Interventional Neuroradiology最新文献

Background: The Woven EndoBridge (WEB) device is increasingly used for treatment of wide-neck bifurcation aneurysms. With the newer 17 system, WEB deployment has been associated with a phenomenon known as incomplete or "sticky" detachment from the delivery wire, which may lead to imprecise placement. Optimal techniques for WEB manipulation and delivery to avoid this problem are poorly defined. This study aimed to evaluate standard WEB deployment techniques and determine the impact of delivery techniques and WEB stickiness on procedural success.

Methods: An in vitro study using identical silicone middle cerebral artery aneurysm models (n = 32) assessed WEB (6 × 2 mm) deployment through a VIA 17 microcatheter via three techniques that involved: "loading," "neutral," and "tension" on the pusher wire. Microcatheter position was placed in varied positions from the WEB device. Woven EndoBridge stickiness was graded during detachment attempts. Primary outcomes were detachment stickiness and attempt number, compared between techniques using Fisher's exact test.

Results: The tension technique resulted in significantly fewer sticky detachments and detachment attempts compared to forward load or neutral techniques (p < 0.001). Sticky detachment was lower with tension (0% sticky) versus forward load (42% sticky, 8% very sticky) (p < 0.001). Forward load had a 50% rate of stickiness versus 0% with tension and neutral (p < 0.001). Forward load required multiple attempts in 100%, compared to 57% with neutral and 8% with tension (p < 0.001). Higher stickiness grades increased the need for multiple attempts (p < 0.001).

Conclusion: The tension technique reduces incomplete WEB detachment and enables precise single-attempt detachment, optimizing delivery precision. In vivo confirmation is needed.

Lumbar synovial cysts (LSC) that protrude into the spinal canal can cause lower back pain, neurogenic claudication, and radiculopathy. Often diagnosed in the elderly population (typically ∼60 years of age) with a slight preponderance for females, their underlying etiology is thought to be due to degeneration of the adjacent facet joint, with the most common location at the level of L4-L5. Treatment of LSC can be conservative (with NSAIDs and physical therapy), percutaneous (with rupture), or surgically (with decompression with or without fusion). Percutaneous treatment of LSC involves rupturing the cyst by injecting it with steroids and local anesthetics. Although this option is less invasive than surgery, multiple studies have documented recurrence with this method and patients eventually undergoing surgical intervention. In this report, we document a case where a patient who presented with a symptomatic LSC underwent successful percutaneous treatment with bleomycin.

Background: We (1) evaluated the effect of aspiration tubing diameter on intraluminal pressure and (2) compared thrombectomy outcomes in patients treated using small diameter tubing versus those treated using large diameter vacuum tubing.

Methods: Intraluminal negative pressure was measured in a validated benchtop set up where consistency of negative pressure (inHg) was measured between static and dynamic aspiration. Static aspiration refers to activation of vacuum once the catheter is engaged with the clot. Dynamic aspiration refers to activation of vacuum when the catheter is slightly proximal to the clot. Four different sizes of vacuum tubing were trialed. We performed a retrospective analysis of consecutive patients who underwent mechanical thrombectomy. Procedural and functional outcomes were compared.

Results: The large diameter aspiration tubing held a consistent high negative pressure in static and dynamic aspiration (p = 0.152). Tubing types I to III were associated with a significant fall off in negative pressure between static and dynamic technique (p < 0.05). Two-hundred and five patients were included in the retrospective analysis; 124 (60%) underwent thrombectomy using small diameter vacuum tubing, and 81 (40%) using the large tubing. Mean thrombectomy time was shorter with the larger tubing [25.9 (17.9) minutes] versus the small tubing [37.5 (28.5) minutes, p = 0.002]. A greater proportion of patients had a thrombolysis in cerebral infarction score ≥2b in the group treated using the large tubing (78, 99%) than those with the small tubing (96, 78%, p < 0.001).

Conclusion: Vacuum tubing diameter is linearly associated with intraluminal aspiration pressure. These findings have clinical significance as shown by increased recanalization rates and decreased thrombectomy times when large-diameter aspiration tubing is used. Shifting the paradigm toward a flow-based technique using large-bore vacuum tubing ought to be considered.

Background and objective: Cerebrospinal fluid (CSF) diversion is typically performed with an external ventricular drain (EVD) for symptomatic hydrocephalus (HCP) following subarachnoid hemorrhage (SAH). Lumbar drain (LD) has also been studied to reduce the incidence of vasospasm after SAH but not HCP. We performed a single center retrospective analysis to evaluate the safety of LD versus EVD for symptomatic HCP following aneurysmal SAH in a naturally randomized patient population.

