Journal of NeuroInterventional Surgery最新文献

Background: Dual-energy computed tomography (DE-CT) can differentiate between hemorrhage and iodine contrast medium leakage following mechanical thrombectomy (MT) for acute ischemic stroke (AIS). We determined whether subarachnoid hemorrhage (SAH) and subarachnoid iodine leakage (SAIL) on DE-CT following MT were associated with malignant brain edema (MBE).

Methods: We analyzed the medical records of 81 consecutive anterior circulation AIS patients who underwent MT. SAH or SAIL was diagnosed via DE-CT performed immediately after MT. We compared the procedural data, infarct volumes, MBE, and modified Rankin scale 0-2 at 90 days between patients with and without SAH and between patients with and without SAIL. Furthermore, we evaluated the association between patient characteristics and MBE.

Results: A total of 20 (25%) patients had SAH and 51 (63%) had SAIL. No difference in diffusion-weighted imaging (DWI)-infarct volume before MT was observed between patients with and without SAH or patients with and without SAIL. However, patients with SAIL had larger DWI-infarct volumes 1 day following MT than patients without SAIL (95 mL vs 29 mL; p=0.003). MBE occurred in 12 of 81 patients (15%); more patients with SAIL had MBE than patients without SAIL (22% vs 3%; p=0.027). Severe SAIL was significantly associated with MBE (OR, 12.5; 95% CI, 1.20-131; p=0.006), whereas SAH was not associated with MBE.

Conclusion: This study demonstrated that SAIL on DE-CT immediately after MT was associated with infarct volume expansion and MBE.

Background: The aim of this study was to investigate the relationships between imaging indicators of obesity, as measured by computed tomography (CT), and clinical outcomes at 90 days and 1 year after emergent endovascular therapy (EVT).

Methods: Participants with emergent large vessel occlusion (ELVO) who underwent EVT were prospectively enrolled. During hospitalization, CT scans were performed to evaluate the visceral adipose tissue area (VATA) and skeletal muscle area (SMA) at the level of the third lumbar spine. Multivariate regression analysis was used to assess the correlation of obesity-related imaging measures with various outcomes: mortality, favorable functional outcomes (modified Rankin scale (mRS) score 0-2), and functional improvement (shift in mRS score) at 90 days and 1 year.

Results: A total of 306 ELVO patients were included in the study, with a median age of 64 years and a median baseline National Institutes of Health Stroke Scale (NIHSS) score of 18. After adjusting for potential confounders, the VATA-to-SMA ratio (VSR) was significantly associated with a favorable functional outcome (OR 0.30, 95% CI 0.13 to 0.70) at 90 days and a favorable functional outcome (OR 0.27, 95% CI 0.12 to 0.61) and functional improvement (OR 0.33, 95% CI 0.12 to 0.92) at the 1 year follow-up.

Conclusion: Our study indicated that lower VSR levels are associated with favorable functional outcomes, along with functional improvement at 90 days and 1 year of follow-up.

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-2024-022279v2/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: Virtual simulation is increasingly used for aneurysm treatment. This study aimed to explore whether mechanical behavior biomarkers of the Woven EndoBridge (WEB) device as computed by Sim&Size simulation software were associated with aneurysmal occlusion status at follow-up.

Methods: Consecutive patients with aneurysms treated with WEB were retrospectively enrolled (January 2014 to December 2021). Aneurysms were included if three-dimensional digital subtraction angiography and follow-up imaging were available. Device apposition and compression within the aneurysm sac were retrospectively calculated by Sim&Size simulation software. Mean global and maximum compression, mid-device and neck compression, and the Spruce index of heterogeneity of deformation of the simulated device were calculated. A multivariate Lasso regression was performed.

Results: A total of 81 aneurysms in 80 patients (56 females; mean age 60±12 years) were analyzed. At a mean radiological follow-up of 3±2 years, 62 (77%) showed an adequate occlusion. Mean apposition in the inadequate and adequate occlusion group was 42.9±11% and 53.97±12%, respectively (P=0.002), mean global compression was 4.95±3% and 7.85±6% (P=0.035), respectively, and maximal compression was 13.44±6% and 20.73±11%, respectively (P=0.009). Compressions at mid-level and neck level were comparable between the two groups. The Spruce index was higher in the inadequate occlusion group (0.16±0.05 vs 0.20±0.05, P=0.005). Multivariate analysis showed that wall apposition, maximum compression and the Spruce index were independent prognosticators of aneurysm occlusion.

Conclusions: Wall apposition, maximum compression and the Spruce index computed by Sim&Size software predicted the likelihood of aneurysm occlusion at follow-up, after WEB treatment.

Background: Heavily calcified carotid stenosis (HCCS) is considered an exclusion for carotid angioplasty and/or stenting (CAS), amenable only to carotid endarterectomy. This study presents preliminary retrospective dual-center experience utilizing the Shockwave S⁴ intravascular lithotripsy (IVL) system (Shockwave Medical) as an adjunct to CAS for HCCS.

Methods: Patients with symptomatic or asymptomatic HCCS (de novo stenosis or in-stent restenosis (ISR)) undergoing IVL+CAS were included. Charts were reviewed for demographic, imaging, procedural, and outcome data. The primary endpoint was composite major adverse event (MAE) rate: death, ipsilateral stroke, or myocardial infarction (MI) within 30 days of IVL+CAS. Secondary endpoints included technical and procedural success, residual stenosis, and ISR postprocedure.

