Journal of NeuroInterventional Surgery最新文献

Background: Intracerebral hemorrhage (ICH) is a common stroke subtype with high morbidity and mortality. The optimal surgical approach remains unclear. This study compared the efficacy and cost-effectiveness of three minimally invasive surgeries-endoscopic surgery, frameless navigated aspiration, and small-bone flap craniotomy-in patients with hypertensive basal ganglia ICH.

Methods: In this parallel-group, multicenter randomized trial at 16 centers (July 2016 to June 2022), 515 patients were randomly assigned to endoscopic surgery (n=169), navigated aspiration (n=177), or craniotomy (n=169). The primary outcome was favorable functional outcome (modified Rankin Scale 0-2) at 6 months. Economic evaluation included hospitalization costs and quality-adjusted life years (QALYs).

Results: Among the 515 enrolled patients, 468 completed the 6-month follow-up. Favorable outcomes occurred in 29.7% (46/155) of the endoscopy group, 28.1% (45/160) of the aspiration group, and 15.7% (24/153) of the craniotomy group (P=0.007). Mean hospitalization costs were ¥91 517 ($12 853), ¥77 786 ($10 925), and ¥101 208 ($14 214), respectively (P<0.001). Endoscopy produced an incremental QALY gain of 0.0665 with cost savings of ¥13 660 ($1919) versus craniotomy, while aspiration achieved a QALY gain of 0.0545 and cost savings of ¥29 423 ($4132), indicating dominance for both minimally invasive strategies.

Conclusions: For patients with hypertensive basal ganglia ICH, both endoscopic surgery and frameless navigated aspiration can improve long-term outcomes compared with small-bone flap craniotomy, while also reducing medical costs. Among the three treatments, aspiration provided the most favorable incremental cost-effectiveness profile.

Trial registration number: NCT02811614.

Background: Current clinical decision tools for assessing the risk of symptomatic intracranial hemorrhage (sICH) in patients with vertebrobasilar artery occlusion (VBAO) who received endovascular treatment (EVT) have limited performance. This study develops and validates a clinical risk score to precisely estimate the risk of sICH in VBAO patients.

Methods: The derivation cohort recruited patients with VBAO who received EVT from the Posterior Circulation IschemIc Stroke Registry in China. Based on the posterior circulation-Alberta Stroke Program Early CT Score (pc-ASPECTS) evaluation method, the cohort was further divided into non-contrast CT (NCCT) and diffusion weighted imaging (DWI) cohorts to construct predictive models. sICH was diagnosed according to the Heidelberg Bleeding Classification within 48 hours of EVT. Clinical signature was constructed in the derivation cohort using machine learning and was validated in two additional cohorts from Asia and Europe.

Results: We enrolled 1843 patients who underwent EVT and had complete data. pc-ASPECTS of 1710 patients was evaluated on NCCT and 699 patients on DWI. In the NCCT cohort, 1364 individuals made up the training set, of whom 101 (7.4%) developed sICH. In the DWI cohort, the training set consisted of 560 individuals, with 44 (7.9%) experiencing sICH. Predictors of sICH were: glucose, pc-ASPECTS, time from estimated occlusion to groin puncture (EOT), poor collateral circulation, and modified Thrombolysis in Cerebral Infarction (mTICI) score. From these predictors, we derived the weighted poor collateral circulation-EOT-pc-ASPECTS-mTICI-glucose (PEACE) score. The PEACE score showed good discrimination in the training set (area under the curve (AUC)_NCCT=0.85; AUC_DWI=0.86), internal validation set (AUC_NCCT=0.81; AUC_DWI=0.82), and two additional external validation set (Asia: AUC_NCCT=0.78, AUC_DWI=0.80; Europe: AUC_NCCT=0.74, AUC_DWI=0.78).

Conclusion: The PEACE score reliably predicted the risk of sICH in VBAO patients who underwent EVT.

Background: To estimate the current number of middle meningeal artery embolization (MMAE) procedures for subdural hematomas (SDH) and project growth compared with endovascular treatments for cerebral aneurysms and acute ischemic stroke (AIS).

