Interventional Neuroradiology最新文献

BackgroundBalloon-assisted deployment/remodelling is a proven adjunctive technique for coil embolization of intracranial aneurysms, and it may be a helpful adjunct in delivering the Woven EndoBridge (WEB) device.ObjectiveTo evaluate the safety, efficacy and feasibility of balloon-assisted WEB deployment in both ruptured and unruptured intracranial aneurysms in both typical and atypical locations.MethodsPatients who underwent treatment of ruptured and unruptured intracranial aneurysms with the BAWD technique were retrospectively identified from a prospectively maintained database at two neurointerventional centres. Patient demographics, aneurysm characteristics, technical procedure details, clinical and imaging outcomes were reviewed.ResultsThirty-three aneurysms (23 women) were identified with a median age of 58 years. There were 15 (45.5%) ruptured aneurysms, 25 (64.3%) in the anterior circulation and 12 (36.4%) aneurysms having an atypical location for WEB treatment. The average aneurysm size was 6.8 mm (greatest dimension), 4.6 mm (height) and 4.5 mm (width), and 25 (75.8%) aneurysms had a wide neck morphology. One patient died (3.0%) secondary to a procedure-related complication, and there was no procedure-related permanent morbidity. Complete and adequate aneurysm occlusion on mid-term follow-up DSA was 85.2% and 92%, respectively.ConclusionBalloon-assisted WEB deployment appears to be a safe and effective technique that may increase the utility of the WEB device. Further prospective studies on BAWD should be considered.

BackgroundThe occurrence of persistent intra-device filling (BOSS 1, using the Bicêtre Occlusion Scale Score (BOSS)) in aneurysms treated with a Woven Endobridge (WEB) device is infrequent based on angiographic follow-up. To date, three monocentric case series were published studying BOSS 1 cases. Through a multicenter retrospective study, we aimed to report the incidence, and risk factors of intra-WEB persistent filling.MethodsWe reached out to European academic centers that treat patients using WEB devices and requested de-identified data of patients treated with a WEB device and underwent angiographic follow-up, at least 3 months after embolization, to assess the BOSS 1 occlusion score. We compared baseline characteristics, treatment modalities, and aneurysm data of the included BOSS 1 patients with those of a control group consisting of non-BOSS 1 patients (n = 116) who had an available angiographic follow-up. Univariable and multivariable models were employed for analysis.ResultsAmong the pooled sample of 591 aneurysms treated with WEB, the rate of persistent flow (BOSS 1) at angiographic follow-up was 5.2% (n = 31 out of 591), performed after an average of 8.7 ± 6.3 months. In the multivariable-adjusted analysis, dual antiplatelet therapy in the postoperative period (adjusted odds ratio [aOR] 4.3 [95% CI 1.3-14.2]), and WEB undersizing (aOR 10.8 [95% CI 2.9-40]) were independently associated with a BOSS 1 persistent flow result.ConclusionPersistent blood flow within the WEB device during angiographic follow-up (BOSS 1) is an uncommon occurrence. Our findings indicate that post-procedural dual antiplatelet therapy and undersizing of the WEB device are independently associated with the presence of BOSS 1 at follow-up.

IntroductionMiddle meningeal artery embolization (MMAE) has emerged as a promising new treatment for patients with chronic subdural hematomas (cSDH). Its efficacy, however, upon the subtype with a high rate of recurrence-septated cSDH-remains undetermined.MethodsFrom our prospective registry of patients with cSDH treated with MMAE, we classified patients based on the presence or absence of septations. The primary outcome was the rate of recurrence of cSDH. Secondary outcomes included a reduction in cSDH thickness, midline shift, and rate of reoperation.ResultsAmong 80 patients with 99 cSDHs, the median age was 68 years (IQR 59-77) with 20% females. Twenty-eight cSDHs (35%) had septations identified on imaging. Surgical evacuation with burr holes was performed in 45% and craniotomy in 18.8%. Baseline characteristics between no-septations (no-SEP) and septations (SEP) groups were similar except for median age (SEP vs no-SEP, 72.5 vs. 65.5, p = 0.016). The recurrence rate was lower in the SEP group (SEP vs. no-SEP, 3 vs. 16.7%, p = 0.017) with higher odds of response from MMAE for septated lesions even when controlling for evacuation strategy and antithrombotic use (OR = 0.06, CI [0.006-0.536], p = 0.012). MMAE resulted in higher mean absolute thickness reduction (SEP vs. no-SEP, -8.2 vs. -4.8 mm, p = 0.016) with a similar midline shift change. The rate of reoperation did not differ (6.2 vs. 3.1%, p = 0.65).ConclusionMMAE appears to be equal to potentially more effective in preventing the recurrence of cSDH in septated lesions. These findings may aid in patient selection.

