Journal of NeuroInterventional Surgery最新文献

Background: The selection of antiplatelet agents plays a crucial role in ensuring the safety and efficacy of endovascular treatment for intracranial aneurysms (IA). Currently, the primary agents used include tirofiban and traditional dual antiplatelet therapy (DAPT). Due to the lack of high-level consolidated evidence in this field, we conducted the first systematic review and meta-analysis aimed at comparing the safety and efficacy of tirofiban vs traditional DAPT in the endovascular treatment of IA.

Methods: Studies published before November 1, 2024, were searched in PubMed, Embase, Web of Science, and Cochrane Central Register of Controlled Trials. The primary outcome was thrombosis, and secondary outcomes included intracranial hemorrhage (ICH), non-intracranial bleeding events (NoICH-BE), ischemic stroke (IS), and follow-up prognosis. Relative risks (RRs) were synthesized for comparison between tirofiban and DAPT groups.

Results: Nine studies involving 2481 patients were included. Tirofiban significantly reduced the risk of thrombosis compared with DAPT (RR, 0.292; 95% CI, 0.174 to 0.492; P<0.001). It did not increase risks of ICH (RR, 0.633; P=0.125), NoICH-BE (RR, 0.253; P=0.259), IS (RR, 0.730; P=0.172), or poor prognosis (RR, 0.981; P=0.896).

Conclusion: Tirofiban effectively lowers the risk of thrombosis without increasing bleeding or adverse prognosis risks compared with DAPT. It shows promise as an alternative antiplatelet therapy for IA treatment, but further large-scale studies are needed to confirm these findings.

Background: Approximately one in three patients with acute ischemic stroke (AIS) suffer from a premorbid disability prior to their incident AIS. These patients have largely been excluded from clinical trials of endovascular thrombectomy (EVT) for the treatment of AIS and current literature remains unclear regarding the safety and efficacy of EVT in these patients.

Methods: We queried our prospectively maintained registry of patients with AIS from December 1, 2014 to October 31, 2023 to identify all patients who underwent EVT. Patients were stratified by their baseline modified Rankin Scale (mRS) score into those with (mRS 2-5) and without (mRS 0-1) baseline disability. Univariate analyses using the χ² test for categorical variables and the Wilcoxon rank-sum test for continuous variables were performed to compare demographics between the two groups. Generalized logistic and linear regression models for multivariable analysis were used to compare outcomes between the groups.

Results: Of a total of 1489 patients, 367 (24.6%) had a pre-existing disability. Patients with baseline disability were older (79.6 years vs 67.7 years, P<0.001), more likely to be female (65.7% vs 45.9%, P<0.001), and had higher rates of stroke risk factors. There were higher odds of return to baseline (90-day ΔmRS =<0: OR 2.83, P<0.001) and 90-day ΔmRS =<1 (OR 2.94, P<0.001) for patients with baseline disability post-EVT compared with their healthier counterparts. There was no relative adjusted increase in symptomatic intracerebral hemorrhage or 90-day mortality.

Conclusions: EVT appears to be safe and effective in patients with baseline disability, often associated with a return to their premorbid functional status at 90 days.

Background: Treatment options for cervical internal carotid artery (c-ICA) occlusion in tandem occlusions (TOs) include emergent carotid artery stenting (eCAS) and angioplasty. We attempted to determine the impact of c-ICA reocclusion on the risk of recurrent ischemic stroke (IS) and stroke-related death, as well as functional independence.

Methods: Patients with TOs undergoing endovascular thrombectomy (EVT) from April 2016 to October 2024 were included. The primary outcome was the 90-day composite of recurrent IS and stroke-related death. Secondary outcomes included the rate of 90-day functional independence (modified Rankin Scale (mRS) 0-2) and mortality. We used binary logistic regression to explore the association between c-ICA reocclusion and the outcomes and to identify predictors of c-ICA reocclusion or future revascularization.

