Journal of NeuroInterventional Surgery最新文献

Background: Temporary clipping (TC) is an essential adjunct in cerebral aneurysm (CA) surgery. Despite appearing insignificant to the surgeon under the microscope, TC may cause parent vessel injury. Intraoperative diagnostic cerebral angiography (ioDCA) is crucial for assessing aneurysm occlusion and parent vessel integrity. We aimed to assess sequelae of TC evident on immediate ioDCA.

Methods: Elective CA clippings with ioDCA in a hybrid operating room from January 2020 to June 2023 were reviewed. Microsurgical and angiographic assessments were performed to identify post-TC parent vessel alterations. Outcomes were compared between TC and non-TC-groups.

Results: Collectively, 107 patients underwent 111 craniotomies for clipping of 127 CAs. TC was used in 59/111 cases (53.2%) for treatment of 66/127 CAs (51.9%). CA size and neck were significantly larger in the TC group than in the non-TC group (p<0.001). Parent vessel vasospasm at the site of the previous temporary clip location was evident on 3D rotational angiography in 12/59 (20.3%) TC cases. Clip adjustment rates after ioDCA were similar between groups (TC 13.6% vs non-TC 8.2%, p=0.328). In the TC group compared with the non-TC group, the rates of symptomatic radiographic ischemia and functional decline at discharge were significantly higher (p=0.022 and p=0.045, respectively). However, functional status at follow-up was comparable (p=0.620).

Conclusions: TC during CA surgery can cause significant yet microsurgically occult vasospasm in the parent vessel, potentially contributing to symptomatic ischemia and early functional decline. Intraoperative angiography is crucial for detecting this issue, highlighting both its importance and the risks associated with TC.

Background: The angiographic shape of an occlusion, like the clot meniscus sign and the claw sign, has been reported to potentially impact the recanalization rate and clinical outcome in patients undergoing mechanical thrombectomy for acute ischemic strokes.

Method: Following PRISMA guidelines, a systematic literature search was conducted across PubMed, Scopus, Embase and Web of Science databases. Patients were grouped into clot meniscus/claw sign positive and negative groups based on the definitions obtained from each study. Primary outcomes included technical success, with a meta-analysis performed using a random-effects model to calculate proportions and odds ratios (OR) with 95% confidence intervals (Cl).

Results: We included seven studies recruiting 1572 patients. The results indicated that the positive and negative groups had comparable first-pass effect (OR 1.95; 95% CI 0.76 to 5.01; P=0.167) and final recanalization (OR 1.36; 95% CI 0.81 to 2.27; P=0.248) rates. However, the rate of having a favorable functional outcome was significantly higher in the positive group than in the negative sign group (OR 1.91; 95% CI 1.25 to 2.92; P<0.003). Within the sign-positive population, the use of contact aspiration was associated with a significantly higher rate of recanalization compared with using a stent retriever (OR 0.18; 95% CI 0.07 to 0.49; P<0.001). This result did not translate into a clinical impact, as both stent retriever and contact aspiration showed comparable rates of functional independence at 3 months (OR 0.22; 95% CI 0.02 to 2.33; P=0.210).

Conclusion: The presence of the clot meniscus/claw sign is not associated with recanalization outcomes after thrombectomy. However, it might be a good sign to predict which thrombectomy technique might be associated with better recanalization, although current evidence may need further confirmation.

Background: The Contour Neurovascular System (CNS, Stryker, Kalamazoo, MI) has a unique design that allows it to address various aneurysm morphologies, including wide-necked, irregular, and shallow-shaped lesions. However, evidence of its safety and efficacy remains limited. This systematic review and meta-analysis synthesizes the current data on CNS performance.

Methods: A comprehensive search guided by the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) standards was performed across PubMed, Embase, and Web of Science, including studies with ≥5 patients reporting on CNS use. Efficacy outcomes included immediate and last follow-up adequate aneurysm occlusion and technical success. Safety outcomes included good functional outcome (modified Rankin Scale (mRS) score of 0-2 at last follow-up), procedure-related morbidity (permanent neurological deficits), procedure-related mortality, intraoperative and postoperative complications. Pooled analyses with 95% confidence intervals (CI) were conducted, with heterogeneity assessed using I² statistics, and a random-effects model was applied.

