Journal of NeuroInterventional Surgery最新文献

Background: The choice of angiography system could influence the outcomes of mechanical thrombectomy (MT) in the treatment of acute ischemic stroke (AIS), but its impact is not yet well understood. This study aims to compare the clinical and technical outcomes of MT performed with single plane versus biplane angiography systems.

Method: We conducted a systematic review and meta-analysis, following PRISMA guidelines, by searching PubMed, Embase, Web of Science, and Scopus to include studies on patients with AIS who underwent MT with either single plane or biplane angiography up to May 4, 2024. The primary outcome was a favorable outcome defined as a modified Rankin Scale (mRS) score of 0-2 at 90 days after the procedure. Data were analyzed using a random-effects model and heterogeneity was assessed using the I² test and Q statistics.

Results: Five studies with a total of 1562 patients were analyzed. Of these, 68.4% were treated with biplane systems and 31.6% with single plane systems. Single plane angiography was associated with a significantly higher rate of favorable outcomes (OR 1.43; 95% CI 1.13 to 1.80; P<0.01). There were no significant differences in successful recanalization, periprocedural complications, procedure time, total fluoroscopy time, or contrast volume between the two systems.

Conclusion: While single plane angiography systems may offer slightly better outcomes in MT for AIS, both systems appear equally effective in most clinical and technical perspectives, suggesting that system selection may be more dependent on availability and procedural requirements rather than inherent superiority. Our findings may encourage clinicians to use single-plane angiography in settings where the biplane angiography suite availability is limited, but it should be noted that this observation may have been influenced by selection bias, particularly since the larger studies included in our meta-analysis did not observe this effect in adjusted analyses for potential confounder factors.

Background: The patency of intracranial stents may not be reliably assessed with either CT angiography or MR angiography due to imaging artifacts. We investigated the potential of ultra-high resolution CT angiography using a photon counting detector (PCD) CT to address this limitation by optimizing scanning and reconstruction parameters.

Methods: A phantom with different flow diverters was used to optimize PCD-CT reconstruction parameters, followed by imaging of 14 patients with intracranial stents using PCD-CT. Images were reconstructed using three kernels based on the phantom results (Hv56, Hv64, and Hv72; Hv=head vascular) and one kernel to virtually match the resolution of standard CT angiography (Hv40). Signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) measurements were calculated. Subjective image quality and diagnostic confidence (DC) were assessed using a five point visual grading scale (5=best, 1=worst) and a three point grading scale (1=best, 3=worst), respectively, by two independent neuroradiologists.

Results: Phantom images demonstrated the highest image quality across dose levels for 0.2 mm reconstructions with Hv56 (4.5), Hv64 (5), and Hv72 (5). In patient images, SNR and CNR decreased significantly with increasing kernel sharpness compared with control parameters. All reconstructions showed significantly higher image quality and DC compared with the control reconstruction with Hv40 kernel (P<0.001), with both image quality and DC being highest with Hv64 (0.2 mm) and Hv72 (0.2 mm) reconstructions.

Conclusion: Ultra-high resolution PDC-CT angiography provides excellent visualization of intracranial stents, with optimal reconstructions using the Hv64 and the Hv72 kernels at 0.2 mm.

Registration: BASEC 2021-00343.

The Woven EndoBridge (WEB) device is a well established treatment for bifurcation aneurysms.1-6 However, failed detachment after deployment can present significant challenges. In this technical video (video 1), we report on a patient with a left middle cerebral artery (MCA) bifurcation aneurysm treated with the WEB device. Despite satisfactory deployment, multiple detachment attempts were unsuccessful. After repeated maneuvers, the WEB was finally detached but slightly protruded from the aneurysm sac, compromising blood flow in the superior branch of the MCA. Even after placing an Atlas stent, blood flow was not restored. Ultimately, using a microguidewire and microcatheter, we repositioned the protruded WEB device back into the aneurysm sac, successfully restoring blood flow. This case illustrates that the Atlas stent provides limited support for the WEB device. In similar situations, gently repositioning the protruded WEB back into the aneurysm sac may be a remedial measure. neurintsurg;jnis-2024-022430v1/V1F1V1Video 1Technical video demonstrating rescue techniques for managing intravascular mechanical obstruction following detachment of the WEB device.