Results: We included 163 patients, 85.9% with successful recanalization. Angioplasty and eCAS were performed in 70% and 19%, respectively. c-ICA reocclusion occurred in 22% at a median of 3.5 (0-41.7) days. c-ICA reocclusion increased the odds of recurrent IS or stroke-related death (adjusted OR (aOR) 2.90, 95% CI 1.07 to 8.30, P=0.036) and was associated with lower rates of independence (aOR 0.18, 95% CI 0.05 to 0.58, P=0.004). Among patients who did not undergo eCAS, c-ICA angioplasty (aHR 0.28, 95% CI 0.09 to 0.86, P=0.026) and residual stenosis (aHR 1.04, 95% CI 1.02 to 1.07, P<0.001) were independent predictors of reocclusion or future revascularization.

Conclusion: Maintaining c-ICA patency after EVT might be essential due to the association of reocclusion with recurrent IS, stroke-related death, and worse functional outcomes. Residual c-ICA stenosis and angioplasty are valuable predictors of c-ICA patency that can guide management during EVT.

Background: Advanced-stage head and neck cancers are associated with high morbidity and mortality, often requiring complex therapeutic interventions. In cases of tumor-associated hemorrhage, intra-arterial (IA) chemotherapy combined with embolization offers a potential treatment strategy. This study assesses the safety and efficacy of this approach in a cohort of patients with bleeding head and neck malignancies.

Methods: A retrospective case series of five patients with advanced head and neck cancers who underwent IA chemoembolization between November 2023 and August 2024 is presented. Tumors included oropharyngeal squamous cell carcinoma and sinonasal undifferentiated carcinoma. IA chemotherapy (cisplatin or carboplatin) was administered via selective catheterization of tumor-feeding vessels. Tumor response was measured using three-dimensional (3D) volumetric analysis, and clinical outcomes were evaluated for bleeding control, disease progression, and complications.

Results: All the patients achieved local tumor control, with tumor volume reductions ranging from 29% to 84% and a mean reduction of 66%. No rebleeding was observed at treated sites over a mean follow-up period of 8 months. All patients had an objective response at the treated site, and one patient showed disease progression on the contralateral side. No neurologic complications occurred. Complications included acute kidney injury in two patients (mitigated by adjusted hydration protocols) and flap necrosis in one patient.

Conclusion: IA chemotherapy with embolization appears to be a safe and effective method for managing bleeding in advanced head and neck cancers. The combination offers local tumor control and mitigates the risk of rebleeding, although larger studies are needed to confirm its role in clinical practice.

Background: The use of balloon guide catheter (BGC) has been associated with better reperfusion and clinical outcomes in mechanical thrombectomy (MT) for large vessel occlusion stroke. However, the impact of BGC on angiographic and clinical outcomes in patients with distal medium vessel occlusion (DMVO) strokes undergoing MT has not been extensively investigated.

Methods: This is a retrospective analysis of a prospectively collected database from 14 comprehensive stroke centers in the United States and Europe. Patients with anterior circulation DMVO due to middle cerebral artery (MCA) M3/M4 or anterior cerebral artery (ACA) A1/A2-3 were included. The cohort was divided into BGC and non-BGC groups. Multivariable logistic regression and inverse probability of treatment weighting (IPTW) were used for comparison. The primary outcome was first pass effect (FPE) defined as modified treatment in cerebral infarction (mTICI) grade 2C/3 after single device pass.

