Journal of NeuroInterventional Surgery最新文献

The Woven EndoBridge (WEB) device is a well established treatment for bifurcation aneurysms.1-6 However, failed detachment after deployment can present significant challenges. In this technical video (video 1), we report on a patient with a left middle cerebral artery (MCA) bifurcation aneurysm treated with the WEB device. Despite satisfactory deployment, multiple detachment attempts were unsuccessful. After repeated maneuvers, the WEB was finally detached but slightly protruded from the aneurysm sac, compromising blood flow in the superior branch of the MCA. Even after placing an Atlas stent, blood flow was not restored. Ultimately, using a microguidewire and microcatheter, we repositioned the protruded WEB device back into the aneurysm sac, successfully restoring blood flow. This case illustrates that the Atlas stent provides limited support for the WEB device. In similar situations, gently repositioning the protruded WEB back into the aneurysm sac may be a remedial measure. neurintsurg;jnis-2024-022430v1/V1F1V1Video 1Technical video demonstrating rescue techniques for managing intravascular mechanical obstruction following detachment of the WEB device.

Residual brain arteriovenous malformations (BAVMs) following stereotactic radiosurgery are not uncommon and the optimal subsequent management remains undetermined.1-3 Endovascular embolization has been reported as an effective treatment for residual BAVMs after radiosurgery,4 5 and has the advantage over repeat radiosurgery in selected cases as angiographic weak points can be secured immediately and the risk of radiation-induced complications is less of a concern.6 7 In this technical video (video 1), we demonstrate the transvenous embolization of a previously-irradiated arteriovenous malformation and a persistent venous pouch using the retrograde pressure cooker technique, with emphasis on the important recommendations for avoiding periprocedural complications.neurintsurg;jnis-2024-022035v1/V1F1V1Video 1Video demonstrating Onyx embolization of the residual brain arteriovenous malformation using the retrograde pressure cooker technique.

Coil migration poses a significant intraprocedural risk during coil embolization in interventional neuroradiology procedures. In this technical video we describe the technique of removal of errand coils using the low profile Tigertriever-13 device.1 Traditional methods of errant coil retrieval rely on the use of stent retrievers;2 however, these devices are usually too large to fit through smaller inner diameter 0.013-0.0165 inch coiling catheters, thus requiring upsizing materials in emergency situations.3 We demonstrate the technique of coil retrieval using this low-profile device ex-vivo in silicone flow models, then its application in vivo as a 'bail-out' technique during acute embolization of a ruptured peri-callosal aneurysm which required retrieval of errant coils (video 1).neurintsurg;jnis-2024-021923v1/V1F1V1Video 1Errant coil retrieval using the Tigertriever device.

Video 1 shows three cases of intraoperative rupture during aneurysm coiling. Management of intraoperative aneurysm rupture is reviewed in brief, including reversal of anticoagulation/antiplatelets, intracranial pressure control, and rapid balloon deployment for control across the aneurysm neck. However, in all three cases, contrast extravasation continues despite aneurysm coiling, reversal of anticoagulation, and maximizing medical management. This is presumed to occur when the neck of the aneurysm is the site of rupture. We review the use of a salvage technique that can be considered as a last-ditch maneuver in these scenarios, which is deployment of Onyx liquid embolic (Medtronic). Onyx is the preferred liquid embolic for this use as it is cohesive instead of adhesive. The solvent used with Onyx, dimethyl sulfoxide, is also compatible with standard balloons.1 This is relevant because a balloon is needed both for control of hemorrhage during salvage embolization and for protection of the parent vessel from the embolic material.neurintsurg;jnis-2023-021402v1/V1F1V1Video 1Demonstrating the technique of Onyx embolization for salvage hemostasis after intraoperative aneurysm rupture during coiling. Three example cases are shown.

