Interventional Neuroradiology最新文献

Advances in mechanical thrombectomy (MT) devices have reduced mortality and improved the quality of life among stroke patients. Favorable (mRS 0-2 at 90 days) post-procedure outcomes depend heavily upon the degree of recanalization. Fibrin-rich thrombi pose a major impediment to adequate (TICI 2B) clot retrieval, as their firm composition resists extraction. We describe a low-temperature plasma process for modifying stent retrievers with fibrinogen. Fibrinogen binding translates into greater efficacy in capturing fibrin-rich clots in vitro. This advance may improve MT outcomes through faster and more complete clot retrievals.

BackgroundIn-stentstenosis (ISS) is a recognized complication following flow-diverting stent placement for intracranial aneurysms. Although typically asymptomatic and self-resolving, severe cases may result in ischemic complications. Gold-standard detection relies on invasive digital subtraction angiography (DSA). This study sought to determine whether quantitative magnetic resonance angiography with non-invasive optimal vessel analysis (qMRA NOVA) can accurately identify patients with ISS following flowdiverter placement.MethodsThis retrospective study evaluated 373 patients treated with flow-diverting stents at a single institution between 2017 and 2023. Sixteen patients met the inclusion criteria for DSA-confirmed ISS with matched post-procedure and follow-up NOVA imaging and catheter angiography. Vessel flow, velocity, and diameter were analyzed. Receiver operating characteristic (ROC) analysis was used to determine optimal thresholds for detecting ISS based on flow changes.ResultsAmong ISS patients, 88% demonstrated significant flow reductions in the treated vessel on follow-up NOVA (mean decrease: 76.2 ± 65.0 ml/min, P = .0002). ROC analysis showed that the percent change in ICA flow had high discriminative ability, with optimal thresholds demonstrating sensitivity of 86% and negative predictive value (NPV) of 98%. A dual-threshold model combining ≥40 mL absolute and ≥20% relative ICA flow reduction afforded improved specificity (75%) while maintaining high NPV (97%).ConclusionsNOVA is a sensitive non-invasive tool for early ISS detection following flow diversion, potentially detecting subclinical ISS patients that should undergo subsequent angiography, while also reducing the need for early angiography in patients unlikely to have ISS or repeated angiography to follow-up ISS.

BackgroundFlow diverter stent (FDS) treatment is an effective option for wide-necked intracranial aneurysms, but adequate neointimal formation and stent apposition are critical to prevent thromboembolic complications. Non-invasive, reliable imaging techniques for assessing neointimal formation remain limited. This study aimed to evaluate the utility of Dyna-3D imaging in assessing neointimal formation after FDS treatment and to compare its performance with conventional 2D-DSA.MethodsThis retrospective study included 61 patients with unruptured intracranial aneurysms treated with FDS between August 2019 and October 2024. Radiological follow-up was performed 3-6 months post-procedure using both 2D-DSA and Dyna-3D imaging. Neointimal coverage was classified into Groups A-C based on the positional relationship between the stent wires and the vessel wall (Group A = wire outside; Group B = partial overlap; Group C = the vessel wall outside). Interobserver agreement, imaging accuracy, and associated clinical factors were analyzed.ResultsComplete neointimal formation (Group A) was identified in 51 cases (83.6%; 95% CI 72.4-90.8) using Dyna-3D and 21 cases (34.4%; 95% CI 23.7-47.0) using 2D-DSA (P < .0001). Dyna-3D demonstrated superior interobserver agreement (Cohen's κ=0.893; 95% CI 0.75-1.00) compared to 2D-DSA (κ=0.459; 95% CI 0.28-0.64) in the evaluation of neointimal formation. Multivariate analysis identified younger age as a significant factor associated with Group A classification across both modalities (2D-DSA: OR 0.93, 95% CI 0.88-0.98, P = .008; Dyna-3D: OR 0.90, 95% CI 0.8-0.97, P = .018). No thromboembolic or hemorrhagic complications were identified during follow-up.ConclusionDyna-3D imaging provides superior visualization of neointimal formation compared to conventional 2D-DSA and enables comprehensive circumferential assessment of stent apposition. These findings suggest that Dyna-3D may offer a useful tool for guiding post-FDS treatment management, including the potential for age-adjusted optimization of antiplatelet therapy duration.

Wide neck bifurcation aneurysms are treated by intrasaccular implants, stent-assisted coiling, or flow diverters (FDs). The latter two options require long-term dual anti-platelet agents (DAPTs) and the former require access to the vulnerable aneurysm dome.^{1- 5} In patients requiring oral anticoagulation (OAC), an alternative treatment strategy would be advantageous to mitigate the foregoing risks. This report describes using a dedicated bifurcation FD, eCLIPs eBFD, to treat a basilar tip bifurcation aneurysm in a patient with atrial fibrillation requiring long-term OACs. The non-tubular eBFD aneurysm neck-bridging implant provides coil-retaining and flow diverting features and serves as a platform for endothelial growth.^{6, 7} It has shown flow velocity reduction at a bifurcation equivalent to a tubular FD at a sidewall.⁸ In this case, eBFD, without coils, resulted in protracted intrasaccular stasis and resulted in complete aneurysm occlusion and neck remodeling within three months of discontinuation of dual anti-platelet therapy, without interrupting OAC.