Methods: Estimates of SDH admissions were obtained from the National Inpatient Sample and Medicare Inpatient 100% Standard Analytic Files for 2019-23. MMAE volumes (2019-23) were estimated by cross referencing international classification of diseases, 10th revision, clinical modification (ICD-10 CM) codes for non-acute, non-traumatic SDH with ICD-10 procedure coding system (ICD-10 PCS) codes for surgical and endovascular interventions during the same admission to approximate MMAE volumes. These estimates were compared with volumes of endovascular cerebral aneurysm and AIS treatments, with projections based on historical growth rates.

Results: MMAE procedures increased significantly, from 4014 in 2019 to 20 836 in 2023, representing a 51% compound annual growth rate (CAGR). In comparison, endovascular aneurysm treatments grew from 34 754 to 42 491 (5% CAGR) and AIS procedures from 34 451 to 44 822 (7% CAGR). In the next 5 years, MMAE is projected to surpass other neurovascular procedures, with an estimated 79 483 procedures, compared with 79 405 for AIS and 56 942 for aneurysms, by 2029. Annual SDH admissions remained steady at just over 200 000 from 2019 to 2022, with most (~66%) managed medically. Only an estimated 2% of SDH admissions received an MMAE procedure in 2019, rising to 8% in 2022.

Conclusion: MMAE procedures have seen rapid adoption and may become the dominant neurovascular intervention, with potential implications for healthcare infrastructure and workforce planning.

Objective: To evaluate early and mid-term imaging and clinical outcomes following transvenous embolization of cerebrospinal fluid-venous fistulas (CSFVFs) in patients with spontaneous intracranial hypotension (SIH).

Methods: From November 2022 to November 2024, 60 consecutive patients with SIH and confirmed CSFVF underwent transvenous embolization using Onyx. Of these, 40 patients underwent brain MRI pre-treatment, 24 hours post-treatment, and at a 3-month follow-up. The primary outcome was regression of brain MRI abnormalities at 24 hours and 3 months. Secondary outcomes included rates of symptom improvement, predictors of clinical improvement, and complication rates.

Results: The mean patient age was 61 years, and 65% were female. All procedures were technically successful. The median SIH score significantly decreased from 6 pre-treatment to 3.5 at 24 hours (P=0.01) and to 2 at 3 months (P=0.004). Early improvement in SIH score correlated with clinical improvement at 24 hours (P=0.002), which was observed in 77.5% of patients. Pachymeningeal enhancement (87.5%) and venous sinus engorgement (75%) were the most common MRI abnormalities. Both findings regressed in approximately 50% of patients at 24 hours and in 80% of patients at 3 months. At 3 months, 82.5% of patients achieved complete clinical recovery. Rebound post-treatment headaches occurred in 32.5% of patients but resolved within 7 days. The morbidity rate was 0%.

Conclusions: Transvenous embolization of CSFVFs results in early and sustained clinical and imaging improvements in patients with SIH. These findings support the efficacy of this intervention as a primary treatment for CSFVFs.

Background: Timely endovascular thrombectomy (EVT) is crucial for improving outcomes in acute ischemic stroke (AIS). This study evaluated the effectiveness of a national quality improvement collaborative (QIC) in reducing process times for potential EVT candidates across a national stroke network.

Methods: A pre-post intervention design using a modified Breakthrough Series approach was implemented across 24 hospitals. Multidisciplinary teams participated in monthly learning sessions and action periods focused on reducing 'Door to Decision' (time from hospital arrival to EVT decision) to under 30 min. Mixed-effects linear models and mixed-effects ANOVA were used to analyse the impact of the QI program on Door to Decision and Door to CT times, comparing intervention and control cohorts.

Results: The QI program significantly reduced Door to Decision time in the intervention cohort by 15.9% (p<0.001) from a mean of 92.8 min to 78.9 min. Door to CT time also decreased by 15.6% (p<0.001). No significant changes were observed in the control cohort. Mixed-ANOVA revealed a significant interaction effect for both Door to Decision (p<0.004) and Door to CT (p<0.04), indicating that the QI program impacted these times as compared with the control group. The QIC effectively improved the efficiency of stroke care pathways across a national stroke network. This effect was sustained across the network and over time. This success was facilitated by a bottom-up approach, fostering collaboration and shared learning within and across hospitals.

Conclusions: This study demonstrates the effectiveness of a collaborative, network-wide QI program in reducing critical process times for AIS patients. Continued efforts to sustain these improvements and optimize stroke care pathways are warranted.