Video 1 shows three cases of intraoperative rupture during aneurysm coiling. Management of intraoperative aneurysm rupture is reviewed in brief, including reversal of anticoagulation/antiplatelets, intracranial pressure control, and rapid balloon deployment for control across the aneurysm neck. However, in all three cases, contrast extravasation continues despite aneurysm coiling, reversal of anticoagulation, and maximizing medical management. This is presumed to occur when the neck of the aneurysm is the site of rupture. We review the use of a salvage technique that can be considered as a last-ditch maneuver in these scenarios, which is deployment of Onyx liquid embolic (Medtronic). Onyx is the preferred liquid embolic for this use as it is cohesive instead of adhesive. The solvent used with Onyx, dimethyl sulfoxide, is also compatible with standard balloons.1 This is relevant because a balloon is needed both for control of hemorrhage during salvage embolization and for protection of the parent vessel from the embolic material.neurintsurg;jnis-2023-021402v1/V1F1V1Video 1Demonstrating the technique of Onyx embolization for salvage hemostasis after intraoperative aneurysm rupture during coiling. Three example cases are shown.

Coil migration poses a significant intraprocedural risk during coil embolization in interventional neuroradiology procedures. In this technical video we describe the technique of removal of errand coils using the low profile Tigertriever-13 device.1 Traditional methods of errant coil retrieval rely on the use of stent retrievers;2 however, these devices are usually too large to fit through smaller inner diameter 0.013-0.0165 inch coiling catheters, thus requiring upsizing materials in emergency situations.3 We demonstrate the technique of coil retrieval using this low-profile device ex-vivo in silicone flow models, then its application in vivo as a 'bail-out' technique during acute embolization of a ruptured peri-callosal aneurysm which required retrieval of errant coils (video 1).neurintsurg;jnis-2024-021923v1/V1F1V1Video 1Errant coil retrieval using the Tigertriever device.

Residual brain arteriovenous malformations (BAVMs) following stereotactic radiosurgery are not uncommon and the optimal subsequent management remains undetermined.1-3 Endovascular embolization has been reported as an effective treatment for residual BAVMs after radiosurgery,4 5 and has the advantage over repeat radiosurgery in selected cases as angiographic weak points can be secured immediately and the risk of radiation-induced complications is less of a concern.6 7 In this technical video (video 1), we demonstrate the transvenous embolization of a previously-irradiated arteriovenous malformation and a persistent venous pouch using the retrograde pressure cooker technique, with emphasis on the important recommendations for avoiding periprocedural complications.neurintsurg;jnis-2024-022035v1/V1F1V1Video 1Video demonstrating Onyx embolization of the residual brain arteriovenous malformation using the retrograde pressure cooker technique.

Background: In the neonatal period, transfemoral access may be complicated by sheath size needed for embolization, especially if retreatment is required. A viable alternative is access through an umbilical artery (UA) which allows for preservation of the femoral artery for access in future intervention.

Methods: We conducted a retrospective study from January 2014 to March 2023, focusing on 19 vein of Galen malformation, dural arteriovenous (AV) fistula, and pial AV fistula cases treated via transumbilical (TU) access for endovascular embolization in neonates.

Results: TU access was achieved successfully in 20 out of 21 intended cases, with a 4 French sheath placed intraprocedurally in all instances. We observed a median retreatment time of 7 months for patients requiring subsequent femoral artery access, highlighting the importance of preserving femoral access for future interventions. There were no complications associated with TU access or sheath retention and no procedural mortality attributed to this approach. Despite intraprocedural and periprocedural complications of other etiologies (including post-procedural hemorrhages and fever requiring antibiotic treatment), the TU approach demonstrated overall safety and efficacy.

Conclusions: Our findings align with previous reports of TU access in vascular malformations, emphasizing its role as a vital technique in neonatal neurointervention. The TU approach offers advantages such as sparing femoral arteries for future treatments and potential applicability to other high-flow brain fistulas. Our study contributes to the growing body of evidence supporting the use of TU access in neonatal neuroendovascular interventions, underscoring its importance in managing complex vascular malformations in this vulnerable population.

Background: Transcranial Doppler (TCD) is a non-invasive, bedside tool that allows for real-time monitoring of the patient's hemodynamic status following mechanical thrombectomy (MT). This systematic review and meta-analysis aims to evaluate the predictive value of TCD parameters following successful MT (Thrombolysis in Cerebral Infarction 2b-3).

