Journal of NeuroInterventional Surgery最新文献

Background: Flow diverters (FDs) are increasingly used off-label for distal cerebral aneurysms (DCAs), those located at or beyond the anterior cerebral artery (ACA) A2, middle cerebral artery M2, and posterior cerebral artery P2 segments. However, data on their safety and efficacy remain limited. This systematic review and meta-analysis synthesizes current evidence on FD treatment for DCAs.

Methods: A comprehensive search was performed across PubMed, Scopus, and Web of Science, including studies with ≥5 patients reporting FD treatment of DCAs. Efficacy outcomes included adequate and complete aneurysm occlusion and retreatment rates. Safety outcomes included good functional outcome (modified Rankin Scale (mRS) score 0-2), procedure-related morbidity, mortality, complications, in-stent stenosis, and covered branch occlusion at follow-up. Pooled analyses with 95% confidence intervals (CI) were conducted using a random-effects model.

Results: Eighteen studies (441 patients, 70% women; mean age: 57.2±13.6 years) with 445 DCAs were included. Most aneurysms were unruptured (93.7%) and located in the ACA territory (78.4%). Adequate and complete occlusion at last follow-up were 90% (95% CI, 86 to 95) and 79% (95% CI, 74 to 85), respectively. The retreatment rate was 1.6% (95% CI, 0.2 to 3). Good functional outcome was achieved in 97% (95% CI, 95 to 99). Procedure-related complications occurred in 9% (95% CI, 5 to 13), with morbidity and mortality of 1.5% and 0.6%, respectively. In-stent stenosis and covered branch occlusion rates were 3% (95% CI, 0 to 8) and 5.5% (95% CI, 2 to 9), respectively.

Conclusion: FDs appear to be safe and effective for DCAs, with high occlusion rates and low retreatment and complication rates.

Background/aim: Endovascular stroke therapy (EVT) improves functional outcome and reduces mortality in patients with large vessel occlusion. However, data on risk factors for early mortality after EVT are scarce. We investigated the predictive value of clinical information already available on the day of hospital admission on early mortality following EVT.

Methods: We analyzed data from the nationwide Austrian Stroke Unit Registry (ASUR) covering consecutive stroke patients that had received EVT between 2013 and 2023. We used multivariable regularized regression analysis to identify factors associated with early mortality (defined as deceased within 7 days post-stroke). We further tested the accuracy of a modified version of the 'Predicting Early Mortality of Ischemic Stroke' (mPREMISE) score extending the original model by post-EVT recanalization status.

Results: The data showed that 5900 patients (median age: 75 years, 52.4% female) had received EVT, of whom 340 (5.7%) died within 7 days after admission. Stroke severity at admission, followed by higher age, incomplete recanalization (Thrombolysis in Cerebral Infarction scores (TICI) ≤2 a), vertebrobasilar occlusion site, diabetes, chronic heart disease, and pre-stroke disability (modified Rankin Scale >1) were independently associated with early mortality. The area under the receiver operating curve (AUC-ROC) for the mPREMISE score was 0.74 (95% confidence interval (CI), 0.71 to 0.77). Patients with a score ≥9 had a 25.8% (95% CI, 25.4 to 26.2%) risk of early mortality.

Conclusion: In this nationwide analysis, we identified risk factors for early mortality after EVT that can be assessed on the admission day. The mPREMISE score seems to be a reasonable tool for estimating early mortality in stroke patients undergoing EVT.

Background: Predicting the final infarct after an extended time window mechanical thrombectomy (MT) is beneficial for treatment planning in acute ischemic stroke (AIS). By introducing guidance from prior knowledge, this study aims to improve the accuracy of the deep learning model for post-MT infarct prediction using pre-MT brain perfusion data.