Results: Fifteen patients underwent 17 IVL+CAS procedures: de novo HCCS=13, heavily calcified ISR=4; symptomatic disease was addressed in seven cases. Procedures were performed transfemorally under conscious sedation with dual protection; flow reversal through a balloon guide catheter, and distal embolic protection system (EPS) use. Median pre-IVL+CAS stenosis was 73% (IQR 60-80%). Technical success (IVL+CAS+ EPS use) was achieved in all cases. Median post-IVL+CAS residual stenosis was 27% (IQR 12-33%), achieving <50% residual stenosis and procedural success in all. Five patients required dopamine infusion for postprocedural hypotension. No periprocedural ipsilateral strokes occurred. MAE rate was 6.7% (95% CI 0.2% to 32%), including one MI resulting in death. Additionally, one ISR (6.3%; 95% CI 0.2% to 30.2%) identified 160 days after IVL+CAS was retreated with angioplasty.

Conclusions: IVL+CAS was safe and effective for treating symptomatic and asymptomatic HCCS, achieving high rates of freedom from MAE. IVL has potential to expand the role of CAS in difficult to treat HCCS.

Background: The benefit of distal embolite penetration for middle meningeal artery (MMA) embolization in chronic subdural hematomas (cSDH) remains controversial.

Objective: To compare the use of diluted Onyx with undiluted Onyx in the management of cSDH.

Methods: This is a retrospective study of patients with cSDH who underwent MMA embolization using Onyx 18 at our institution. The study population was divided into two subgroups based on whether the Onyx used was diluted or not. Baseline characteristics and technical aspects were compared. Primary outcome was cSDH resolution at follow-up. Secondary outcomes included time to resolution and duration of procedure. Univariate statistical analysis was performed.

Results: Of the 111 MMA embolizations performed at our institution, 99 were performed using Onyx 18 only. Within this cohort, 53 (53.5%) cases used standard Onyx and 46 (46.5%) cases used diluted Onyx. The diluted Onyx group had significantly greater volume of embolic agent used measured radiographically (P<0.001). There was no significant difference in duration of procedure. The percentage of cSDH resolution at last follow-up was similar between the two groups (P=0.98), but the time to resolution was significantly shorter in the diluted Onyx group (P=0.02).

Conclusion: The use of diluted Onyx for MMA embolization is associated with greater embolization volume achieved under similar procedural times. While the percentage of patients who achieved cSDH resolution with diluted Onyx is similar to that for standard Onyx, the time to cSDH resolution is significantly shorter. Adoption of Onyx dilution can be considered in MMA embolization for cSDH.

Background: The Flow Re-direction Endoluminal Device (FRED) X is a next generation flow-diverting stent for treating intracranial aneurysms. Its surface modification (X technology) aims to minimize device thrombogenicity. Early post-market multicenter data from the US are lacking.

Methods: We conducted a retrospective multicenter analysis of consecutive FRED X procedures performed to treat unruptured intracranial aneurysms at four US centers (March 2022 to January 2024). Cases with ruptured aneurysms or extracranial aneurysm location were excluded (n=10). We assessed patient and aneurysm characteristics, antithrombotic management, safety events, and both clinical and angiographic (effectiveness) outcomes.

Results: In this cohort, 101 patients underwent FRED X stenting for 117 aneurysms. Most aneurysms were saccular in shape (95.7%) and located at the C6-C7 segments of the internal carotid artery (72.6%). Thromboembolic events occurred in 5.9% of the cases, leading to one instance of permanent procedure related morbidity (1.0%). No procedure related mortality (0%) was observed. Device related issues were recorded in 2.0% of cases. At the 6 month follow-up, complete aneurysm occlusion was achieved in 58% of aneurysms. At the last available follow-up (6-12 months), 74.8% of aneurysms were adequately occluded.

Conclusions: FRED X stenting for unruptured intracranial aneurysms demonstrated low rates of neurological morbidity and periprocedural complications. Early aneurysm occlusion rates were appropriate, but further mid-term and long term follow-up is required. These findings support the early safety and effectiveness of the FRED X device for intracranial aneurysm treatment.

Background: The time to maximum (Tmax) profile based on computed tomography perfusion (CTP) provides a quantitative assessment of cerebral hemodynamic compromise. We aimed to delineate the Tmax profile in stroke patients with symptomatic intracranial atherosclerotic stenosis (ICAS) and to investigate its predictive role in stroke recurrence after optimal medical treatment.

Methods: Consecutive patients with ischemic stroke within 30 days attributed to 50%-99% ICAS were prospectively enrolled. Baseline tissue volume at different perfusion parameter thresholds based on CTP was automatically calculated using the Rapid Processing of Perfusion and Diffusion (RAPID) software. All patients received optimal medical treatment. The primary outcome was a composite of stroke in the territory of qualifying artery or vascular death within 1 year.

Results: Among 204 patients with symptomatic ICAS, the median volume of Tmax >4 s, Tmax >6 s, and relative cerebral blood flow (rCBF) <30% were 61 mL, 0 mL, and 0 mL, respectively. The 1 year rate of primary outcome was 16.2% (33/204). Tmax >4 s volume was significantly associated with the primary outcome (per 10 mL increase, adjusted hazard ratio (HR), 1.028 (1.008-1.049), P=0.005). The optimal cut-off value of Tmax >4 s volume for predicting the primary outcome was 83 mL. Patients with Tmax >4 s volume >83 mL had a higher risk of the 1 year primary outcome than those with Tmax >4 s volume ≤83 mL (adjusted HR, 7.346 (3.012-17.871), P<0.001), after adjusting for degree of stenosis and stroke mechanisms.

Conclusion: Tmax >4 s volume is a promising perfusion parameter to define hemodynamic compromise in patients with symptomatic ICAS. Patients with a larger volume of Tmax >4 s are likely to have a higher risk of stroke recurrence despite optimal medical treatment.