Journal of NeuroInterventional Surgery最新文献

Background: This meta-analysis aims to evaluate the clinical and angiographic outcomes of low profile flow diverters (FDs) used in treating intracranial aneurysms in small parent vessels (≤3.5 mm).

Methods: A systematic review was conducted using Medline, Scopus, and Web of Science databases from inception to October 2024. Studies reporting clinical and angiographic outcomes for Silk Vista Baby, Flow Re-direction Endoluminal Device Junior (FRED Jr), and p48 MW Flow Modulation Device were included. Favorable outcomes were defined as those reported directly in studies or as a modified Rankin Scale score of 0-2.

Results: 33 studies involving 998 patients with 1049 aneurysms were analyzed. Favorable neurological outcomes were reported in 94% of cases overall, with unruptured aneurysms achieving better outcomes (97.1%) than ruptured aneurysms (80%). Procedure related complications were observed in 15.7% of cases, with a lower rate in unruptured aneurysms (12.7%) compared with ruptured aneurysms (20%). Complete or near complete occlusion was achieved in 79.5% of aneurysms from 28 studies, with similar rates for both unruptured (73.6%, from 14 studies) and ruptured (74%, from 13 studies) aneurysms. Among devices, the FRED Jr showed the highest favorable outcome rate (97.6%), while the p48 MW device had the highest complication rate (17.2%). Adjunctive coiling did not significantly affect neurological outcomes but was associated with a slightly lower complication rate (12.1%).

Conclusion: Low profile FDs demonstrated high rates of favorable neurological outcomes in small parent vessel aneurysms, particularly in unruptured cases. These FDs achieved acceptable rates of adequate aneurysm occlusion and complications.

Background: Better reperfusion status results in smaller infarct volumes and better outcomes after thrombectomy. However, if large tissue volumes are already infarcted at baseline, reperfusion might also increase the risk of intracranial hemorrhage. This study aims to investigate the interaction between reperfusion status, baseline ischemic changes, and intracranial hemorrhage following thrombectomy.

Methods: Retrospective analysis of the ESCAPE-NA1 randomized trial. Unadjusted and adjusted logistic regression models were used to estimate the associations of Alberta Stroke Program Early CT Score (ASPECTS) and expanded Treatment In Cerebral Infarction (eTICI) score on post-treatment hemorrhage. Treatment effect modification was assessed by including multiplicative interaction terms (ASPECTS*eTICI) in these models.

Results: A total of 1077 patients were included. Median age was 70.8 (IQR 60.7-79.7) and 543 (50.4%) were female. Any intracranial hemorrhage on 24-hour follow-up imaging occurred in 368/1077 (34.2%) patients. There was evidence of modification of the effect of final angiogram eTICI score on any intracranial hemorrhage by baseline ASPECTS (P=0.008). Marginal probabilities showed increased hemorrhage risk for patients with low ASPECTS with increasing final eTICI scores. This association was reversed in patients with small baseline ischemic changes and successful reperfusion. There was no association with symptomatic intracranial hemorrhage or parenchymal hematoma.

Conclusion: The association of post-thrombectomy reperfusion status and post-treatment hemorrhage may be modified by the extent of baseline ischemia. Reperfusion is associated with reduced risk of hemorrhage in patients with small baseline infarcts, but increased hemorrhage risk in patients with extensive ischemic changes at baseline. However, no significant association was found with symptomatic intracranial hemorrhage or parenchymal hematoma.

Trial registration number: NCT02930018.

Background: Endovascular embolization is an accepted treatment modality for brain arteriovenous malformations (bAVM); however, treatment outcomes are highly variable, warranting accurate prediction for adequate patient selection. Several predictive scores have been proposed for this purpose. The objective of this study was to externally validate these scores for embolization of bAVM.