There are multiple treatment alternatives for cavernous dAVFs, with transvenous routes being most common. Among these routes, occluded inferior petrosal sinus is well-described, and, apart from being imaginative and elegant, it is also safe and effective. Herein we describe the application of this method to reach the fistulous pouch of a cavernous dAVF via an occluded superior petrosal sinus.

BackgroundCervicofacial arteriovenous malformations (AVMs) are a significant source of morbidity. Endovascular embolization has emerged as a promising treatment technique for these lesions. However, current literature on cervicofacial AVM embolization mostly consists of single-agent oriented case series, and to date, no comprehensive study has compared the outcomes of available embolic agents.PurposeTo investigate the performance of different embolic agents in the management of cervicofacial AVMs.MethodsWe systematically searched Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials Scopus, and Web of Science. Studies providing data for the endovascular treatment of cervicofacial AVMs were included. The data regarding complication and cure rates were collected for each embolic agent. Pooled event rates were presented as descriptive statistics.ResultsEleven studies comprising 204 patients were included in the review. The overall complete and partial cure rates were 62.2% (127/204) and 36.2% (74/204), respectively. Embolization failed to achieve significant improvement in only 1.6% (3/204) of the patients. The complete cure rates were 87.5% (75-100%) for n-Butyl cyanoacrylate (NBCA, glue), 80.5% (61-100%) for Onyx (Medtronic, MN, USA), and 51.5% (18-85%) for ethanol. The overall complication rate was 30% (61/204). The complication rates were 33% (12.5-53%) for ethanol, 14% (0-28%) for Onyx, and 0% for NBCA.ConclusionsOur systematic review supports that endovascular embolization is an effective treatment option for cervicofacial AVMs. In our review, the use of Onyx and NBCA was associated with consistently high complete cure rates and a promising safety profile. However, more research is needed to investigate the use of different embolic agents in the treatment of cervicofacial AVMs.

BackgroundThis study assessed the efficacy and safety of thrombectomy for acute ischaemic stroke in a population with pre-stroke modified Rankin scale (mRS) scores of 2-3 using real-world data.MethodsOur sample set included 2313 consecutive patients enrolled in the Kanagawa Registry of Intravenous and Endovascular Treatment of Acute Ischemic Stroke registry between January 2018 and June 2020 in 40 stroke centres in Kanagawa Prefecture, Japan. Patients treated with intravenous tissue plasminogen activator (t-PA), thrombectomy, or both were included. Patients with pre-stroke mRS scores of 4-5 and those treated only with intra-arterial thrombolysis were excluded. The primary outcome of this study was an mRS score of 0-3 at 90 days after onset to assess the efficacy of thrombectomy for pre-stroke disabled individuals. We performed multivariate logistic regression analyses to investigate independent factors for a 90-day mRS score of 0-3. We also performed nearest-neighbour within-calliper matching between thrombectomy and t-PA only.ResultsAfter excluding patients meeting the exclusion criteria, we analysed data of 2136 consecutive patients, of which 315 (14.7%) had pre-stroke disabilities (mRS score 2-3). A 90-day mRS score of 0-3 was achieved by 33.3% of patients with pre-stroke mRS scores of 2-3. According to multivariate analysis, the National Institutes of Health Stroke Scale (NIHSS) score was an independent factor. Furthermore, after propensity-score matching, thrombectomy showed considerable superiority for achieving a 90-day mRS score of 0-3.ConclusionIntravenous t-PA and especially thrombectomy were safe and effective for the population with pre-stroke disabilities, particularly for patients with low NIHSS scores.

BackgroundAlthough flow diversion (FD) is safe and effective in the treatment of intracranial aneurysms, a subset tends to continue filling on serial angiography. Risk factors for failed flow diversion include old age, large aneurysm size, and overstenting an adjacent end-arterial vessel. The hemodynamic modes of persistent aneurysm filling, or 'endoleaks', after FD are poorly understood. This study aims to characterize the various types of endoleaks following aneurysmal FD.MethodsWe performed a retrospective review of a prospectively maintained database of all endovascular procedures performed at a single institution between 2017 and 2021. Patients were included if they demonstrated evidence of unique modes of intracranial aneurysm filling after FD. Data regarding treatment, follow-up angiography, as well as clinical course were collected.ResultsFive patients (mean age 50 years, four females) were included with mean 19-month angiographic follow-up. Five major endoleak types are proposed: Type 1 - due to graft porosity (A - low flow, B - high flow), Type 2 -through an overstented branch vessel, Type 3 - via stent migration no longer covering aneurysmal neck, Type 4 - endoleak due to malapposition of the stent wall, and Type 5 - endoleak via collateralization from adjacent blood vessels. All endoleak types were represented, except for the Type 4 endoleak.ConclusionWe propose an endoleak classification scheme to describe the hemodynamic modes of failure following FD of intracranial aneurysms. Future studies are needed to evaluate the natural history of aneurysmal filling following FD and retreatment success according to endoleak type.

