Journal of NeuroInterventional Surgery最新文献

Background: The Monopoint reperfusion system (Monopoint; Route 92 Medical, San Mateo, California, USA) is a large bore (0.088 or 0.070 inch inner diameter) aspiration thrombectomy platform designed to minimize ledge effect and improve neurovascular navigation and embolectomy. We aimed to describe a multicenter, real world experience of the safety and performance of the Monopoint system in first line aspiration thrombectomy for large vessel occlusions (LVOs), outside of the recently completed SUMMIT MAX (A Randomized, Controlled Trial to Evaluate the Safety and Effectiveness of the Route 92 Medical Reperfusion System) clinical trial.

Methods: Adults with acute anterior circulation LVO stroke between January 2019 and December 2024 consecutively treated with first line aspiration thrombectomy using the Monopoint at 10 centers were retrospectively reviewed. The primary outcome was first pass effect (FPE, modified Thrombolysis in Cerebral Infarction (mTICI) 2C/3 on first pass) and modified FPE (mFPE, mTICI 2B/2C/3 on first pass). The primary safety outcome was the rate of intraprocedural complications attributed to the Monopoint system.

Results: In 193 included patients, median age was 67 years (IQR 67-78), and 46.6% (90/193) were women. Successful delivery of the aspiration catheter to the clot site occurred in 96.2% (185/193) of patients. FPE was achieved in 57.5% (111/193) and mFPE was achieved in 68.4% (132/193) of patients. Of 10 (5.2%) total complications, most were vasospasm treated with intra-arterial verapamil (8/193, 4.1%); major complications included one dissection (1/193, 0.5%) and one perforation (1/193, 0.5%).

Conclusion: This multicenter study of the Monopoint reperfusion system for LVO thrombectomy outside of the SUMMIT MAX trial demonstrated a high FPE rate and a low rate of major complications.

Background and objectives: Acute occlusion of the internal carotid artery (ICA) accompanied by contralateral A1 segment agenesis (CA-A1) presents distinct clinical and radiological features. Differentiating CA-A1 from non-CA-A1 cases in acute ICA occlusion based on preoperative angiography images is challenging. We hypothesized that CT perfusion (CTP) could help to quickly and accurately recognize acute ICA occlusions with CA-A1 and that the double stent retriever (DSR) technique might improve radiological outcomes in ICA occlusion with CA-A1.

Methods: ICA occlusion cases were categorized into CA-A1 and non-CA-A1 groups. The diagnostic performance of CTP for CA-A1 was assessed, and radiological outcomes were compared between DSR and non-DSR groups in the CA-A1 group.

Results: A total of 281 cases of acute ICA occlusion were included: 34 with CA-A1 and 247 without CA-A1. Bilateral anterior cerebral artery (ACA) perfusion abnormalities on CTP were more frequent in the CA-A1 group (97.1% vs 5.3%, P<0.001). CTP showed 97% sensitivity, 95% specificity, and 95% accuracy for diagnosing CA-A1. Distal embolism into the ipsilateral ACA was more frequent in the CA-A1 group (29.4% vs 6.5%, P<0.001). Seven ICA occlusions with CA-A1 underwent the DSR technique as the first-line strategy. The risk of distal embolism into the ipsilateral ACA was significantly reduced compared with that in non-DSR cases (0% vs 40.7%, P=0.046).

Conclusion: CTP can accurately and quickly detect CA-A1 in acute ICA occlusion. Distal embolism into the ipsilateral ACA is common in the CA-A1 group, and the DSR technique significantly reduces its incidence, showing promise as a first-line strategy.

Background: A critical evaluation of the US Food and Drug Administration (FDA) recommendation to avoid intracranial stent placement (ICAS) within 7 days of a qualifying cerebral ischemic event.

Methods: This evaluation compared the rates of 1 month stroke and/or death associated with ICAS performed within 7 days and more than 7 days after a qualifying cerebral ischemic event in patients with high-grade (70-99% in severity) intracranial stenosis in two randomized controlled trials. A logistic regression analysis was performed to identify the impact of time interval strata between the qualifying cerebral ischemic event and ICAS on 1 month stroke and/or death rate (independent ascertainment).