Middle meningeal artery embolization (MMAE) is an effective adjunctive treatment for chronic subdural hematomas and carries a low risk of significant complications.1 Here we describe the management of a retained and fractured microcatheter following liquid embolic MMAE. A patient with chronic recurrent subdural hematomas underwent bilateral MMAE with Onyx liquid embolic material (Medtronic). The Headway Duo (Microvention) microcatheter was placed in a small distal frontal branch of the middle meningeal artery to aid in reflux into the posterior middle meningeal artery branches. Following successful MMAE, the microcatheter became trapped within the Onyx cast and, on attempted removal, the microcatheter fractured, resulting in a retained fragment extending from the middle meningeal artery cast to the guide catheter in the common carotid artery.To retrieve the fractured microcatheter, a stent retriever was deployed and resheathed multiple times until the retained microcatheter became visibly entangled with the stent retriever. Next, the stent retriever was pulled back into the guide catheter and continuous aspiration was performed through the guide catheter, and the fragmented microcatheter was successfully removed in entirety. Final angiography demonstrated no further catheter fragments, vessel damage, extravasation, flow limitation, or thromboembolic complications.Methods to avoid the complication include using a detachable tip microcatheter, dual lumen balloon microcatheter, allowing less reflux, embolizing from a larger caliber branch, and a slower microcatheter pull. Additional methods for managing the complication include using a snare, leaving the retained microcatheter and putting the patient on aspirin, and carotid stenting to tack the fractured portion down (video 1).neurintsurg;jnis-2024-022279v1/V1F1V1Video 1 Management of a fractured microcatheter during middle meningeal artery embolizationThis case demonstrates the successful use of a stent retriever and aspiration to retrieve a retained and fractured microcatheter following liquid embolic MMAE.

Background: In the neonatal period, transfemoral access may be complicated by sheath size needed for embolization, especially if retreatment is required. A viable alternative is access through an umbilical artery (UA) which allows for preservation of the femoral artery for access in future intervention.

Methods: We conducted a retrospective study from January 2014 to March 2023, focusing on 19 vein of Galen malformation, dural arteriovenous (AV) fistula, and pial AV fistula cases treated via transumbilical (TU) access for endovascular embolization in neonates.

Results: TU access was achieved successfully in 20 out of 21 intended cases, with a 4 French sheath placed intraprocedurally in all instances. We observed a median retreatment time of 7 months for patients requiring subsequent femoral artery access, highlighting the importance of preserving femoral access for future interventions. There were no complications associated with TU access or sheath retention and no procedural mortality attributed to this approach. Despite intraprocedural and periprocedural complications of other etiologies (including post-procedural hemorrhages and fever requiring antibiotic treatment), the TU approach demonstrated overall safety and efficacy.

Conclusions: Our findings align with previous reports of TU access in vascular malformations, emphasizing its role as a vital technique in neonatal neurointervention. The TU approach offers advantages such as sparing femoral arteries for future treatments and potential applicability to other high-flow brain fistulas. Our study contributes to the growing body of evidence supporting the use of TU access in neonatal neuroendovascular interventions, underscoring its importance in managing complex vascular malformations in this vulnerable population.

Background: Transcranial Doppler (TCD) is a non-invasive, bedside tool that allows for real-time monitoring of the patient's hemodynamic status following mechanical thrombectomy (MT). This systematic review and meta-analysis aims to evaluate the predictive value of TCD parameters following successful MT (Thrombolysis in Cerebral Infarction 2b-3).

Methods: In July 2024, we searched PubMed, Embase, and Scopus, to identify observational studies in which TCD parameters were measured within 48 hours of MT. Using random-effects models, we compared four TCD parameters (mean flow velocity (MFV), MFV index, pulsatility index (PI), and peak systolic velocity (PSV) among groups with vs without hemorrhagic transformation (HT) and favorable vs poor functional recovery (modified Rankin Scale 0-2 vs 3-6).

Results: Eleven studies comprising 1432 patients (59% male; mean age range: 63-73 years) were included. The MFV and MFV index were higher in patients with HT (Hedges' g=0.42 and 0.54, P=0.015 and 0.005, respectively). Patients with MFV index ≥1.3 showed a higher risk of all HT (RR 1.97; 95% confidence interval (CI) 1.28 to 3.03, P=0.002), symptomatic HT (RR 4.68; 95% CI 1.49 to 14.65, P=0.008), and poor functional status at 90 days (RR 1.65; 95% CI 1.27 to 2.14, P=0.029), respectively. There was no difference in mean PSV (P=0.1) and PI (P=0.3) among groups with and without HT.

Conclusion: This study underscores the prognostic value of the MFV index in predicting HT, symptomatic HT, and poor functional recovery after successful MT in the anterior circulation. Large-scale, multi-center studies are necessary to confirm these findings and to validate the MFV index as a reliable predictor for improving post-thrombectomy care.

Background: Despite the increasing use of non-invasive imaging, DSA remains the gold standard for cerebrovascular imaging. However, trends in DSA utilization are poorly understood. The goal of this study was to describe DSA utilization in a large claims database in the US over a 13 year period.

Methods: This retrospective cohort study assessed a nationwide database of privately insured individuals from 2005 to 2018 for patients undergoing cranial CT angiography (CTA), MR angiography (MRA), and DSA. We assessed trends in the overall use of and indications for each modality. For DSA, we examined the types of performing proceduralists.