Methods: This retrospective study collected CT perfusion data at admission for AIS patients receiving MT over 6 hours after symptom onset, from January 2020 to December 2024, across three centers. Infarct on post-MT diffusion weighted imaging served as ground truth. Five Swin transformer based models were developed for post-MT infarct segmentation using pre-MT CT perfusion parameter maps: BaselineNet served as the basic model for comparative analysis, CollateralFlowNet included a collateral circulation evaluation score, InfarctProbabilityNet incorporated infarct probability mapping, ArterialTerritoryNet was guided by artery territory mapping, and UnifiedNet combined all prior knowledge sources. Model performance was evaluated using the Dice coefficient and intersection over union (IoU).

Results: A total of 221 patients with AIS were included (65.2% women) with a median age of 73 years. Baseline ischemic core based on CT perfusion threshold achieved a Dice coefficient of 0.50 and IoU of 0.33. BaselineNet improved to a Dice coefficient of 0.69 and IoU of 0.53. Compared with BaselineNet, models incorporating medical knowledge demonstrated higher performance: CollateralFlowNet (Dice coefficient 0.72, IoU 0.56), InfarctProbabilityNet (Dice coefficient 0.74, IoU 0.58), ArterialTerritoryNet (Dice coefficient 0.75, IoU 0.60), and UnifiedNet (Dice coefficient 0.82, IoU 0.71) (all P<0.05).

Conclusions: In this study, integrating medical knowledge into deep learning models enhanced the accuracy of infarct predictions in AIS patients undergoing extended time window MT.

Background: Hemimegalencephaly (HME) is a rare, congenital brain malformation associated with drug-resistant seizures that are challenging to manage in young infants. Hemispheric surgery in infants <3 months of age carries increased risks of blood loss and complications due to the fragility of the immature brain parenchyma and cerebral vasculature. Transarterial embolization (TAE) has emerged from an adjunct to surgery to a potential alternative to hemispherectomy in a subset of HME patients.

Objective: To review the safety, efficacy, and evolution of TAE performed in infants <3 months of age with medically refractory seizures due to HME.

Methods: We retrospectively reviewed patient demographics, intraprocedural events, procedure-related complications, and epilepsy characteristics for all infants who underwent TAE between 2013 and 2024 at a single quaternary institution.

Results: Thirteen patients underwent a total of 41 embolizations, with a mean age of 45.5±26.8 (range 10-99) days at first embolization. Procedure-related complications included femoral arterial occlusion (n=2), symptomatic intracranial hemorrhage resulting in progressive hydrocephalus requiring cerebrospinal fluid shunting (n=1), and non-target embolization (n=2). One mortality occurred from multifocal intraparenchymal hemorrhages due to post-procedure coagulopathy. Two patients developed delayed contralateral ischemic injury. Engel Class I (free of disabling seizures) was achieved in 72.7% (8/11) of patients, with a mean follow-up age of 4.4±3.6 (range 1.3-11.0) years.

Conclusions: TAE is a potential alternative to hemispherectomy for refractory epilepsy due to HME in infants <3 months of age; however, technical and perioperative challenges remain important considerations. Optimizing patient selection and periprocedure care are critical factors to improve patient outcomes.

Background: Flow diverters (FDs) are the first-line treatment of intracranial aneurysms (IAs). A groundbreaking mechanical balloon-based FD device was developed to enhance the precise landing and deployment efficiency for FDs.

Objective: To investigates the efficacy and safety of this innovative device in a prospective cohort.

Methods: This study was a prospective multicenter observational study conducted between September 2019 and November 2021. Patients diagnosed with unruptured IAs and treated with this innovative FD device alone were included. The immediate implantation success rate, the successful aneurysm occlusion rate (Raymond I-II or OKM C-D), the complete occlusion rate (Raymond I or OKM D), and the parent artery stenosis rate (>50%) at follow-up were evaluated as the evaluation index of efficacy. The mortality rate, adverse events (AEs), neurological AEs, and serious adverse events (SAEs) were evaluated as the evaluation index of safety.