Methods: Patients admitted for aneurysmal SAH who developed symptomatic HCP were treated with EVD or LD depending on neurosurgeon on call. Of the 10 neurosurgeons on call, five would place EVD in all patients while the other five would request LD be placed by interventional neuroradiology; however, the distribution on call was not evenly distributed. We retrospectively compared these two groups for drain complications and outcomes with Modified Rankin Scale (mRS).

Results: From 2018 to 2021, there were a total of 77 patients with aneurysmal SAH requiring CSF diversion for HCP. There were 56 cases of EVD placement and 21 cases of LD placement. Overall drain complications were 32.0% of cases with EVD and 9.5% with LD, p = .0773. EVD versus LD complications consisted of hemorrhage (1.8% vs 0%, p = 1.0000), infection (7.1 vs 0%, p = .5698), clogged (25% vs 0%, p = .008), dislodgement (1.8% vs 4.6%, p = .4737) and replacement (16% vs 4.8%, p = .2698). No case of cerebellar tonsillar herniation occurred. mRS between EVD versus LD obtained at baseline (0.3 vs 0.3, p = .3943), discharge (3.8 vs 2.7, p = .047), 90 days (2.9 vs 2.0, p = .060), and 1 year (2.6 vs 1.6, p = .081). One year mortality rates between EVD versus LD (26.8% vs 19.0%, p = .483).

Conclusion: Symptomatic HCP after aneurysmal SAH can be effectively and safely treated with LD. LD had lower overall complications than EVD with no hemorrhage, infection or malfunction. Further prospective randomized control study may be helpful in elucidating optimal CSF diversion for patients with symptomatic HCP.

Background: Although transfemoral carotid artery stenting (CAS) is widely performed for carotid stenosis, serious or even fatal complications such as embolic and access site complications can still occur. We devised a novel dual protection system with continuous flow reversal to the cephalic vein of the forearm in transradial CAS, referred to as the "trans-forearm dual protection" technique.

Methods: A 75-year-old man with a diagnosis of symptomatic left cervical internal carotid artery (ICA) stenosis underwent CAS using the trans-forearm dual protection technique.

Results: A 4F sheath was introduced into the cephalic vein of the right forearm. After an 8F balloon-guiding catheter was navigated into the left common carotid artery (CCA) via right sheathless radial access, a distal filter protection device was advanced into the high cervical ICA. The 8F balloon-guiding catheter was inflated and connected to the 4F sheath with a blood filter interposed. Under the dual protection of flow reversal and distal filter, the CAS procedure was performed. The postprocedural course was uneventful. Diffusion-weighted imaging 2 days after the procedure showed no evidence of ischemic stroke. The patient was discharged home without any complications 1 week after the procedure. Carotid duplex ultrasound performed 9 months after the procedure showed no signs of restenosis.

Conclusions: This method allows for CAS under the dual protection of flow reversal and filter device protection via the trans-forearm access, reducing the risk of embolism and access site complications. Therefore, the trans-forearm dual protection technique can be a useful option for CAS.

Background: Radiographic visualization of liquid embolic agents (LEAs) during embolization procedures in neurovascular territory represents a crucial feature to ensure efficacy and safety for the patients during endovascular treatment of arteriovenous shunting lesions. Radiopacity of available LEAs varies significantly and limited methods are currently available for comparison. The purpose of this study was to compare the contrast resolution (CR) during injection under blank roadmap of various LEAs, as well as standard contrast material.

Methods: An injectable angiographic phantom was designed consisting of parallel tubings between 313 and 1000 micron. Under roadmap, eight radiopaque liquid agents were injected and analyzed: Onyx18^®, 34^® Squid^®12, 18, PHIL^®25% (PHIL^®25), PHIL^®30% (PHIL^®30).Trufill^TM (NBCA), 30% dilution and Omnipaque^®300. CR was evaluated as a contrast to noise ratio (CNR) and calculated as mean peak signal (Sa) minus mean background signal (Sb) divided by the standard deviation of the background signal (Std) $(CNR=\frac{Sa-Sb}{Std})$.

Results: Omnipaque 300 and NBCA were found to have the highest CR. PHIL^®25 demonstrated the lowest CNR (45% of Omnipaque CNR). Onyx 18 and 34 (Both around 82% of Omnipaque CNR) demonstrated higher CNR compared to Squid^®12 and 18 (52-55% of Omnipaque CNR). On average, at 500 micron there is a >70% reduction in CNR, and at 313 micron there is a 90% reduction in CNR compared to 1000 micron.

Conclusions: Significantly different CNR between most LEAs and iodinated contrast media was evident under roadmap conditions and should be considered prior to injection.