Results: Among 199 patients who were eligible for analysis, 81 (40.7%) were female. The median age was 69 (60-81) years, and National Institutes of Health Stroke Scale score was 13 (7-18). The BGC group (n=73) had higher rates of FPE (53.4% vs 13.7%; IPTW aOR 5.63, 95%CI (2.43 to 13.10), P<0.001) compared with the non-BGC group (n=126). The BGC group had higher rates of modified Rankin Scale (mRS) 0-1 (42.9% vs 27.1%; IPTW aOR 2.78, 95% CI (1.10 to 7.07), P=0.031), mRS 0-2 (60.3% vs 41.5%; IPTW aOR 4.31, 95% CI (1.66 to 11.19), P=0.003), and lower rates of mortality at 90-days (12.7% vs 25.4%; IPTW aOR 0.32, 95% CI (0.11 to 0.98), P=0.047) compared with the non-BGC group. The rates of successful reperfusion at the end of the procedure and symptomatic intracerebral hemorrhage were comparable between both groups.

Conclusion: The present study suggests that the use of BGC in DMVO undergoing MT may be associated with improved angiographic and clinical outcomes with no safety concerns. Prospective studies are warranted.

Background: Preoperative embolization has been used for intracranial meningiomas for nearly 40 years with varying preferences for embolic materials and limited comparative data on their efficacy.

Methods: Consecutively treated patients from 2013 until 2023 who underwent preoperative embolization for meningioma from 12 centers across North America and Europe were included and classified by embolic material: (1) particles, (2) Onyx, and (3) coils. Primary outcomes included estimated blood loss (EBL), procedural complications, surgery duration, gross total resection (GTR), unplanned rescue surgery, modified Rankin Scale (mRS), and mortality. After unmatched analysis. Propensity score matching (PSM) subgroup analyses compared each pair of embolic materials, controlling for age, sex, body mass index, smoking, comorbidities, prior surgery, pre-treatment antithrombotics, WHO grade, tumor location, maximal diameter, and baseline mRS.

Results: A total of 275 patients (median age 47 years, 62.9% female) underwent preoperative embolization for meningioma. The mean maximum tumor diameter was 32.9±10.1 mm, with 61.1% classified as WHO I. Onyx was most frequently used 117 (42.5%), followed by particles 107 (38.9%), and coils (18.5%). Unmatched analysis revealed that Onyx was significantly associated with reduced EBL, surgery duration, and increased GTR, while decreasing unplanned rescue surgeries compared to particles and coils. PSM produced 89, 48, and 44 matched pairs for Onyx vs. Particles, Particles vs. Coils, and Onyx vs. Coils, respectively. Onyx demonstrated significant reductions against Particles in EBL (250 mL vs. 350 mL, P = 0.011) and surgical time (291 min vs. 403 min, P < 0.001), and against Coils in EBL (250 mL vs. 400 mL, P = 0.012) and surgical time (255 min vs. 347 min, P = 0.002). Onyx also showed higher rates of gross total resection compared to Particles (80.9% vs. 56.2%, P = 0.021) and Coils (88.6% vs. 56.8%, P = 0.002). No significant differences were observed in blood transfusion requirements, embolization-related complications mRS, or mortality rates across all comparisons.

Conclusions: Onyx, a liquid embolic agent, reduces EBL which may explain the shorter surgery duration, higher GTR rates, and lower retreatment rates. Procedural risks and patient selection require further investigation.

Background: Subarachnoid hemorrhage (SAH) is a life-threatening condition with a high risk of disability requiring specialized care. This study investigated the relationship between hospital annual case volume and outcomes for patients undergoing clipping and endovascular treatment (EVT) of ruptured intracranial aneurysms (IAs) in Germany.

Methods: German Federal Statistical Office data (2013-2022) derived from all German hospitals were analyzed for ruptured IA cases treated with EVT or clipping. Primary outcomes were in-hospital mortality and poor neurological outcome according to the National Inpatient Sample-SAH Outcome Measure. Poisson regression was used to assess the annual case volume-outcome relationship.

Results: In 35 187 treatment cases for ruptured IA, a significant inverse relationship was found between annual case volume and both mortality and poor neurological outcomes for both treatment modalities. Each additional case performed annually decreased adverse outcome risk by 1%. EVT showed lower rates of poor neurological outcome (39.8% vs 49.8%, P<0.001), shorter hospital stays, less intensive care, and lower costs, but similar in-hospital mortality rates (18.5% vs 19.1%, P=0.127) compared with clipping. The in-hospital mortality rate for clipping increased in 2016-2018, 2021, and 2022 compared with the 2013 baseline, whereas it remained stable for EVT. Age was a significant predictor of mortality and poor neurological outcome.