Results: A total of 128 patients were included, and all of the FD deployments were successful (success rate reached 100%). At the 12-month mark, 91.4% (117/128) of patients achieved successful occlusion, 85.9% (110/128) achieved complete occlusion, and only 0.8% (1/128) exhibited parent artery stenosis >50% (without need for additional treatment). During the follow-up, there were no reported mortalities or cerebral hemorrhage, while 6 neurological adverse events (4.69%) and 4 SAEs (3.1%) were observed.

Conclusions: The mechanical balloon-based FD showed a remarkable occlusion rate alongside minimal ischemic and hemorrhagic adverse events compared with existing FDs. This innovative mechanical balloon-based design may be an important direction for future FD design.

Background and objectives: Large-bore aspiration catheters have demonstrated better recanalization times and higher first-pass effects in large vessel occlusions. However, vessel tortuosity and branching vessels can hinder navigability, potentially increasing the 'ledge effect', procedural times, and the risk of vessel injury. Recently, a newly designed delivery catheter (Carrier Delivery Catheter (CDC), Balt, France) has been introduced to the US market. This paper aims to report our combined experience with this catheter in a real-life clinical setting.

Methods: This is a retrospective, multicenter study based on a prospectively maintained database of patients with ischemic stroke who underwent mechanical thrombectomy between February 2024 and January 2025. All consecutive patients who underwent mechanical thrombectomy in which a CDC was used were included.

Results: A total of 43 patients from three centers in the USA were included. The mean age was 69.74 years, and most of the patients were male (60.5%). The CDC delivered the aspiration catheter to the clot in all cases. The mean National Institutes of Health Stroke Scale (NIHSS) score was 18, and the mean time between puncture to clot access was 18.14 min. No vessel dissection or perforation was reported, and 4.6% of symptomatic hemorrhagic complications were reported. None of the complications were adjudicated to be directly related to the use of the Carrier.

Conclusion: Our case series shows that the CDC is a useful and reliable tool as a delivery catheter for treating vessel occlusions in both the anterior and posterior circulation. This study serves as proof of concept and may provide a foundation for future prospective analyses of this innovative delivery system.

Paediatric neurointervention (PNI) markedly differs from adult neuro-intervention, requiring highly subspecialized clinical skills, knowledge, and techniques. Minimum standards of practice are well established in adult neurointervention but are lacking in the field of PNI. We sought to develop expert consensus on best practices for neurointervention in children.Using a two-stage Delphi consensus model we sought expert opinions from PNI practitioners worldwide regarding best practices. A two-stage online de-identified survey of PNI practitioners was undertaken assessing opinions on a range of topics including minimum recommended caseloads for PNI centres. Minimum agreement rates of >60% were set to determine consensus on any specific question. Consensus opinions on best practices were reviewed by the International Paediatric Stroke Organization Executive Committee.For the first-stage survey there were n=50 responses and for the second-stage n=45 responses, with practitioners from all inhabited continents represented. Consensus-based best practices included: i) Elective endovascular therapeutic neuro-interventions should be performed in high-volume paediatric centres with an established multi-disciplinary paediatric neurovascular team, and ii) High-volume centres are those that undertake at least 20 paediatric endovascular therapeutic neuro-interventions annually. Paediatric thrombectomy in large-vessel occlusion stroke, an area of increasing interest and attention, poses unique time-sensitive multidisciplinary logistical challenges meriting a dedicated analysis, and as such is not within the purview of this report.Best practices for PNI reported here have been identified through expert consensus and are designed to enhance patient safety whilst providing appropriate clinical access to life-saving procedures.

Objective: Our study aims to introduce a novel interventional treatment strategy for the management of chronic occlusion of the internal carotid artery (CO-ICA) using a specially designed thrombectomy stent, named the Chronic artery OccluSion recanalization with Intracranial protection using Stent retriever (COSIS) technique.