Background: Endovascular treatment with the woven endobridge (WEB) device has been widely utilized for managing intracranial aneurysms. However, predicting the probability of achieving adequate occlusion (Raymond-Roy classification 1 or 2) remains challenging.

Objective: Our study sought to develop and validate a predictive calculator for adequate occlusion using the WEB device via data from a large multi-institutional retrospective cohort.

Methods: We used data from the WorldWide WEB Consortium, encompassing 356 patients from 30 centers across North America, South America, and Europe. Bivariate and multivariate regression analyses were performed on a variety of demographic and clinical factors, from which predictive factors were selected. Calibration and validation were conducted, with variance inflation factor (VIF) parameters checked for collinearity.

Results: A total of 356 patients were included: 124 (34.8%) were male, 108 (30.3%) were elderly (≥65 years), and 118 (33.1%) were current smokers. Mean maximum aneurysm diameter was 7.09 mm (SD 2.71), with 112 (31.5%) having a daughter sac. In the multivariate regression, increasing aneurysm neck size (OR 0.706 [95% CI: 0.535-0.929], p = 0.13) and partial aneurysm thrombosis (OR 0.135 [95% CI: 0.024-0.681], p = 0.016) were found to be the only statistically significant variables associated with poorer likelihood of achieving occlusion. The predictive calculator shows a c-statistic of 0.744. Hosmer-Lemeshow goodness-of-fit test indicated a satisfactory model fit with a p-value of 0.431. The calculator is available at: https://neurodx.shinyapps.io/WEBDEVICE/.

Conclusion: The predictive calculator offers a substantial contribution to the clinical toolkit for estimating the likelihood of adequate intracranial aneurysm occlusion by WEB device embolization.

Introduction: Thirty-three-year-old female underwent diagnostic work-up for chronic headaches.

Case report: Cerebral DSA on the right side showed fetal posterior cerebral artery (PCA) with unusually shaped arterial malformation on its proximal part. Malformation was formed by multiple convolutions and loops with no arteriovenous shunting. During endovascular procedure, flow diverter stent was placed in the right C6 segment. Patient was put on double antiaggregation therapy. Four weeks after procedure, patient was admitted to ER with signs of dyphasia. No recent ischemic lesions were detected on emergent magnetic resonance. Dyphasia resolved spontaneously. On follow-up magnetic resonance angiography 5 years after the procedure, main portion of malformation has diminished with slightly filling of posterior part supplied by right P1.

Discussion: Here, reported finding is consistent with previously described pure arterial malformation (PAM). Main intention of our treatment was to induce malformation remodeling with flow diverter placement. Two main risks arise when using flow diverters on fetal PCA region. Firstly, there is possibility of occluding fetal PCA alongside malformation. On the contrary, high flow through fetal PCA could hinder malformation thrombosis. Some case series reported high rate of fetal PCA occlusion without ischemic sequelae in the PCA teritory. Others consider flow diverters highly ineffective treatment for the fetal PCA aneurysms due to low rate of complete aneurysm occlusion.

Conclusion: We presented first reported case in which flow diverter was used to treat PAM. Slow malformation thrombosis leaves enough time for collateral circulation to recruit and supply territory of the vessel affected by the malformation.

Background and purpose: This study aims to elucidate the early changes in blood biochemistry thrombosis parameters following stent-assisted endovascular treatment of intracranial aneurysms.

Methods: Consecutive patients with unruptured aneurysms undergoing stent implantation during endovascular treatment were included in this prospective study with approval from the local ethics committee. Blood samples were collected immediately before and 24 h after the procedure for biochemical analysis, including basic thrombosis indicators, bleeding tests, and a complete blood count.

Results: The study included 80 patients (60 women, 20 men) with 134 aneurysms. A total of 135 stents (110 flow-diverting, 25 standard) were used. Additionally, intrasaccular coiling was utilized in 28 aneurysms among 27 patients. Following the procedure, there was a significant decrease in activated partial thromboplastin time, fibrinogen, hemoglobin, and platelet levels, and a significant increase in prothrombin time, D-dimer, von Willebrand factor (vWF) activity/antigen ratio, and leukocyte levels in all patients. Correlation analyses revealed significant positive associations between platelet and fibrinogen levels, and a negative association between D-dimer and fibrinogen levels in the coil (-) group. Additionally, there was a significant negative correlation between aneurysm volume and vWF activity/antigen ratio, and procedure duration and thrombocyte count, while a positive association was found between aneurysm number and leukocyte count in the coil (-) group.

Conclusions: Analysis of blood chemistry alterations indicates that intravascular thrombosis occurs in the intracranial circulation following stent-assisted endovascular treatment of intracranial aneurysms. This thrombotic process is more pronounced in patients whose aneurysms were left open (i.e. flow-diverting stent alone).