Journal of NeuroInterventional Surgery最新文献

Background: The hypoperfusion intensity ratio (HIR) has emerged as a vital measure of tissue-level collateral blood flow, helping to identify patients who are likely to benefit from mechanical thrombectomy (MT). We aimed to assess the HIR's predictive accuracy for clinical outcomes following MT in patients with acute ischemic stroke.

Methods: PubMed, Embase, and Scopus were searched to identify studies comparing good versus poor HIR groups based on studies' reported cut-offs. We pooled binary outcomes to calculate odds ratios (OR) and continuous outcomes to calculate mean differences (MD) with 95% confidence intervals (95% CI) using random-effects models. PROSPERO registration code: CRD42024609185.

Results: 14 studies with 2987 patients, 1553 with good HIR and 1434 with poor HIR, were included in this meta-analysis. Patients with poor HIR exhibited a significantly higher baseline infarct volume compared with those with good HIR (MD 30.6 mL, 95% CI 20.8 mL to 40.3 mL, P<0.01), though baseline National Institutes of Health Stroke Scale (NIHSS) (P=0.12) and Alberta Stroke Program Early CT Score (ASPECTS) (P=0.35) were comparable between groups. The rates of infarct growth (MD 22.4 mL, 95% CI 6.7 mL to 38.0 mL, P<0.01) and 3-month mortality (OR 2.18, 95% CI 1.04 to 4.58, P=0.04) were higher among the poor HIR group and good functional recovery (modified Rankin Scale 0-2 at 3 months) was lower (OR 0.58, 95% CI 0.42 to 0.80, P<0.01). The rates of symptomatic intracranial hemorrhage (P=0.37) and successful reperfusion (P=0.47) were comparable among groups.

Conclusion: This meta-analysis highlights the significant negative impact of poor HIR on patient outcomes. These findings emphasize the need for personalized treatment strategies for patients with poor HIR.

Background: Ocular ischemic syndrome (OIS) and subsequent neovascular glaucoma (NVG) lead to irreversible visual impairment. This study aimed to investigate the association of carotid artery revascularization and the collateral circulation types via the circle of Willis (CoW) with NVG and visual prognosis in patients with OIS.

Methods: This retrospective cohort study included 22 patients with OIS, with a median follow-up of 12 months. The collateral circulation patterns via the CoW were classified into five types. The association of the carotid artery revascularization, collateral circulation types via the CoW, and morphological characteristics of the CoW with the presence of NVG and visual outcomes was assessed.

Results: The median time interval from baseline to visual decline during follow-ups in patients with carotid artery revascularization was longer than that in patients without carotid artery revascularization (13 months vs 9.5 months, P=0.041). Lacking collateral inflow via the CoW to the hemisphere ipsilateral to OIS was associated with NVG (odds ratio (OR), 11.000; P=0.022). The diameters of the C6 and C7 segments of the internal carotid artery, the A1 segment of the anterior cerebral artery, and the ophthalmic artery in OIS eyes were smaller than those in the contralateral eyes.

Conclusion: Early carotid artery revascularization should be considered in patients with OIS, with or without NVG, as it may contribute to an improved visual prognosis. Patients without collateral inflow via the CoW to the hemisphere ipsilateral to OIS may have a higher risk of NVG.

Background: The proximity of transverse sinus stenosis (TSS) to inner ear structures and the temporal bone makes it a substantial cause of pulsatile tinnitus (PT). Treatment typically involves venous sinus stenting. This study investigates the hemodynamic stressors in TSS patients with PT along the pulse-transmitting temporal bone area and evaluates its treatment effects.

Methods: Four patients with idiopathic intracranial hypertension, PT, and TSS, and four control patients were imaged using MR venography (MRV) and flat panel CT (FP-CT). Patient-specific blood flow simulations were conducted using boundary conditions based on quantitative MR angiography before and after VSS. Catheter-based trans-stenotic pressure gradient measurements were used to validate the simulation results.

Results: The prediction of pressure gradients was close to catheter-based measurements using FP-CT-based segmentations (absolute deviation of 0.35 mm Hg) and is superior to MRV-based reconstructions (absolute deviation of 6.9 mm Hg). In TSS patients, the sinus temporal bone contact areas revealed notably higher time-averaged wall shear stress by 47±22% and velocity values by 41±18% compared with the sinus brain side. The relative residence time decreased by 57±58%. After stenting, the hemodynamic parameters dropped at the temporal side and throughout the sigmoid sinus. Almost all control patient hemodynamics remained lower than post-interventional results.

Conclusion: Our simulations based on patient-specific flows highly predicts pressure gradients across the stenosis. Flow conditions in TSS reveal flow jet formation and high shear rates at the temporal bone, potentially causing sound transmission. The treatment reduces these stressors, demonstrating its targeted therapeutic effect.

Background: Intracranial atherosclerotic disease (ICAD) is a leading cause of stroke, often refractory to aggressive medical therapy. Recent advancements in drug-eluting stents (DES) show promise for improved efficacy in intracranial applications relative to traditional ICAD treatments.

Methods: We retrospectively collected all consecutive deployments of the Onyx Frontier [Medtronic, Santa Rosa, CA] stent in the setting of ICAD between August 2022 and August 2024 at six high-volume neuro-interventional centers across the US. Patients were included if their indication for stenting (eg, acute/recurrent stroke) was secondary to ICAD. Primary outcome was periprocedural stroke (<72 hours) and secondary outcomes included degree of pre- and post-stent vessel stenosis and National Institutes of Health Stroke Scale (NIHSS) scores at most recent follow-up. Secondary outcomes were assessed via paired t-tests.