Methods: This study involved bAVM patients treated with transarterial embolization. Endovascular predictive scores were identified through literature search. Relevant data for scoring of included patients was extracted. Primary study outcomes were radiological cure and neurological complications. The performance of the scores was evaluated by analyzing calibration (z-scores from logistic regression), discrimination (area under the receiver operating characteristic curve, AUROC), and classification (Youden's index and corresponding sensitivity and specificity). Additionally, sensitivity analyses were performed restricting the study population by size, location, and embolization intent.

Results: A total of 198 bAVM (190 patients) were included. The rates of radiological cure and neurological complications were 18.2% and 14.1%, respectively. The literature search identified seven predictive scores. In the overall analysis, the Toronto score showed the best performance for radiological cure (AUROC 0.905). No significant difference was observed between the performance of the assessed scores for neurological complications. The sensitivity analysis showed improved performance of most scores. The Toronto score exhibited the highest performance for radiological cure (AUROC 0.857). The AVM Embolization Prognostic Risk Score (AVMEPRS) showed the highest performance for neurological complications (AUROC 0.751). The AVM Embocure Score (AVMES) showed fair to good performance for both efficacy and safety outcomes.

Conclusion: Among the selected scores, the Toronto, AVMEPRS, and AVMES scores showed the best performances.

Background: Intracranial aneurysm embolization is traditionally performed in a hospital setting, but there is growing interest in transforming these procedures to outpatient facilities, while ensuring patient safety and effectiveness. We present the first series of patients undergoing flow diverting embolization at an ambulatory neurosurgery center (ANSC) and assessed feasibility, safety, and patient satisfaction.

Methods: We retrospectively reviewed the medical records of patients undergoing flow diverting embolization at the ANSC between August 1, 2024, and January 3, 2025. Patient demographics, procedural details, and periprocedural events were recorded. Patients were observed at the ANSC before transfer to a rehabilitation facility for overnight monitoring in a simulated home environment. A postprocedural satisfaction survey (scale 0-5; 5=best experience) was completed at the 2 week follow-up.

Results: Nine patients (mean age 55±13 years) underwent embolization under conscious sedation. Eight aneurysms in the internal carotid artery (mean aneurysm size 6.3±2.8 mm) and one cervical pseudoaneurysm were treated using the Pipeline Vantage (Medtronic, Dublin, Ireland) via a transfemoral approach. Mean procedural time was 35±1 min; mean turnover time was 17±0.2 min. No periprocedural or delayed complications occurred. Patients were observed for a mean 5.3±1.5 hours in the ANSC and discharged home from rehabilitation on postprocedure day 1. Patient satisfaction was unanimously rated 5.

Conclusions: The results showed that flow diverting embolization for aneurysms can be safely and feasibly performed in the outpatient setting with careful patient selection and use of the latest generation flow diverters. An ANSC may offer meaningful benefits, including reducing hospital burden, lower costs, and improvement of overall efficiency, while maintaining patient safety and quality.

The effectiveness of middle meningeal artery (MMA) embolization for chronic subdural hematoma is well established,1-3 and distal and multibranch penetration of embolic agents is recognized as a key factor for better outcomes.4 5 In recent years, several studies have described artificial intelligence (AI)-assisted neuroendovascular treatment.6-9 We recently reported that AI-assisted MMA embolization may enhance procedural safety through reflux detection and notification.10 This case (video 1) focuses on the overlay feature, highlighting its potential to improve procedural efficacy by enabling greater distal and multibranch penetration, resulting in a larger embolization volume. The overlay feature provided by the AI system enhanced visualization and notifications, enabling not only improved safety but also more effective multibranch penetration. As MMA embolization becomes more widespread, especially among younger operators, AI support that combines safety with efficacy holds promise for both clinical practice and training. Larger studies are needed to validate these findings further. neurintsurg;18/3/894/V1F1V1Video 1Artificial intelligence-assisted middle meningeal artery embolization with overlay visualization promoting distal and multibranch penetration.

Background: The stent type may be associated with adverse events in carotid artery stenting (CAS). This study aimed to compare the clinical outcomes (stroke/myocardial infarction (MI)/death) of CAS with open- and closed-cell stents for patients with carotid artery stenosis.