Background: The contact aspiration (CA) technique is often used to perform endovascular thrombectomy (EVT) for acute ischemic stroke (AIS); however, rescue strategies are necessary if CA fails to achieve recanalization. This study investigates the outcomes of incorporating stent retriever (SR) thrombectomy in the rescue strategy following failed CA.

Methods: EVT patients with failed CA attempts were identified from a large multicenter registry and stratified by rescue technique: CA alone or incorporating SR in the rescue strategy. Outcomes included successful recanalization, 90-day functional outcomes (defined by the modified Rankin Scale (mRS) score), symptomatic intracranial hemorrhage (sICH), and 90-day mortality.

Results: Among 1885 patients with failed CA attempts, conversion to SR was associated with higher recanalization rates (85.2% vs 80.6%; p=0.03), higher rates of second-pass recanalization (31.2% vs 23.4%; p<0.001), and better 90-day outcomes (mRS 0-2: 35.2% vs 29.9%; p=0.04) when compared with repeated CA attempts. Trevo SRs showed higher odds of successful recanalization (adjusted odds ratio (aOR)=1.9; p=0.02), second-pass recanalization (aOR=1.7; p=0.01), and reduced odds of sICH (aOR=0.3; p=0.02). EmboTrap SRs were associated with higher odds of 90-day mortality (aOR=2.6; p=0.004) and sICH (aOR=2.9; p=0.04) and lower odds of recanalization (aOR=0.5; p=0.03).

Conclusions: Incorporating SR in the rescue strategy after a failed CA improves recanalization rates and functional outcomes. Trevo SRs demonstrated superior efficacy and safety when incorporated into the rescue strategy.

Background: Newly diagnosed glioblastoma (ndGBM) remains one of the most challenging malignancies to treat. Since the majority of patients experience tumor recurrence (rGBM) after first-line therapy, advancements in both initial and salvage treatments are essential.

Objective: We report our single-center experience on the feasibility and safety of superselective intra-arterial cerebral infusion (SIACI) with bevacizumab or cetuximab after osmotic blood-brain barrier disruption (oBBBd).

Methods: Partial results of three distinct trials (anonymized for blinded review) were analyzed. All patients were histopathologically confirmed to have either ndGBM or previously diagnosed ndGBM that progressed to rGBM despite standard therapy and had aKarnofsky Performance Status (KPS)≥70. All patients were admitted on the same day of the surgery, and the intervention followed similar steps in all included patients. Under general anesthesia, after oBBBd with mannitol, patients received SIACI.

Results: Between October 2014 and March 2024, 70 patients with a mean age of 56.2±12.4 years (range: 19-78) underwent successful treatment, encompassing 139 SIACIs and 246 infusions. All planned SIACIs were completed successfully. Forty-one patients with rGBM received bevacizumab-SIACI, 7 with ndGBM bevacizumab-SIACI, and 22 with ndGBM cetuximab-SIACI. In 133 of 139 SIACIs (95.7%), patients were discharged home with a length of stay of 1 day. The incidence of patients who experienced procedure-related and drug-related adverse events was 11.4% and 8.6%, respectively. No procedure-related deaths occurred.

Conclusion: In our single-center experience, comprising the largest cohort of bevacizumab or cetuximab SIACI treatment for rGBM and ndGBM, this promising and cutting-edge intervention is highly feasible and safe.

Background: Automated machine learning (ML)-based large vessel occlusion (LVO) detection algorithms have been shown to improve in-hospital workflow metrics including door-to-groin time (DTG). The degree to which care team engagement and interaction are required for these benefits remains incompletely characterized.

Methods: This analysis was conducted as a pre-planned post-hoc analysis of a randomized prospective clinical trial. ML-based LVO detection software was implemented at four comprehensive stroke centers (CSCs) from January 1, 2021, to February 27, 2022. Patients were included if they underwent endovascular thrombectomy for LVO acute ischemic stroke. ML software utilization was quantified as the total number of active users and the ratio of the number of comments to the number of patients analyzed by the software by site per week. Primary outcome was the reduction in DTG relative to pre-ML implementation by hospital utilization level. Data are expressed as median (IQR).

