Journal of NeuroInterventional Surgery最新文献

BackgroundRescue stenting may be needed for intracranial atherosclerosis (ICAS)-related large vessel occlusion (LVO). Balloon-expandable (BE) stent implantation often fails due to its stiffness. Balloon-expandable stent angioplasty with the dIstal support of stent-retriever (BASIS-Stent) technique is a novel technique that increases the success and safety of BE stent implantation. Our study presents our initial experience with the BASIS-Stent technique for ICAS-related LVO that requires rescue stenting and to assess its feasibility.

Method: The clinical and angiographic data of acute ICAS-related LVO patients treated with the BASIS-Stent technique were retrospectively analyzed. The primary outcome was technical success, defined as successful BE stent implementation (successful deployment and satisfactory expansion). The secondary outcome was good prognosis at 90 days after the procedure, defined as a modified Rankin Scale (mRS) score of 0 to 2. The safety outcomes were procedural-related complications (ie, vessel perforation, dissection, vessel injury, distal embolism), postprocedural re-occlusion, and symptomatic intracranial hemorrhage (sICH).

Results: A total of 19 patients with acute ICAS-related LVO treated at two stroke centers were included, and the median age of the patients was 62 years. Drug-eluting BE stents were successfully implanted in all patients; expanded treatment in cerebral infarction (eTICI) 3 reperfusion was achieved in all patients, no patients experienced procedural-related occlusion, and one (1/19, 5.3%) experienced re-occlusion post-procedure due to in-stent thrombus. None of the patients had sICH. Good clinical outcomes were observed in 13 patients (68.4%), and no patients died.

Conclusion: BE stent implantation using the BASIS-Stent technique may be feasible and safe for treating acute ICAS-related LVO.

Background: The proximity of transverse sinus stenosis (TSS) to inner ear structures and the temporal bone makes it a substantial cause of pulsatile tinnitus (PT). Treatment typically involves venous sinus stenting. This study investigates the hemodynamic stressors in TSS patients with PT along the pulse-transmitting temporal bone area and evaluates its treatment effects.

Methods: Four patients with idiopathic intracranial hypertension, PT, and TSS, and four control patients were imaged using MR venography (MRV) and flat panel CT (FP-CT). Patient-specific blood flow simulations were conducted using boundary conditions based on quantitative MR angiography before and after VSS. Catheter-based trans-stenotic pressure gradient measurements were used to validate the simulation results.

Results: The prediction of pressure gradients was close to catheter-based measurements using FP-CT-based segmentations (absolute deviation of 0.35 mm Hg) and is superior to MRV-based reconstructions (absolute deviation of 6.9 mm Hg). In TSS patients, the sinus temporal bone contact areas revealed notably higher time-averaged wall shear stress by 47±22% and velocity values by 41±18% compared with the sinus brain side. The relative residence time decreased by 57±58%. After stenting, the hemodynamic parameters dropped at the temporal side and throughout the sigmoid sinus. Almost all control patient hemodynamics remained lower than post-interventional results.

Conclusion: Our simulations based on patient-specific flows highly predicts pressure gradients across the stenosis. Flow conditions in TSS reveal flow jet formation and high shear rates at the temporal bone, potentially causing sound transmission. The treatment reduces these stressors, demonstrating its targeted therapeutic effect.

Background: Intra-arterial chemotherapy (IAC) is a growing method of therapy for retinoblastoma (Rb). There is an absence of data to support the safety of catheterization with intra-arterial infusion in this pediatric population OBJECTIVE: To focus on the non-ocular catheter/procedural-related complications that our practice has experienced in order to lay a foundation for practices interested in performing these procedures and hopefully, to help prevent them from occurring.

Methods: This is a retrospective review of the patient population with Rb treated in our center from May 2006 through May 2024. Every procedure performed was reviewed for non-ocular catheterization-related complications. This review included complications of access, the distal vessel (thrombosis, stenosis, and dissection), and non-ocular infarcts.

Results: There were 2281 vascular access events, and 2681 distal catheterization procedures were performed for IAC infusion on 623 pediatric patients with Rb. Mean age of the population was 18.9 months. There were 31 complications directly related to catheterization: 7 (0.3%) related to femoral artery access and 24 (0.9%) were distal vessel injuries. Two (0.07% of total catheterizations) of the distal vessel injuries were asymptomatic cerebral infarcts diagnosed on follow-up MRI.

Conclusion: Catheterization with IAC can be performed safely in this young pediatric population. There is a trend for fewer complications when using the smallest catheter system possible for procedures.

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.