Results: The rates of 1 month stroke and/or death were 14 of 112 (12.5%) and 33 of 172 (19.2%) in patients treated within 7 days and more than 7 days after a qualifying cerebral ischemic event, respectively (P=0.071). There was no difference in the 1 month stroke and/or death rate in patients who were treated within 7 days and those treated after 7 days after a qualifying cerebral ischemic event (OR 1.0004, 95% CI 0.55 to 1.84) after adjusting for age, gender, severity of stenosis strata, qualifying cerebral ischemic event type (transient ischemic attack or minor ischemic stroke), and stent used (self-expanding vs balloon expandable stents).

Conclusions: This analysis did not show any increased risk of 1 month stroke and/or death in patients who underwent ICAS within 7 days compared with those treated more than 7 days after the qualifying cerebral ischemic event. Delaying the ICAS according to current FDA recommendations may not be necessary when ICAS is indicated.

Background: The efficacy of mechanical thrombectomy (MT) for treating large infarcts has been established through multiple recent randomized controlled trials (RCTs). Nevertheless, hemorrhagic transformation (HT) remains one of the significant challenges following thrombectomy in these patients.

Methods: This study presents a post-hoc analysis of the Study of Endovascular Therapy in Acute Anterior Circulation Large Vessel Occlusive Patients with a Large Infarct Core (ANGEL-ASPECT) trial. We included all patients with large infarcts who underwent thrombectomy and had imaging data available for HT assessment. Multivariate regression models were developed to determine the predictive factors for post-thrombectomy parenchymal hemorrhage (PH) and examine the relationship between PH and patient outcomes.

Results: This study enrolled 217 patients, of whom 35 (16.1%) experienced PH 24-48 hours after thrombectomy. Multivariate analysis showed that patients with PH had a significantly worse functional outcome compared with patients without PH (modified Rankin Scale (mRS) score 5 vs 3, adjusted common OR (acOR) 0.31, 95% CI 0.16 to 0.61, P<0.01). Alcohol use (acOR 3.22, 95% CI 1.29 to 8.03, P=0.01) and an increased number of thrombectomy attempts (acOR 1.43, 95% CI 1.02 to 2.00, P=0.04) were independently associated with a heightened risk of PH. Conversely, local sedative anesthesia (acOR 0.10, 95% CI 0.01 to 0.84, P=0.03) was linked to a reduced risk of PH.

Conclusions: In patients with large infarcts, PH is associated with a poorer functional prognosis after thrombectomy. Alcohol use and a higher number of thrombectomy attempts were positively associated with the occurrence of PH, whereas local sedative anesthesia was negatively correlated with its occurrence.

Trial registration number: ClinicalTrials.gov Identifier: NCT04551664.

Background: In intracranial atherosclerotic stenosis (ICAS), low fractional flow (FF) may indicate hemodynamic significance.

Objective: To investigate, using simulation models, whether invasive measurement could accurately reflect 'true' FF, when the catheter/pressure wire might disturb focal flow during measurement.

Methods: We recruited 5 patients with high-grade, symptomatic M1 middle cerebral artery stenosis in three-dimensional rotational angiography (3DRA). In each case, the stenotic severity was manually manipulated to 50%, 60%, 70%, and 80%. At each stenotic severity, we simulated four situations: no catheter/pressure wire insertion ('in vivo' status); only catheter inserted proximally to the ICAS; catheter inserted and pressure sensor placed at 1 cm and 2 cm distally to the ICAS lesion. The blood flow was simulated with computational fluid dynamics modeling, and FF measured as post-stenotic and pre-stenotic pressure ratio. We calculated relative differences of FFs simulated at other situations compared with in vivo status.

Results: Compared with in vivo status, catheter insertion had no significant influence on simulated FFs. With pressure wire passing through the ICAS, simulated FFs slightly decreased (mostly <10%) at 50% and 60% stenoses, which significantly decreased (up to 50% and 88%) at 70% and 80% stenoses. The effects of pressure wire on FFs were similar when the pressure sensor was placed at 1 cm and 2 cm distally to the ICAS.