Methods: Thirty-two patients from four centers with CO-ICA between March 2023 to September 2024 were analyzed, retrospectively. All patients were classified into four types based on the occlusion segment. Patient demographics, endovascular thrombectomy (EVT) details, recanalization rates, intraoperative complications, and follow-up outcomes were evaluated.

Results: All 32 patients achieved successful recanalization. Dissection occurred in four patients (12.50%). No reocclusion, perforation, or other severe intraoperative complications occurred. Thrombus was extracted in 21 patients (65.62%). The median modified Rankin Scale (mRS) score at the 3 month follow-up was 1.0 (interquartile range (IQR): 0.0-1.0). The recanalization success rate and intraoperative complications showed no significant differences among the four types of occlusions.

Conclusion: The COSIS technique has improved the recanalization rate and safety in different types of CO-ICA patients. Further prospective studies are needed to validate its clinical efficacy.

Background: Mechanical thrombectomy for the treatment of acute ischemic stroke has undergone relevant technical improvements over recent years. However, distal emboli and incomplete reperfusion after mechanical thrombectomy are still shortcomings in the care of patients with endovascular acute ischemic stroke. The NeVa NET 5.5 thrombectomy device (Vesalio, Nashville, Tennessee, USA) is the first stent retriever featuring an integrated clot micro-filtration system, aiming to enhance first pass efficacy and reduce distal embolization. This study evaluates the safety and efficacy of the NeVa NET 5.5 thrombectomy device.

Methods: Patients with acute anterior circulation occlusions and vessel diameters >2 mm treated with the NeVa NET 5.5 stent retriever as a first-line approach were retrospectively included in this study. Data were collected from three European comprehensive stroke centers between October 2022 and April 2024. Patient data, occlusion details, clinical outcomes, and procedure-related parameters were analyzed.

Results: A total of 51 patients were included. The most common occlusion locations were the internal carotid artery terminus and intradural internal carotid artery (70.6%). The mean±SD clot length was 25.1±13.3 mm (range 4-50 mm). First pass reperfusion (eTICI 2b-3) was achieved in 78.5%, with a final reperfusion rate of eTICI 2b-3 in 98.1%. Distal embolization in new territories occurred in 3.9%. No device-related adverse events were reported, and procedure-related adverse events occurred in 7.6% of the overall included cases.

Conclusion: The NeVa NET 5.5 stent retriever has a high first pass reperfusion rate in large vessel occlusions of the anterior circulation, with a good safety profile and low rate of distal embolization.

Background: In this randomized controlled trial we aim to validate the efficacy and safety of a hydrogel vascular closure device (VCD) for hemostasis after transfemoral intervention.

Methods: Between January and August 2023, 212 patients were enrolled, including 202 in a non-inferiority randomized controlled trial (1:1 hydrogel vs ExoSeal; prespecified margin -10%) and 10 in a hydrogel-only observational arm (8 F). The primary endpoint was device success rate and secondary endpoints including hemostasis time and procedural blood loss.

Results: Among 102 hydrogel and 100 ExoSeal recipients, hydrogel had non-inferior success rates (99.02% vs 94.00%; 95% CI -0.27% to 11.74%). Hydrogel achieved significantly faster hemostasis (1.99 vs 3.14 min, P<0.001) and reduced blood loss (0.83 mL vs 8.93 mL, P<0.001). No major access site complications were observed in either group. No secondary complications occurred in patients in the experimental group and secondary complications occurred in one patient in the control group (P=0.497). The supplementary cohort of 10 patients supported the efficacy and safety of hydrogel VCD.

Conclusions: Hydrogel VCD shows non-inferior efficacy to ExoSeal for transfemoral cerebrovascular interventions, with superior hemostatic speed and reduced blood loss while maintaining comparable safety.

Trial registration number: ChiCTR2300068029 (https://www.chictr.org.cn/showproj.html?proj=178962).