IntroductionThe Vertebrobasilar Flow Evaluation and Risk of Transient Ischemic Attack and Stroke (VERiTAS) study determined patients with low flow in their vertebrobasilar (VB) system are at increased risk of recurrent stroke. Endovascular interventions such as angioplasty and stenting are reserved for patients with refractory symptoms; however, few series to date have demonstrated either hemodynamic or clinical outcomes in this high-risk patient group. We present our combined institutional series of patients with symptomatic VB atherosclerotic disease and low-flow state who underwent angioplasty and stenting.MethodsRetrospective chart review of patients undergoing angioplasty and stenting for symptomatic VB atherosclerotic disease at two institutions was performed. Clinical and radiographical outcomes were collected including flow rates using quantitative MRA (QMRA) pre- and post-stenting.ResultsSeventeen patients underwent angioplasty and stenting for symptomatic VB atherosclerotic disease and met VERiTAS low-flow state criteria. There were four cases (23.5%) of periprocedural stroke, two of which were minor and transient. The stent was placed intracranially in 82.4% of patients. Basilar and bilateral posterior cerebral artery (PCA) flows significantly improved post-stenting (p < 0.05) and normalized based upon VERiTAS criteria in all patients. Fourteen patients had delayed QMRA at mean follow-up 20 months demonstrating appropriate patency and flow post-stenting. Two patients (10%) had recurrent stroke, one from medication nonadherence and in-stent thrombosis, and the other from a procedural dissection that subsequently became symptomatic.ConclusionsOur series demonstrates angioplasty and stenting significantly improve intracranial flow over long-term. Angioplasty and stenting may improve the natural history of low-flow VB atherosclerotic disease.

IntroductionCarotid Web (CaW) is an increasingly recognized etiology of ischemic stroke, and has been shown to be amenable to endovascular stenting. The technical complexity of stenting for CaW may be lower than for carotid atherosclerotic disease (CAD). We aimed to assess procedural characteristics of stenting for CaW as compared to CAD.MethodsWe retrospectively analyzed a cohort of consecutive patients at a single comprehensive stroke center from 2014 to 2021, who had undergone elective endovascular stent placement for symptomatic CAD or CaW.ResultsIn total, 118 patients underwent elective stent placement following ischemic stroke/transient ischemic attack; 88 patients had CAD and 30 patients had CaW. CAD patients were older (63.2 vs 51.2 years, p < 0.001), less likely to be female (28.4% vs 73.3%, p < 0.001), and more likely to have pre-existing vascular risk factors. Procedure time (73.0 vs 57.5 min, p = 0.007), radiation exposure (1482 vs 1125 milliGray, p = 0.03), filter time (24 vs 14 min, p = 0.04), and use of pre-stent (68.2% vs 0%, p < 0.001) and post-stent (34.1% vs 3.3%, p < 0.001) balloon angioplasty were higher in CAD cases. There was no significant difference between groups in the rate of periprocedural complications such as hypotension, use of vasopressors, or bradycardia. Recurrent stroke/TIA was reported in five CAD patients and 0 CaW patients by the end of the follow-up period (8.3% vs 0%, p = 0.12). In-stent restenosis was detected in seven CAD patients and 0 CaW patients (10.1% vs 0%, p = 0.09) at a median follow-up of 4 vs 16 months (p = 0.01), respectively. Periprocedural intracranial hemorrhage was not observed in either group.ConclusionStenting for CaW was found to be technically simpler than CAD and not to confer increased risk of baroreceptor dysregulation. Intimal hyperplasia was uncommon in CaW cases.

Acute ischemic stroke (AIS) due to distal, medium vessel occlusion (DMVO) is increasingly recognized as the next frontier for mechanical thrombectomy. Distal, medium vessel occlusions are typically defined as an occlusion in the following arteries: anterior cerebral artery, M2-M4 segments of the middle cerebral artery, posterior cerebral artery, posterior inferior cerebellar artery, anterior inferior cerebellar artery, and superior cerebellar artery. It is estimated that 25-40% of all AIS is due to DMVO. Because of the large burden of DMVO, the frequency of literature published regarding these occlusions has greatly increased in recent years. Furthermore, treatment modalities have been created specifically for DMVOs. Due to the rapidly evolving literature on this topic, remaining up to date on DMVO definitions, anatomy, management, imaging, and clinical course is difficult. In this review article, we synthesized existing literature regarding the aforementioned topics and discussed future directions.