Methods: In July 2024, we searched PubMed, Embase, and Scopus, to identify observational studies in which TCD parameters were measured within 48 hours of MT. Using random-effects models, we compared four TCD parameters (mean flow velocity (MFV), MFV index, pulsatility index (PI), and peak systolic velocity (PSV) among groups with vs without hemorrhagic transformation (HT) and favorable vs poor functional recovery (modified Rankin Scale 0-2 vs 3-6).

Results: Eleven studies comprising 1432 patients (59% male; mean age range: 63-73 years) were included. The MFV and MFV index were higher in patients with HT (Hedges' g=0.42 and 0.54, P=0.015 and 0.005, respectively). Patients with MFV index ≥1.3 showed a higher risk of all HT (RR 1.97; 95% confidence interval (CI) 1.28 to 3.03, P=0.002), symptomatic HT (RR 4.68; 95% CI 1.49 to 14.65, P=0.008), and poor functional status at 90 days (RR 1.65; 95% CI 1.27 to 2.14, P=0.029), respectively. There was no difference in mean PSV (P=0.1) and PI (P=0.3) among groups with and without HT.

Conclusion: This study underscores the prognostic value of the MFV index in predicting HT, symptomatic HT, and poor functional recovery after successful MT in the anterior circulation. Large-scale, multi-center studies are necessary to confirm these findings and to validate the MFV index as a reliable predictor for improving post-thrombectomy care.

Background: Despite the increasing use of non-invasive imaging, DSA remains the gold standard for cerebrovascular imaging. However, trends in DSA utilization are poorly understood. The goal of this study was to describe DSA utilization in a large claims database in the US over a 13 year period.

Methods: This retrospective cohort study assessed a nationwide database of privately insured individuals from 2005 to 2018 for patients undergoing cranial CT angiography (CTA), MR angiography (MRA), and DSA. We assessed trends in the overall use of and indications for each modality. For DSA, we examined the types of performing proceduralists.

Results: Among patients undergoing DSA in 2018, median age was 52 years, and 60% were women. MRA and DSA use decreased, from 289 to 275 claims, and from 38 to 29 claims per 100 000 enrollees, respectively, while CTA use increased from 31 to 286 claims per 100 000 enrollees. These trends differed by geographic region and indication. Nearly half of DSA procedures but <25% of non-invasive imaging were inpatient studies. DSA performed by neurosurgeons increased from 0.5 to 4.1 while those performed by radiologists decreased from 7.2 to 4.0 studies per 100 000 enrollees.

Conclusions: DSA use decreased slightly while CTA use increased by ninefold. The reasons for this change are likely complex and may reflect more aggressive imaging for stroke, increased detection of incidental findings, and increased quality of non-invasive imaging. Over time, the proportion of DSA procedures performed by neurosurgeons overtook that performed by radiologists.

Background: Periprocedural ischemic stroke remains a serious complication in patients undergoing transcatheter aortic valve replacement (TAVR). We used a novel robotic transcranial Doppler (TCD) system equipped with artificial intelligence (AI) for real-time continuous intraoperative neuromonitoring during TAVR to establish the safety and potential validity of this tool in detecting cerebral emboli, report the quantity and distribution of high intensity transient signals (HITS) with and without cerebral protection, and correlate HITS occurrence with various procedural steps.

Methods: Consecutive patients undergoing TAVR procedures during which the robotic system was used between October 2021 and May 2022 were prospectively enrolled in this pilot study. The robotic TCD system included autonomous adjustment of the TCD probes and AI-assisted post-processing of HITS and other cerebral flow parameters. Basic demographics and procedural details were recorded. Continuous variables were analyzed by a two-sample Mann-Whitney t-test and categorical variables by a χ² or Fisher test.

Results: Thirty-one patients were prospectively enrolled (mean age 79.9±7.6 years; 16 men (51.6%)). Mean aortic valve stenotic area was 0.7 cm² and mean aortic-ventricular gradient was 43 mmHg (IQR 31.5-50 mmHg). Cerebral protection was used in 16 cases (51.6%). Significantly fewer emboli were observed in the protection group than in the non-protection group (mean 470.38 vs 693.33; p=0.01). Emboli counts during valve positioning and implantation were significantly different in the protection and non-protection groups (mean 249.92 and 387.5, respectively; p=0.01). One (4%) transient ischemic attack occurred post-procedurally in the non-protection group.

Conclusion: We describe a novel real-time intraoperative neuromonitoring tool used in patients undergoing TAVR. Significantly fewer HITS were detected with protection. Valve positioning-implantation was the most significant stage for intraprocedural HITS.