Results: Nine studies, including 483 patients (58.8% female; mean age: 59.3±15.6 years) with 484 aneurysms, were analyzed. Of the 467 patients in whom rupture status was reported, 81.8% presented with unruptured aneurysms and 18.2% with ruptured aneurysms. Immediate adequate aneurysm occlusion rate was 53% (95% CI: 1% to 100%), with follow-up adequate occlusion at 93% (95% CI: 88% to 97%) and technical success at 98% (95% CI: 95% to 100%). Intraoperative and postoperative complication rates were 3% (95% CI: 0% to 7%) and 7% (95% CI: 3% to 12%), respectively. Procedure-related morbidity was 2% (95% CI: 0% to 3%), with no procedure-related mortality.

Conclusion: The CNS is a safe and effective novel intrasaccular device for treating intracranial aneurysms.

Background: Isolated anterior cerebral artery occlusions (ACAo) in patients with acute ischemic stroke present significant challenges due to their rarity. The efficacy and safety of endovascular therapy (EVT) in comparison with best medical therapy (BMT) for ACAo remains unclear. This study aimed to assess the outcomes of these treatments.

Methods: This multinational, multicenter study analyzed data from the MAD-MT registry. Data were collected retrospectively from 37 sites across North America, Asia, and Europe. Inverse probability of treatment weighting (IPTW) was applied to balance confounding variables. The primary outcome was functional independence (modified Rankin Scale (mRS) scores of 0-2) at 90 days. Secondary outcomes included excellent outcomes (mRS 0-1), mortality at 90 days, and NIH Stroke Scale (NIHSS) score on day 1 post treatment.

Results: Of the 108 patients, 36 received BMT and 72 underwent EVT. The median age was 75 years, and 56% were male. At 90 days, 40% of patients achieved mRS 0-2, with no significant difference between EVT and BMT (38% vs 45%, p=0.46). Procedural success (mTICI 2b-3) was 91% in the EVT group, with a sICH rate of 2.9%. IPTW-adjusted analysis showed no significant difference between EVT and BMT for functional independence (OR 1.17, 95% CI 0.23 to 6.02, p=0.85), mortality (25% vs 21%, p=0.71) or day 1 NIHSS scores (Beta 2.2, 95% CI -0.51 to 4.8, p=0.11).

Conclusions: EVT showed high procedural success but did not significantly improve functional outcomes or mortality compared with BMT in patients with ACAo. Further randomized trials are needed to clarify EVT's role in ACAo.

Introduction: Anatomic factors that predict outcomes following basal ganglia intracranial hemorrhage (bgICH) evacuation are poorly understood. Given the compact neuroanatomic organization of the basal ganglia, we hypothesized that bgICH spatial representation could predict postoperative functional outcomes.

Methods: Patients undergoing minimally invasive surgical bgICH evacuation between 2013 and 2024 at one center were retrospectively reviewed. bgICH volumes were segmented and stereotactically localized using anatomic landmarks. Heat maps that identified bgICH spatial representation across functional outcome states were generated. Differential bgICH volume overlap with each heat map was calculated after subtracting out that patient's contribution to the map. Area under the receiver operating characteristic curve (AUC) was used to evaluate the diagnostic accuracy of differential volume overlap for poor functional outcome (modified Rankin Scale score of 4-6 within 1 year of surgery) and compared with that of the intracranial hemorrhage (ICH) score with a z test.