Conclusions: Invasive measurement of FF may overestimate the hemodynamic significance of ICAS with severe stenosis, as the pressure wire may further reduce the flow across the small residual lumen. The findings warrant verification in larger-scale studies, with information on collateral circulation and validation with other imaging modalities.

Background: Carotid lipid core plaques (LCPs) have been detected during assessment of carotid artery stenosis using catheter-based near-infrared spectroscopy (NIRS). Treatment with carotid artery stenting (CAS) using dual-layered stents might cause plaque protrusion, and subsequent thromboembolic complications.

Objective: We aimed to evaluate whether the telescopic carotid stenting (TCS) method suppresses plaque protrusion in patients with high LCPs as assessed by NIRS during CAS.

Methods: Participants comprised 63 consecutive patients with high LCP, defined as maximal lipid core burden index >400, undergoing CAS using dual-layered stents. For comparison, the study was divided into two distinct periods, with stenting by the standard method in the earlier period, and TCS in the later period. NIRS and intravenous ultrasonography (IVUS) were performed at baseline and after balloon dilatation to analyze the maximal lipid core burden index at the minimal luminal area (MLA) (max-LCBI_MLA), and the frequency of plaque protrusion.

Results: Baseline clinical and lesion characteristics, including symptoms, degree of stenosis, and plaque assessment by NIRS-IVUS, were not significantly different. MLA post-balloon percutaneous transmural angioplasty (PTA) was significantly smaller with the TCS method (9.2±1.5 mm²) than with the standard method (11.7±3.5 mm², P=0.002), and MLA change ratio before and after post-balloon PTA was significantly smaller with the TCS (2.2±0.6) than with the standard method (2.8±1.1, P=0.038). Plaque protrusion post-CAS was significantly less with the TCS (0 case, 0%) than with the standard method (4 cases, 20%, P=0.008).

Conclusion: The TCS method suppresses plaque protrusion in patients with high LCPs undergoing CAS, as assessed by NIRS.

Background: A1 hypoplasia is associated with anterior communicating artery (AcomA) aneurysms, but optimal imaging follow-up timing remains unclear. This study aimed to investigate whether concomitant A1 hypoplasia influences the post-treatment outcomes of AcomA aneurysms.

Methods: This retrospective cohort study (2013-24) included patients treated endovascularly for AcomA aneurysms, grouped by the presence or absence of A1 hypoplasia. Outcome measures included complete occlusion and good clinical outcomes at short term and long term follow-up, aneurysm recurrence, retreatment rates, and procedure related complications. Subgroup analysis compared treatment modalities within the A1 hypoplasia group.

Results: 298 AcomA aneurysms were included (median age 58 years, 63% women), with 205 in the symmetric group and 93 in the A1 hypoplasia group. Anterior dome projection was more common with A1 hypoplasia (61% vs 46%; P=0.01), as were recurrence rates (31% vs 15%; P=0.005). A1 hypoplasia correlated with reduced long term complete occlusion rates (OR 0.32, P=0.01). In A1 hypoplasia patients, coiling/balloon assisted coiling showed lower long term occlusion rates (P=0.008), higher recurrence (P=0.049), and a trend toward increased retreatment (P=0.07). Stent assisted coiling was linked with higher long term occlusion rates (P=0.009) and a trend toward reduced retreatment (P=0.07). Flow diverter treatment showed no significant effect.

Conclusion: In this study, A1 hypoplasia affected long term outcomes of endovascular treatment for AcomA aneurysms, leading to lower occlusion and higher recurrence rates. Closer long term monitoring is needed in these patients.

Background: Bias from contrast injection variability is a significant obstacle to accurate intracranial aneurysm (IA) occlusion prediction using quantitative angiography (QA) and deep neural networks (DNNs). This study explores bias removal and explainable AI (XAI) for outcome prediction.

Objective: To implement an injection bias removal algorithm for reducing QA variability and examine the impact of XAI on the reliability and interpretability of deep learning models for occlusion prediction in flow diverter-treated aneurysms.