Results: Among 101 patients who met the inclusion criteria, the median age was 71 years (IQR 59-79), with 48.5% being female. CSC 4 had the greatest number of total active users per week (32.5 (27.5-34.5)), and comment-to-patient ratio per week (5.8 (4.6-6.9)). Increased ML software utilization was associated with improvements in DTG reduction. For every 1 unit increase in the comment-to-patient ratio, DTG time decreased by 2.6 (95% CI -5.09 to -0.13) min, while accounting for site-level random effects. Number of users-to-patient was not associated with a reduction in DTG time (β=-0.22, 95% CI -1.78 to 1.33).

Conclusions: In this post-hoc analysis, user engagement with software, rather than total number of users, was associated with site-specific improvements in DTG time.

Background: Studies have been conducted to explore the potential predictive indicators of unfavorable outcomes in patients with acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). However, few studies have proposed a comprehensive predictive model combined with clinical baseline data and ancillary examination before surgery.

Method: In a retrospective study, we collected data on 823 patients with AIS-LVO who had undergone endovascular therapy (EVT); 562 patients who achieved successful revascularization with complete clinical and prognostic information were incorporated into the study. Those patients with a 90-day modified Rankin Scale (mRS) score of 0-2 were defined as having a favorable outcome, while a score of 3-6 represented an unfavorable outcome or futile reperfusion. To build up a predictive model, we applied multivariate logistic regression stepwise backward selection to decide which factors are supposed to be the components of the predictive model. Final model validity was testified by the variance inflation factor test and the Hosmer-Lemeshow (HL) goodness of fit test. The ultimate efficacy was supported by an area under the curve (AUC) value in both training groups and validation groups.

Results: 562 patients were enrolled in our study and divided into the training group and verification group in a ratio of 7:3. Factors of baseline data with P<0.1 in univariate logistic regression analysis were enrolled as the potential risk variables to conduct stepwise backward selection. The model was constructed by eight variables; higher mRS score (adjusted OR (aOR) 93.64, 95% CI 12.05 to 727.82, P<0.01), age >80 years (aOR 91.11, 95% CI 1.36 to 6116.36, P<0.05), National Institutes of Health Stroke Scale (NIHSS) >14 (aOR 0.15, 95% CI 0.02 to 0.99, P<0.05), operation history (aOR 8.13, 95% CI 1.32 to 50.20, P<0.05), creatinine (aOR 1.10, 95% CI 1.04 to 1.17, P<0.01), and neutrophil count (aOR 1.07, 95% CI 1.01 to 1.13, P<0.05) were associated with poor outcomes.

Conclusion: We established an estimation model for invalid reperfusion in AIS-LVO patients and constructed the nomogram for individualized predictions. The AUC of the training group and validation group were both 0.96, with excellent HL and decision curve analysis, presenting excellent clinical prediction efficiency and application potential.

Background: Complete recanalization (CR, modified Treatment in Cerebral Ischemia (mTICI) score of 2c or better) is associated with favorable outcomes after endovascular thrombectomy (EVT) for stroke patients. However, the degree of inter-proceduralist differences in CR rates is unknown, and whether higher CR rates are being achieved by performing more passes or by focusing on first-pass effectiveness is also unclear.

Methods: This was a multicenter retrospective study of anterior circulation large vessel occlusion stroke patients in the United States from 2016 to 2022. Patients treated by proceduralists with at least 50 cases were included. CR rates for each proceduralist were assessed and proceduralists were divided into tertiles. First-pass effect (FPE, defined as CR after one pass) and the number of passes for patients treated by the top tertile of proceduralists were compared with the bottom tertile. Mediation analyses were conducted to assess causal links between CR rates and number of passes or FPE.

Results: A total of 1096 EVTs performed by 11 proceduralists were identified. CR rates were highly variable across providers (43.1% to 75.3%, p<0.001). Patients treated by the top tertile were more likely to experience FPE (OR 1.99, 95% CI 1.49 to 2.67, p<0.001) and did not undergo more passes (p=0.69) compared with the bottom tertile. Higher rates of FPE among patients was a significant mediator of higher odds of CR among patients treated by the top tertile (p<0.001).

Conclusions: Angiographic outcomes among EVT proceduralists are highly variable. Proceduralists who achieve higher rates of CR are doing so with higher rates of FPE, not more passes.