Journal of NeuroInterventional Surgery最新文献

Background: Preclinical reports suggest that intra-arterial (IA) 20% albumin may have neuroprotective effects. A 3+3 dose-escalation pilot clinical trial preliminarily confirmed the safety and feasibility of doses up to 0.6 g/kg. Based on these findings, we aimed to evaluate the safety and explore the potential efficacy of adjunctive IA albumin in acute ischemic stroke patients undergoing endovascular thrombectomy (EVT).

Methods: This prospective single-center cohort trial enrolled patients with successful recanalization (defined as a score on the expanded Thrombolysis In Cerebral Infarction (eTICI) scale of 2b to 3). Patients were classified into the EVT alone group and IA albumin group. The primary endpoint was any intracranial hemorrhage (ICH). Secondary endpoints included pulmonary edema/congestive heart failure, symptomatic ICH, and all-cause mortality within 90 days. Exploratory efficacy endpoints included excellent outcome at 90 days (defined as a modified Rankin Scale score of 0-1), final infarct volume, and glymphatic system activity quantified by diffusion tensor imaging via the ALPS (analysis along the perivascular space) index.

Results: We enrolled 251 patients, with 103 in the IA albumin group and 148 in the EVT alone group. After propensity score matching, each group had 103 patients with balanced baseline characteristics. The primary safety outcome of any ICH occurred in 16.5% of the albumin group versus 25.2% of controls, with no statistically significant difference between groups (OR 0.25, 95% CI 0.25 to 1.09, P=0.081). No significant differences were observed in other safety outcomes. In the post hoc exploratory efficacy analyses, the IA albumin group had a greater likelihood of excellent neurological outcome at 90 days, smaller final infarct volumes, and higher ALPS index.

Conclusion: In patients with acute large vessel occlusion, adjunctive IA albumin after successful thrombectomy was safe and well-tolerated. In post hoc exploratory analyses, this treatment was associated with a higher likelihood of achieving an excellent neurological outcome at 90 days and with reduced final infarct volume. The neuroprotective effect may be mediated by restoration of glymphatic function. These promising findings warrant validation in multicenter randomized trials.

Background: Randomized clinical trials have demonstrated that middle meningeal artery embolization (MMAe) reduces reoperation rates in surgically treated patients with subacute/chronic subdural hematoma (SDH). The effect of embolization on outcomes beyond reoperation remains to be determined. We analyzed the impact of reoperation and healthcare encounters among patients enrolled in the EMBOLISE trial.

Methods: Symptomatic subacute/chronic SDH patients were randomized to surgical evacuation alone (control) or surgical evacuation plus Onyx MMAe (treatment). Changes in modified Rankin Scale (mRS) scores, frequency of unscheduled follow-up visits, and radiographic evolution of hematomas in patients with versus without reoperation were analyzed.

Results: A total of 197 patients were randomly assigned to the treatment group and 203 to the control group. Patients who required reoperation compared with those who did not exhibited a ~threefold higher incidence of mRS >2 (37.0% vs 12.9%, P=0.0025) and an ~2.5 fold increase in mRS worsening (22.2% vs 9.5%, P=0.0503) at 180 days. In patients who did not receive MMAe, there was a ~threefold fold increase in rate of SDH recurrence/progression even among those who did not require reoperation (14.3% vs 5.3%, P=0.0045) and a ~twofold increase in unscheduled physician follow-up visits (27.1% vs 14.7%, P=0.0031).

Conclusion: Among patients with symptomatic subacute/chronic SDH, reoperation was associated with increased rates of mRS worsening and higher mRS scores at follow-up. Adjunctive Onyx MMAe resulted in lower rates of hematoma recurrence/progression and fewer unscheduled physician follow-up visits. Thus, in addition to reducing surgical reoperation rates, adjunctive MMAe led to improved clinical outcomes and reduced healthcare encounters.

Background and objectives: Flow diversion for middle cerebral artery (MCA) bifurcation aneurysms remains challenging due to jailed branch considerations and limited evidence. We aimed to evaluate the efficacy and safety of flow diverters (FDs) in this setting, with outcomes grouped by bifurcation subtype.

Methods: We retrospectively collected cases from three centers in which flow diversion was used to treat MCA bifurcation aneurysms. We collated and analyzed demographic, clinical, and aneurysm characteristics; procedural details; and peri-procedural and follow-up safety and efficacy outcomes. Outcomes were assessed overall and by bifurcation subtype (true (TBA) and variant (VBA) bifurcation aneurysms).

Results: We included 195 unruptured and previously untreated MCA bifurcation aneurysms. Periprocedural complications comprised ischemic events in 7.2% and hemorrhage events in 0.5% of all patients. During clinical follow-up (median 17.1 months), new ischemic events occurred in 7.4% and hemorrhagic events in 0.6% of all patients. At imaging follow-up (median 12.7 months), complete occlusion (Raymond-Roy I) was 59.5%, with 11.0% residual neck. Adequate occlusion (Raymond-Roy I-II) was lower in TBA than in VBA (63.0% vs 80.3%). Multivariable Cox regression revealed that a sac-like origin of the jailed branch and a higher jailed-to-FD branch diameter ratio were independent predictors of incomplete occlusion at 12 months. Sensitivity analyses confirmed robustness across different subtypes. The optimal predictive threshold for this ratio differed by subtype (TBA=0.81; VBA=0.70).

Conclusion: Flow diversion is a reasonable endovascular option for MCA bifurcation aneurysms, particularly for variant bifurcations. Pre-procedural assessment of the intended jailed branch may help to improve mid-term occlusion rates.