Conclusions: This study is the first to quantify the volume-outcome relationship for treatment of ruptured IAs in Germany. Consistent results across treatment modalities suggest benefits of increased experience of neurovascular treatment centers. These findings enhance our understanding of factors influencing neurovascular care outcomes in Germany.

Background: The eye lens is particularly vulnerable to radiation during endovascular treatments for intracranial aneurysms due to prolonged exposure under high magnification. This study presents a lens tracking method to monitor lens positions during procedures and estimate radiation doses using a phantom.

Methods: A consecutive series of patients treated between January and March 2023 were retrospectively reviewed. A lens tracking method was used to mark lenses on three-dimensional source images to track their positions on two-dimensional working views. An anthropomorphic head phantom and photoluminescent glass dosimeters were used to estimate lens exposure under simulated conditions. We also evaluated potential radiation reduction with collimation based on the lens position.

Results: Among 42 patients, 20 (48%) had their eye lens in the field of view (FOV). In 10 of these cases, collimation could have prevented direct exposure. The phantom study showed a median lens dose of 7.32 (5.02-9.59) mGy. Lenses within the anterior-posterior (AP) plane FOV received higher doses compared with those outside it (4.32 mGy vs 1.76 mGy, P<0.001). In the lateral plane, lenses outside the FOV showed significant dose differences (left lens: 5.02 mGy vs right lens: 2.45 mGy, P<0.001). Collimation reduced lens doses by 60% in the AP plane and 52% in the lateral plane (P<0.001 and P=0.001, respectively) with greater reductions for lenses initially in the FOV.

Conclusion: In this study, lenses were often included in the FOV, thereby receiving higher radiation doses. This underscores the importance of tracking and excluding lenses from the FOV to reduce radiation exposure during procedures.

Background: Whether rescue intracranial stenting (RIS) should be performed in patients with vertebrobasilar occlusions (VBO) refractory to endovascular mechanical thrombectomy (MT) remains an open question.

Methods: We conducted a pooled analysis using data from two national stroke registries, the Endovascular Treatment in Ischemic Stroke registry in France, and the German Stroke Registry-Endovascular Treatment. Patients with VBO who underwent RIS for failed MT, defined as a modified treatment in cerebral infarction (mTICI) score of 0 to 2a after MT, from January 2015 to December 2023 were included. The primary outcome was a modified Rankin Scale (mRS) score of 0-3 at 90 days. Secondary outcomes included mRS distribution and mortality at 90 days, any intracranial hemorrhage (ICH) and symptomatic intracranial hemorrhage (sICH). Propensity score matching and inverse propensity weighting were employed to balance baseline differences.

Results: Among 2028 patients, 307 (15.1%) patients had MT-refractory VBO. Of these, 127 (41.4%) underwent RIS and 180 (58.6%) patients no RIS. After propensity score matching, two balanced groups were obtained: 106 patients with RIS and 99 without RIS. Patients who underwent RIS had higher odds of achieving an mRS 0-3 (adjusted odds ratio (aOR) 3.45, 95% confidence interval (CI) 1.27 to 9.34. P=0.014), a favorable shift across the mRS distribution (aOR 2.55 per 1-point mRS improvement, 95% CI 1.22 to 5.34; P=0.013) and lower odds of 90-day mortality (aOR 0.26, 95% CI 0.09 to 0.71; P=0.008). There were no significant differences in any ICH and sICH.

Conclusion: This registry-based study provides level 3 evidence supporting the use of RIS in patients with VBO refractory to MT. Prospective randomized trials are necessary to validate the potential benefits of RIS in this condition.