Methods: Between April 2012 and May 2024, the clinical data of 223 patients who underwent CAS in our center were retrospectively analyzed. In terms of the stent type used, patients were divided into a closed-cell stent group and an open-cell stent group. Clinical outcomes between the two groups were compared. Univariate and multivariate analyses were performed to identify the independent risk factors. Subgroup analyses in terms of carotid plaque types and smoking history were conducted in carotid artery stenosis patients receiving CAS with open- and closed-cell stents.

Results: The combined in-hospital stroke/MI/death rate was significantly lower in the closed-cell stent group than in the open-cell stent group (p=0.026). Open-cell stents, smoking, and unstable plaques were the independent risk factors associated with a higher in-hospital stroke/MI/death rate. Subgroup analyses showed that for patients with unstable plaques, the combined in-hospital stroke/MI/death rate was significantly higher in the open-cell stent group than in the closed-cell stent group (p=0.016). For patients who smoked, the combined in-hospital stroke/MI/death rate was significantly higher in the open-cell stent group than in the closed-cell stent group (p=0.038).

Conclusion: For carotid artery stenosis patients with unstable carotid plaques or smoking history, using closed-cell stents in CAS may help reduce the combined in-hospital stroke/MI/death rate.

Background: Intracranial atherosclerotic stenosis (ICAS) represents a major cause of ischemic stroke, with endovascular treatments, such as stenting, facing challenges such as restenosis and complications. Drug coated balloons (DCBs) provide a promising alternative by delivering targeted drug without permanent implants. This review systematically evaluates the efficacy and safety of DCBs for symptomatic ICAS, providing evidence based insights to guide clinical practice.

Methods: Databases were searched from inception to October 16, 2023, to identify studies on DCBs for symptomatic ICAS. Two independent researchers screened the literature and extracted data. A meta-analysis was performed using the Freeman-Tukey double arcsine transformation with random or fixed effects models to assess perioperative safety and restenosis rates. Heterogeneity and publication bias were also evaluated.

Results: The analysis included six controlled studies and 16 single arm studies involving 1308 patients with ≥70% stenosis. In single arm studies, the pooled restenosis rate for DCBs was 7.34% (95% CI 0.05 to 0.10, I²=44%, P=0.04), with a perioperative stroke and mortality rate of 5.75% (95% CI 0.04 to 0.08, I²=25%, P=0.18). The follow-up stroke and transient ischemic attack rate was 1.26% (95% CI 0.00 to 0.03, I²=33%, P=0.11). In controlled studies, DCBs significantly reduced restenosis rates compared with conventional balloons (OR=0.24, P=0.003) and stents (OR=0.20, P<0.001), without increasing perioperative adverse events.

Conclusions: In this study, DCBs showed significant potential as an effective therapeutic option for symptomatic ICAS in clinical practice, offering lower restenosis rates compared with conventional endovascular approaches while maintaining comparable safety profiles. However, further larger scale, high quality prospective studies are essential to validate these findings and establish standardized protocols for their application.

Background: Delayed intraparenchymal hemorrhage (DIPH) is a severe complication after pipeline embolization device (PED) deployment for intracranial aneurysms (IAs). However, predictive models are lacking. This study aims to develop and validate a new nomogram to predict DIPH risk in IA patients.

Methods: This retrospective study included 959 IA patients treated with PEDs at three institutions between October 2018 and June 2024. Patients were categorized into a training cohort (n=685) and a validation cohort (n=274). Predictors were identified using the least absolute shrinkage and selection operator and multivariable regression analyses. A nomogram was developed based on these predictors. The area under the receiver operating characteristic curve (AUC), calibration curves, and decision curve analysis (DCA) were utilized to assess the predictive accuracy and clinical value of the nomograms.

