbidity, and mortality of IA treatment with laser-cut stent-assisted coils versus braided stents.MethodologyRetrospective cohort of patients diagnosed with unruptured intracranial aneurysms treated with coil-assisted laser-cut stents or braided stents between January 2014 and December 2021.ResultsIn total, 138 patients with 147 intracranial aneurysms were analyzed, 91 of them were treated with laser-cut stent and 56 with braided stents. The main antecedent was arterial hypertension (48.55%). In the immediate angiographic control, a Raymond Roy scale (RRO) I was obtained in 86.81% of the patients with laser-cut stents and 87.50% of the patients with braided stents. In the angiographic follow-up at 12 months, an RRO I occlusion rate of 85.19% was reported in both groups. Perioperative complications occur in 16 patients treated with laser-cut stents and 12 patients treated with braided stents. Three patients presented bleeding complications during the 12-month follow-up, of which two correspond to patients treated with braided stents and one with a laser-cut stent.ConclusionTreatment of patients with intracranial aneurysms with laser-cut stents or braided stents and coils is just as safe and effective.

Background and purposeAcute carotid artery stenting (CAS) for ischemic stroke patients with anterior circulation tandem occlusion requires periprocedural antiplatelet therapy to prevent stent thrombosis. However, due to the lack of randomized trials and inconsistent published results, there is no reliable information regarding the safety of additional antiplatelet treatment. Therefore, we compared the safety and functional outcomes of patients treated with acute CAS plus Aspirin during tandem occlusions thrombectomy with isolated intracranial occlusions patients treated with thrombectomy alone.MethodsTwo prospectively acquired mechanical databases from August 2017 to December 2021 were reviewed. Patients were included if they had carotid atherosclerotic tandem occlusions treated with acute CAS and Aspirin (intravenous bolus 250 mg) during thrombectomy. Any antiplatelet agent was added after thrombectomy and before the 24-h control imaging. This group was compared with a matched group of isolated intracranial occlusions treated with thrombectomy alone.ResultsA total of 1557 patients were included and 70 (4.5%) had an atherosclerotic tandem occlusion treated with acute CAS plus Aspirin during thrombectomy. In exact coarse matched weight adjusted analysis, the rate of symptomatic intracerebral hemorrhage was similar in both groups (OR, 3.06; 95% CI, 0.66-14.04; P = 0.150), parenchymal hematoma type 2 (OR, 1.15; 95% CI, 0.24-5.39; P = 0.856), any intracerebral hemorrhage (OR, 1.84; 95% CI, 0.75-4.53; P = 0.182), and 90-day mortality (OR, 0.79; 95% CI, 0.24-2.60; P = 0.708). Rates of early neurological improvement and 90-day modified Rankin Scale score 0-2 were comparable.ConclusionsAcute CAS plus Aspirin during thrombectomy for tandem occlusion stroke appears safe. Randomized trials are warranted to confirm these findings.

BackgroundThe MIVI Q aspiration catheters have been shown to achieve significantly greater flow rates than other intracranial aspiration catheters in vitro. We describe our initial real-world experience with the MIVI Q catheter in emergent acute ischemic stroke (AIS) caused by distal and medium vessel occlusions (DMVO).MethodsData was collated from a prospectively maintained database which included patients from October 2019 to December 2022. Occlusion demographics, thrombectomy technique, reperfusion scoring, procedural complications and disposition were assessed. The primary outcome of interest was rate of successful reperfusion defined as thrombolysis in cerebral infarction (TICI) score 2b-3. Secondary outcomes included rate of first pass effect (FPE) and complications.ResultsWe included 64 target occlusions in 51 patients. The Q catheter successfully reached the DMVO in all occlusions. Successful reperfusion was achieved in 49/64 (76.6%) occlusions, and TICI scores were similar for primary and secondary DMVOs (P value = 0.41). FPE was achieved in 39/64 (60.9%) occlusions and did not differ between primary and secondary DMVOs (P value = 0.13). Reperfusion hemorrhage occurred in 3/64 (4.7%) cases, small volume subarachnoid hemorrhage in 3/64 (4.7%) cases, and small hemorrhagic transformation in 1/64 (1.6%) cases; the rate of complications did not differ based on primary versus secondary DMVO (P value = 0.29).ConclusionThe MIVI Q catheter is both safe and effective. Our real-world experience supports the superior flow rates demonstrated in vitro and translates into high rates of successful reperfusion in AIS caused by DMVO in clinical practice.

Carotid-cavernous dural arteriovenous fistulas causing debilitating ocular symptoms and/or retrograde cortical venous drainage necessitate curative treatment, which is achieved by disrupting the proximal draining vein. Transvenous embolization of carotid-cavernous dural arteriovenous fistulas can be achieved through the superior or inferior petrosal sinuses, facial veins, or superior ophthalmic veins.^{1, 2} However, if these approaches are not feasible, various percutaneous approaches have been described that use the skull base foramina to provide direct access to the cavernous sinus.^{3, 4} Here we present the case of a 54-year-old male with carotid-cavernous dural arteriovenous fistulas with cortical venous drainage causing diplopia that was cured using a percutaneous transorbital approach. We discuss the alternative endovascular strategies for treating carotid-cavernous dural arteriovenous fistulas and why they were not chosen, the technical nuances of the transorbital approach as well as the pearls and pitfalls of this seldom used technique. A comprehensive understanding of the many approaches for treating carotid-cavernous dural arteriovenous fistulas is important for neurointerventionalists.

Middle meningeal artery embolization is increasingly becoming popular in the treatment of chronic subdural hematomas. The safety and efficacy of the procedure has previously been demonstrated in the literature; however, complications do arise from time to time. Here we present the case of an elderly gentleman who experienced inadvertent embolization of the superior sagittal sinus through an occult arteriovenous fistula between the middle meningeal artery and the superior sagittal sinus. Multiple rescue techniques including aspiration and stent retriever thrombectomy were performed with restoration of venous flow and an overall optimal result.

Background and PurposeThe degree of internal carotid artery (ICA) stenosis determined by criteria from the North American Symptomatic Carotid Endarterectomy Trial (NASCET) is not the most accurate index to assess distal flow compromise. Distal ICA perfusion is also determined by factors such as tandem carotid stenosis and collateral circulation. Quantification of end-organ ocular perfusion using non-invasive laser speckle flowgraphy (LSFG) may provide insights into distal ICA flow. This study prospectively assessed the degree of ICA flow using LSFG.MethodsEighteen patients with symptomatic carotid stenosis underwent LSFG evaluation. LSFG was used to extract ocular blood flow metrics recorded simultaneously in the retina, choroid, and optic nerve head. The following ocular flow parameters were measured with LSFG: mean blur rate (MBR), flow acceleration index (FAI), and rising rate (RR). Syngo iFlow perfusion imaging was used to objectively quantify contrast flow in the ICA and brain parenchyma during digital subtraction angiography. Time to peak (TTP) and contrast delay were extracted from seven different regions of interest (ROIs).ResultsMBR, FAI, and RR were correlated with NASCET degree of stenosis. FAI and RR also improved after stenting. TTP improved after stenting in three ROIs. A moderate negative correlation was observed between FAI and contrast delay.ConclusionsLSFG non-invasively quantifies end-organ blood flow distal to the ICA origin. LSFG metrics have the potential to quantify end-organ perfusion and determine if a proximal carotid stenosis is symptomatic.