Results: Forty-five patients were included (62% men, 7% Caucasian, median age 53 years). Thirty-two patients (71%) had poor functional outcome (median follow-up 4.1 months), which was associated with increased age (P=0.032), bgICH volume (P=0.005), intraventricular hemorrhage severity (P=0.032), National Institutes of Health Stroke Scale (P=0.006), and differential volume overlap (P<0.001). Anatomically, poor outcome was associated with bgICH extension into the anterior limb of the internal capsule (P=0.004), caudate (P=0.042), and temporal lobe (P=0.006). The AUC for differential volume overlap was 0.87 (95% CI: 0.76-0.97), which was higher than chance alone (P<0.001), but statistically similar to that (0.82 (0.71-0.97)) of the ICH score (P=0.545).

Conclusion: Stereotactic bgICH localization enabled functional outcome prognostication in patients undergoing minimally invasive surgical evacuation.

Background: We investigate the association of imaging biomarkers extracted from fully automated body composition analysis (BCA) of computed tomography (CT) angiography images of endovascularly treated acute ischemic stroke (AIS) patients regarding angiographic and clinical outcome.

Methods: Retrospective analysis of AIS patients treated with mechanical thrombectomy (MT) at three tertiary care-centers between March 2019-January 2022. Baseline demographics, angiographic outcome and clinical outcome evaluated by the modified Rankin Scale (mRS) at discharge were noted. Multiple tissues, such as muscle, bone, and adipose tissue were acquired with a deep-learning-based, fully automated BCA from CT images of the supra-aortic angiography.

Results: A total of 290 stroke patients who underwent MT due to cerebral vessel occlusion in the anterior circulation were included in the study. In the univariate analyses, among all BCA markers, only the lower sarcopenia marker was associated with a poor outcome (P=0.007). It remained an independent predictor for an unfavorable outcome in a logistic regression analysis (OR 0.6, 95% CI 0.3 to 0.9, P=0.044). Fat index (total adipose tissue/bone) and myosteatosis index (inter- and intramuscular adipose tissue/total adipose tissue*100) did not affect clinical outcomes.

Conclusion: Acute ischemic stroke patients with a lower sarcopenia marker are at risk for an unfavorable outcome. Imaging biomarkers extracted from BCA can be easily obtained from existing CT images, making it readily available at the beginning of treatment. However, further research is necessary to determine whether sarcopenia provides additional value beyond established outcome predictors. Understanding its role could lead to optimized, individualized treatment plans for post-stroke patients, potentially improving recovery outcomes.

Background: Bioresorbable flow diverters (BRFDs) have the potential to solve several problems associated with conventional permanent flow diverters. We have constructed bare and poly-L-lactic acid (PLLA)-coated magnesium BRFDs (MgBRFDs) using a high-strength corrosion-resistant magnesium alloy. This study aimed to compare bioresorption and biocompatibility between the two types in a rabbit vascular model to determine which is more clinically feasible in humans.

Methods: Bare and PLLA-coated MgBRFDs were fabricated by braiding 48 thin magnesium alloy wires. Mechanical testing was conducted. Bare (n=13) and PLLA-coated (n=13) MgBRFDs were implanted into rabbit aortas and harvested 14, 30, and 90 days after implantation. The physical structure of the resolution process was examined using optical coherence tomography (OCT), micro-computed tomography, and scanning electron microscopy (SEM). The biological response of the vascular tissue was examined using SEM and histopathological analysis.

Results: The porosity and pore density of the bare MgBRFD were 64% and 16 pores/mm², respectively; corresponding values for the PLLA-coated MgBRFD were 63% and 12 pores/mm², respectively. The OCT attenuation score was significantly higher for the PLLA-coated MgBRFD at all time points (14 days, P=0.01; 30 days, P=0.02; 90 days, P=0.004). OCT, micro-computed tomography, and SEM demonstrated better stent structure preservation with the PLLA-coated MgBRFD. Neointimal thickness did not significantly change over time in either type of MgBRFD (bare, P=0.93; PLLA-coated, P=0.34); however, the number of inflammatory and proliferative cells peaked at 14 days and then decreased.

Conclusions: Both bare and PLLA-coated MgBRFDs had excellent biocompatibility. The PLLA-coated MgBRFD has greater clinical feasibility because of its delayed bioresorption.