Background: Appropriate management of spontaneous intracerebral hemorrhage (ICH) and intraventricular hemorrhage (IVH) requires rapid, accurate volume estimation. Viz.AI has developed an artificial intelligence (AI)-powered ICH calculation tool that may improve existing methods.

Methods: Adult patients presenting to a large healthcare system between December 2015 and December 2021 with spontaneous ICH greater than 10mL and within 72 hours since ictus were analyzed for hematoma volume. mABC/2 (modified ABC/2) was measured by a board-certified neurosurgeon. Semi-autonomous segmentation (SAS) was performed by a trained medical student on 3D Slicer, adjudicated by a board-certified neurosurgeon and used as a surrogate ground-truth volume.

Results: 139 CTs met inclusion criteria. Mean ICH volume via ground-truth SAS was 47.69±27.19 mL. Mean ICH volume difference between SAS and AI and SAS and mABC/2 was 4.77±4.06 mL and 8.36±9.48 mL, respectively (p<0.01). Bland-Altman plots yielded AI and SAS limits of agreement between -4.45 and 13.18 mL, and mABC/2 and SAS limits of agreement between -21.35 and 27.02 mL. The average absolute difference between IVH volume yielded by SAS and AI was 3.26±3.55 mL. Bland-Altman plots yielded IVH volume limits of agreement between -7.48 mLand 10.47 mL. AI was 94.6% sensitive and 94.0% specific for detecting IVH in the presence of ICH. The average time-to-volume for SAS and AI was 424±208 and 151±49.7 s (P<0.01), respectively.

Conclusion: Viz.AI is more accurate than mABC/2, and more rapid than SAS. The combination of speed and accuracy makes Viz.AI viable for clinical decision-making and clinical trial use.

Background: Endovascular thrombectomy (EVT) is the standard of care for patients with acute ischemic stroke (AIS) and intracranial vessel occlusion. Tandem occlusions (TO) comprise 20% of all anterior circulation AIS and are related to a poorer prognosis. The optimal EVT treatment strategy remains controversial. Our main objective was to determine if simultaneous endovascular treatment of intracranial and extracranial occlusions in patients with TO results in faster recanalization times, with similar efficacy and safety, compared with the sequential approach.

Methods: Single center, retrospective analysis of patients with TO undergoing EVT using the simultaneous or sequential technical approach. The primary outcome was puncture-to-final recanalization time. Secondary outcomes included modified Rankin scale (mRS) score at 3 months, 30 day mortality, and hemorrhagic transformation.

Results: We included 111 patients with TO (35 treated with the simultaneous approach and 76 treated with the sequential approach). Successful recanalization was achieved in 91.9% of cases, and the first pass effect was 50.5%, with no differences between groups. The simultaneous technique resulted in shorter puncture-to-final recanalization time (33.0 min (IQR 25.0-55.0) vs 52.0 (30.0-73.0), P=0.018), adjusting for number of passes, first pass effect, thrombolysis, age, and previous stroke (adjusted β -0.21 (95% CI -29.47 to -2.79); P=0.018). No significant differences were found in 30 day functional outcome, mortality, or rate of hemorrhagic transformation when comparing simultaneous and sequential techniques.

Conclusion: The simultaneous approach was effective, safe, and faster than the classic sequential approach in patients with TO. This result may obviate the debate over which occlusion should be addressed first during EVT.

Background: Post-stroke epilepsy (PSE) is a major complication of stroke. However, data about the predictors of PSE in patients with acute ischemic stroke (AIS) undergoing mechanical thrombectomy are limited.

Objective: To evaluate the relationship between intraoperative angiographic signs and PSE risk in patients with anterior circulation AIS who underwent mechanical thrombectomy.

Methods: We conducted a retrospective study. A total of 800 patients with AIS who underwent mechanical thrombectomy were classified into case and control groups based on the occurrence of PSE. Propensity score matching (PSM) (1:4) was applied using covariates such as age, sex, National Institutes of Health Stroke Scale score at admission, and baseline modified Rankin Scale score. Conditional logistic regression and mediation analysis were performed. Subgroup analyses were conducted to assess the effect of modification. A diagnostic model based on the angiographic signs and clinical characteristics was developed.

Results: After PSM, 67 and 234 patients with and without PSE, respectively, were selected. The PSE group had significantly higher incidences of hemorrhagic transformation, early seizures, early venous filling (EVF) sign, inferior frontal gyrus (IFG), hippocampus, basal ganglia blush sign, and larger infarct size. After adjusting for hypertension, diabetes, hemorrhagic transformation, infarct size, early seizure, IFG, and hippocampus involvement, EVF remained independently associated with PSE. Hemorrhagic transformation mediated 14.87% of the EVF-PSE associations. Comparison of the evaluation metrics of each model showed that model 3 exhibited the best overall performance.

Conclusion: Hemorrhagic transformation mediates the EVF-PSE association. EVF signs are key predictors of PSE following mechanical thrombectomy.

Here we present a fusiform, partially thrombosed, previously ruptured aneurysm in the posterior cerebral artery that was treated with parent vessel sacrifice after a micro-WADA and micro-balloon test occlusion (video 1). These aneurysms pose treatment challenges due to their deep location, morphology, and potentially eloquent distal supply.1 2 Primary coiling, stent assisted coiling, or microsurgical clipping are often not viable options, whereas flow diversion, parent vessel sacrifice,3 or trapping with bypass are usually employed. Pharmacological provocative testing via a micro-WADA4 5 with or without a micro-balloon test occlusion is critical to establish whether the territory at risk has functional eloquence, although specific reports for using these techniques are limited. We describe the patient presentation, initial treatment attempt and failure, and our protocol for performing a micro-WADA/balloon test occlusion test. neurintsurg;18/1/301/V1F1V1Video 1 Micro wada for PCA aneurysm.

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.