Methods: This study used angiograms from 458 patients with flow diverter-treated IAs, with 6-month follow-up defining occlusion status. We minimized injection variability by deconvolving the parent artery input to isolate the aneurysm's impulse response, then reconvolving it with a standardized injection curve. A DNN trained on these QA-derived biomarkers predicted 6-month occlusion. Local Interpretable Model-Agnostic Explanations (LIME) identified the key imaging features influencing the model, ensuring transparency and clinical relevance.

Results: The DNN trained with uncorrected QA parameters achieved a mean area under the receiver operating characteristic curve (AUROC) of 0.60±0.05 and an accuracy of 0.58±0.03. After correcting for injection bias by deconvolving the parent artery input and reconvolving it with a standardized injection curve, the DNN's AUCROC increased to 0.79±0.02 and accuracy to 0.73±0.01. Sensitivity and specificity were 67.61±1.93% and 76.19±1.12%, respectively. LIME plots were added for each prediction to enhance interpretability.

Conclusions: Standardizing QA parameters via injection bias correction improves occlusion prediction accuracy for flow diverter-treated IAs. Adding explainable AI (eg, LIME) clarifies model decisions, demonstrating the feasibility of clinically interpretable AI-based outcome prediction.

Background: Contrast-induced encephalopathy (CIE) is an increasingly observed complication following neurointervention, but remains poorly defined with limited evidence for clinical decision-making. We sought to characterize the stereotypical clinical features of CIE in a nationwide, multicenter cohort.

Methods: A multicenter cohort study was conducted between 10 neurovascular sites across Australia. Patients were screened according to the previously proposed Australian diagnostic criteria. Descriptive analysis was conducted to characterize the clinical course and outcomes of CIE, and associations between clinical and radiological variables on patient outcomes were analyzed using Fisher's exact and χ² tests.

Results: A total of 56 patients (median age 65 years) were included. The median contrast volume was 170 mL (IQR 140-229). Median time to symptom onset was 6 hours (IQR 1-12), with frequent symptoms including motor deficit (55.4%), dysphasia (39.3%), and confusion (35.7%). Common radiological findings included sulcal effacement (45.5%) and subarachnoid contrast staining (30.9%) on CT. Hemianopia (p=0.001) and cortical blindness (p=0.018) were associated with posterior circulation interventions, while motor deficit was correlated with anterior circulation interventions (p=0.001). At discharge, 87.5% of patients achieved complete resolution of symptoms, of which 69.4% achieved complete recovery within 72 hours.

Conclusion: CIE is a recognized complication of neurointervention. Symptoms occur within hours of contrast administration and correlate with the territory of contrast administration. Most patients achieve complete symptom resolution. Ongoing investigation is required to further define CIE as a clinical entity.

Background: Carotid artery web (CW) is an under-recognized cause of cryptogenic stroke, with variability in practice and controversy regarding its optimal management. Due to the lack of society guidelines, it is unclear how neurointerventional radiologists (NIRs) and vascular neurologists approach this condition. Therefore, we conducted a survey to understand practice patterns for the management of CW.

Methods: A 10-question survey, including demographic data and clinical vignettes, was developed using REDCap (Research Electronic Data Capture) and sent to board-certified vascular neurologists and NIRs. Responses were categorized into binary outcomes (medical therapy vs carotid revascularization). Statistical analyses, including Chi-square, Fisher's exact, and Kruskal-Wallis, were used for group comparisons.

Results: Of 1640 participants, 247 completed the survey, with 77% being vascular neurologists and 23% neurointerventionalists. Participants identified cryptogenic stroke (80.1%) and recurrent stroke (74.4%) as key factors considering CW as the underlying stroke etiology. For a cryptogenic ischemic stroke, neurointerventionalists were more likely than neurologists to favor carotid revascularization (52% vs 37%, p=0.035). In patients with ischemic stroke and competing mechanisms such as atrial fibrillation, nearly half of neurointerventionalists, but only one-third of neurologists, recommended revascularization for secondary prevention (48% vs 31%, p=0.021). NIRs, when compared with neurologists, had a strong preference for carotid artery stenting over carotid endarterectomy (86% vs 35%, p=0.002).

Conclusions: There is clinical equipoise regarding the management of CW and ischemic stroke. Randomized clinical trials are needed to minimize variability in treatment approaches.