Results: Among patients undergoing DSA in 2018, median age was 52 years, and 60% were women. MRA and DSA use decreased, from 289 to 275 claims, and from 38 to 29 claims per 100 000 enrollees, respectively, while CTA use increased from 31 to 286 claims per 100 000 enrollees. These trends differed by geographic region and indication. Nearly half of DSA procedures but <25% of non-invasive imaging were inpatient studies. DSA performed by neurosurgeons increased from 0.5 to 4.1 while those performed by radiologists decreased from 7.2 to 4.0 studies per 100 000 enrollees.

Conclusions: DSA use decreased slightly while CTA use increased by ninefold. The reasons for this change are likely complex and may reflect more aggressive imaging for stroke, increased detection of incidental findings, and increased quality of non-invasive imaging. Over time, the proportion of DSA procedures performed by neurosurgeons overtook that performed by radiologists.

Background: We compared the outcomes of wide necked aneurysms (WNA) treated with the Neuroform Atlas with those treated with the low profile visualized intraluminal stent (LVIS) or the Woven EndoBridge (WEB).

Methods: Objective, prospectively collected, core laboratory adjudicated data from published trials for the Neuroform Atlas, LVIS, and WEB devices were reviewed. ATLAS (Safety and Effectiveness of the Treatment of Wide Neck, Saccular Intracranial Aneurysms With the Neuroform Atlas Stent System) study patients were included if they met other studies' inclusion criteria. Outcomes included (1) primary effectiveness (complete aneurysmal occlusion without retreatment/>50% parent vessel stenosis), (2) primary safety, (3) complete aneurysmal occlusion, and (4) retreatment rates (outcomes evaluated at the 12 month follow-up). Matching adjusted indirect comparison analysis was used to compare outcomes.

Results: Analytical samples included 141 ATLAS subjects meeting WEB-IT (Woven EndoBridge Intrasaccular Therapy Study) criteria (ATLAS/WEB-IT) and 241 meeting LVIS (Pivotal Study of the Low Profile Visualized Intraluminal Support) criteria (ATLAS/LVIS). ATLAS/WEB-IT exhibited significantly higher rates of primary effectiveness and complete occlusion versus WEB (86.6% vs 53.9 %, P<0.0001, and 90.3% vs 53.9%, P<0.0001, respectively). For LVIS, there was no significant differences in primary effectiveness rates between ATLAS and LVIS (84.2% vs 77.7%, respectively, P=0.12). However, ATLAS/LVIS had a significantly higher proportion of patients achieving complete occlusion than LVIS (88.1 vs 79.1, P=0.03). Retreatment rates and primary safety outcomes were not significantly different (P>0.05) for the Atlas versus other devices except for a lower retreatment rate for ATLAS/WEB-IT versus WEB-IT (2.4% vs 9.8%, P=0.01).

Conclusion: The Neuroform Atlas provided higher occlusion rates and similar retreatment rates in comparable datasets compared with LVIS and WEB devices when treating WNA.

Background: There is evidence that frailty is an independent predictor of worse outcomes after stroke. Similarly, although obesity is associated with a higher risk for stroke, there are multiple reports describing improved mortality and functional outcomes in higher body mass index (BMI) patients in a phenomenon known as the obesity paradox. We investigated the effect of low BMI on outcomes after mechanical thrombectomy (MT).

Methods: We conducted a retrospective analysis of 231 stroke patients who underwent MT at an academic medical center between 2020-2022. The patients' BMI data were collected from admission records and coded based on the Centers for Disease Control and Prevention (CDC) obesity guidelines. Recursive partitioning analysis (RPA) in R software was employed to automatically detect a BMI threshold associated with a significant survival benefit. Frailty was quantified using the Modified Frailty Index 5 and 11.

Results: In our dataset, by CDC classification, 2.6% of patients were underweight, 27.3% were normal BMI, 30.7% were overweight, 19.9% were class I obese, 9.5% were class II obese, and 10% were class III obese. There were no significant differences between these groups. RPA identified a clinically significant BMI threshold of 23.62 kg/m². Independent of frailty, patients with a BMI ≤23.62 kg/m² had significantly worse overall survival (P<0.001) and 90-day modified Rankin Scale (P=0.027) than patients above the threshold.

Conclusions: Underweight patients had worse survival and functional outcomes after MT. Further research should focus on the pathophysiology underlying poor prognosis in underweight MT patients, and whether optimizing nutritional status confers any neuroprotective benefit.