Results: The incidence of DIPH was 2.3% in the training cohort. Multivariate logistic regression analysis demonstrated that age (odds ratio [OR] per 10 years, 2.063, P=0.005), maximum diameter (OR, 1.099, P=0.004), adenosine diphosphate-induced maximal platelet aggregation (OR, 0.896, P<0.001), and overlapping devices (OR, 7.226, P=0.007) were independent risk factors for DIPH. A nomogram was developed based on these four predictors. The AUCs of the nomogram in the training and validation cohorts were 0.875 (95% CI, 0.762 to 0.988) and 0.886 (95% CI, 0.757 to 1.000), respectively. The calibration curve and DCA analyses confirmed the utility and clinical applicability of the nomogram.

Conclusion: A simple to use nomogram for the individualized prediction of DIPH after PED treatment in patients with IAs was constructed, which may facilitate early identification of high-risk patients and the development of advanced treatment strategies.

Background: Although mechanical thrombectomy (MT) is an effective treatment for large vessel occlusion (LVO) with a high successful recanalization rate, MT failure (MTF) occurs in 10-15% of cases and is associated with unfavorable outcomes. However, little is known about the clinical, technical, and radiological reasons for MTF. We investigated the technical factors associated with MTF.

Methods: We conducted a retrospective analysis of consecutive patients with anterior LVO prospectively included in the ongoing observational multicenter ROSSETTI registry. Patients were categorized according to the success (≥mTICI 2b) or failure (

Results: We analyzed 4135 patients, including 325 patients (7.9%) with MTF. Patients in the MTF group had a significantly lower Alberta Stroke Program Early CT Score (ASPECTS) at baseline (8 (7-10) vs 9 (8-10)), longer time since last time seen well (279 min vs 262 min), increased MT procedure time (76 min vs 31 min), higher rate of complications (23% vs 4%), higher symptomatic intracerebral hemorrhage (21% vs 7.9%), higher 24 hour National Institutes of Health Stroke Scale score (19 vs 6), worse functional outcome at 3 months (modified Rankin Scale score 0-2, 15.6% vs 53%), and higher mortality (45% vs 20%). Four or more passes were an independent predictor of MTF (OR 3.46, 95% CI 2.58 to 4.63; P<0.001). None of the endovascular techniques demonstrated a higher likelihood of MTF.

Conclusion: In this study, MTF in anterior circulation LVO was associated with a high complication rate and worse outcomes.

Purpose: Large bore catheters are increasingly used in mechanical thrombectomy (MT) for large vessel occlusions (LVOs).

Objective: To evaluate the efficacy and safety of the super-large bore Cereglide 0.092" (C-92) catheter, featuring the largest inner diameter available.

Methods: A multicenter observational study was conducted across 12 comprehensive stroke centers in the United States. Efficacy outcomes included the first pass effect (FPE) and successful reperfusion. FPE was defined as a first MT pass achieving a modified Treatment in Cerebral Infarction (mTICI) score of ≥2c. Successful reperfusion was defined as final mTICI score ≥2c. Safety outcomes involved device-related complications, symptomatic intracranial hemorrhage (sICH), and inpatient mortality. Functional outcomes included modified Rankin Scale (mRS) score at discharge and delta National Institutes of Health Stroke Scale (NIHSS) score.

Results: Fifty patients were included. The most common LVO was the first segment of the middle cerebral artery in 31/50 cases (62%). The C-92 reached the thrombus in 41 patients (82%). Median puncture-to-thrombus and puncture-to-reperfusion times were 15 min (IQR 10-25) and 26 min (IQR 15-49), respectively. FPE was achieved in 25/50 (50%) cases, and in 25/41 (61%) cases when the C-92 reached the thrombus. Successful reperfusion occurred in 36/41 patients (88%). There were no vessel perforations, or sICH. Distal embolization occurred in 4/50 (8%) cases, and 4/50 (8%) died. The mRS score at discharge was 3 (IQR 2-6), and the delta NIHSS score was 8 (IQR 5-12).

Conclusion: The C-92 catheter demonstrated a safe profile achieving an overall FPE rate of 50%, and favorable functional outcomes in 88% of cases.