Giant, partially thrombosed intracranial aneurysms (GPTIAs) remain among the most technically challenging cerebrovascular lesions to treat, particularly in patients with associated cranial nerve or brainstem compression. Unlike microsurgical clipping with or without decompression, endovascular coiling, parent vessel flow diversion, or parent vessel occlusion, intrasaccular embolization presents a unique opportunity for immediate aneurysm occlusion and reduction of mass effect without requiring long-term antiplatelets or parent vessel compromise. However, to date, no prior intrasaccular devices were available to treat GPTIAs, including the Food and Drug Administration-approved Woven EndoBridge device which could only accommodate aneurysms up to ∼11 mm in width. Here, we present the technical feasibility, safety, and efficacy of minimally invasive endovascular intrasaccular aneurysm embolization for GPTIAs with the novel saccular endovascular aneurysm lattice (SEAL) XL device engineered with a dual-layer mesh design and an expanded size matrix aneurysms up to 20 mm in diameter. Further data from larger prospective case series are needed to validate these promising initial findings.

Labial arteriovenous malformations (AVMs) pose a great challenge due to their location, angiogenic potential, and recurrence rate. Emerging treatments include sclerotherapy, such as intra-arterial bleomycin, which has been proven safe and effective in adults; however, there is limited literature available for children. Here, we present two successful cases of intra-arterial bleomycin use for treating lip AVMs in children, resulting in complete cure and no recurrence after a two-year follow-up period. Our findings support the limited but growing body of literature that presents intra-arterial bleomycin as a safe and viable option for pediatric facial AVMs.

Background and purposeIntracranial arteriovenous shunts (IAVS) are rare vascular diseases in infants. They can be categorized into vein of Galen aneurysmal malformation (VGAM), pial arteriovenous fistula (PAVF), and dural arteriovenous fistula associated with dural sinus malformation (DAVF/DSM). We sought to review the clinical presentation, imaging characteristics, endovascular treatment (EVT), and outcomes of IAVS in infants presenting to a quaternary pediatric referral center over one decade.MethodsA retrospective review of a prospectively maintained database was performed of all infants diagnosed with IAVS between January 2011 and January 2021 in a quaternary pediatric referral center. For each patient, demographic data, clinical presentation, imaging findings, management strategies, and outcomes were reviewed and discussed.ResultsOver the study period, 38 consecutive infants were diagnosed with IAVS. Patients with VGAM (23/38, 60.5%) presented with congenital heart failure (CHF) (14/23), hydrocephalus (4/23), and seizures (2/23), and three patients were asymptomatic. Eighteen patients with VGAM underwent EVT. Among those, 13 patients (72.2%) were successfully treated with an angiographic cure and three patients (3/18, 17%) died. Patients with PAVF (9/38, 23.7%) presented with CHF (5/9), intracranial hemorrhage (2/9), and seizures (2/9), and all of them were successfully treated endovascularly. Patients with Type I DAVF/DSM (4/6, 66.6%) presented with mass effect (2/4), cerebral venous hypertension (1/4), CHF (1/4), and cerebrofacial venous metameric syndrome (1/4). Patients with type II DAVF/DSM (2/6, 33.3%) presented with a thrill behind the ear. Patients with DAVF/DSM were treated endovascularly, five patients were cured, and one with type I DAVF/DSM died.ConclusionIntracranial arteriovenous shunts are rare but potentially life-threatening neurovascular pathologies in infants. Endovascular treatment is challenging but feasible in carefully selected patients.

BackgroundFor stent-retriever (SR) thrombectomy, technical developments such as the Push and Fluff technique (PFT) appear to have a significant impact on procedural success. This study aimed to (1) quantify the enhancement in clot traction when using PFT as compared to the standard unsheathing technique (SUT) and (2) to evaluate the performance of PFT in new versus established users of the technique.MethodsOperators were divided between established PFT and SUT users. Each experiment was labeled according to the SR size, utilized technique, and operator experience. A three-dimensional-printed chamber with a clot simulant was used. After each retriever deployment, the SR wire was connected to a force gauge. Tension was applied by pulling the gauge until clot disengagement. The maximal force was recorded.ResultsA total of 167 experiments were performed. The median overall force to disengage the clot was 1.11 pounds for PFT and 0.70 pounds for SUT (an overall 59.1% increment with PFT; p < 0.001). The PFT effect was consistent across different retriever sizes (69% enhancement with the 3  ×  32mm device, 52% with the 4  ×  28mm, 65% with the 4  ×  41mm, 47% with the 6  ×  37mm). The ratio of tension required for clot disengagement with PFT versus SUT was comparable between physicians who were PFT versus SUT operators (1.595 [0.844] vs. 1.448 [1.021]; p: 0.424). The PFT/SUT traction ratio remained consistent from passes 1 to 4 of each technique in SUT users.ConclusionPFT led to reproduceable improvement in clot engagement with an average ∼60% increase in clot traction in this model and was found not to have a significant learning curve.