Results: Among 55 patients that met our inclusion criteria, the mean age was 62, mean presentation NIHSS was 10, and 40% were female. A total of 62 devices were used. Most common occlusion locations included the middle cerebral and internal carotid arteries. The periprocedural stroke rate was 10.9%, with a mortality rate of 1.8%. Mean vessel stenosis significantly decreased from 84.90% pre-stent to 2.00% post-stent (P<0.05). Mean NIHSS score improved from 10.37 preoperatively to 3.23 at follow-up (p<0.05). Procedural failure did not occur, however complications occurred in 16.4% of cases.

Conclusion: Our findings suggest that stenting in this setting results in a lower periprocedural stroke rate than appreciated in historical trials such as SAMMPRIS and VISSIT. However, recent CASSISS and BASIS trials demonstrate far reduced periprocedural stroke rates in the context of submaximal angioplasty for ICAD. This, in conjunction with complication rate, suggest that the Onyx Frontier, while promising, may not offer a definitive solution to ICAD.

Approximately 20% of ischemic strokes involve the posterior circulation, primarily supplied by the vertebrobasilar system. While much is known about the stroke risk of vertebrobasilar stenotic disease in general, particularly those involving intracranial pathology, extracranial vertebral artery stenosis remains an underinvestigated pathology. In this narrative review, we highlight retrospective, prospective, and randomized trial data on extracranial vertebral artery diseases with a particular focus on the role of endovascular stenting in its management. We also discuss the role of advanced imaging modalities such as quantitative magnetic resonance angiography for stroke risk stratification and patient selection for stenting.

Background: Intracranial dural arteriovenous fistulas (DAVFs) are rare lesions, making it challenging to fully understand and improve their management. Globally, only two major large-scale studies have focused on DAVFs. This report outlines the design of the DREAM-INI (Dural arteriovenous fistula research and management in China) project and provides an overview of the 1101-patient cohort it includes.

Methods: Patient data were sourced from the DREAM-INI database, a retrospective, single-center observational study conducted from January 2001 to December 2022, encompassing a total of 1101 DAVF patients.

Results: The cohort consists of 367 patients diagnosed with Borden type I DAVFs, 172 patients with Borden type II fistulas, and 562 patients with Borden type III fistulas. 565 patients exhibited flow-related symptoms, 176 patients presented with intracranial hemorrhage, and 275 patients had non-hemorrhagic neurological deficits. A large proportion of patients (95.6%, 1053/1101) underwent treatment through endovascular embolization (83.7%, 922/1101), surgery (8.7%, 96/1101), or multimodal therapy (3.2%, 35/1101). The overall immediate angiographic cure rate was 85.2% (897/1053 treated cases), and the rate of treatment-related permanent neurological morbidity was 3.4% (45/1328 total procedures). The median duration from the final treatment to the last follow-up for DAVF was 39 months. The predictive factors for aggressive symptoms, initial angiographic cure, and complications in DAVFs have also been preliminarily explored.

Conclusions: With over 1100 patients, DREAM-INI represents a large and relatively well-documented registry of DAVF patient data in China and even globally. This database will enable numerous future studies, further advancing our understanding of this rare disease.

Background: Our study aimed to investigate the relationship between the geometric distribution of plaque calcification and the occurrence of postprocedural hypotension following carotid artery stenting (CAS).

Methods: We retrospectively analyzed data from CAS patients between April 2018 and February 2023. Plaque calcification was evaluated using cross-sectional images obtained from multiplanar reconstructions perpendicular to the longitudinal axis of the internal carotid artery (ICA). The cross-sectional image of the most stenotic ICA was segmented into four quadrants: interior, exterior, ventral, and dorsal. We innovatively defined the geometric classification of plaque calcification based on physiological anatomy as modified calcification location. Postprocedural hypotension was defined as persistent systolic blood pressure at <90 mmHg, requiring intravenous vasopressor infusions that lasted more than 1 hour.

Results: A total of 477 patients were included in the final analysis. Among them, 41 (8.6%) patients experienced postprocedural hypotension after CAS. For the modified geometric method, plaque calcification was found significantly more frequently in the hypotension group compared with the non-hypotension group in the dorsal quadrant. Binary logistic regression analysis showed that modified calcification location on the dorsal side (OR 3.520, 95% CI 1.497 to 8.274, p=0.004) were independently associated with postprocedural hypotension after CAS.

Conclusions: The presence of plaque calcification on the dorsal side, using the modified geometric method, was found to be associated with a three-fold increased risk of postprocedural hypotension after CAS. These findings may have implications for patient screening, procedure planning, and hospitalization duration expectations.

Objectives: This study aimed to identify factors at baseline associated with visual outcomes of patients with idiopathic intracranial hypertension (IIH) with venous sinus stenosis who underwent venous sinus stenting.

Methods: The study eyes were divided into two groups according to mean deviation (MD) at 6-month post-stenting follow-up: MD better than -2.0 dB (the favorable visual outcome group) and equal to -2.0 or worse (the poorer visual outcome group). Variables at baseline between the two groups were compared. A multivariable logistic regression model was performed to identify the factors at baseline associated with poorer MD outcomes at 6 months.

Results: The poorer recovery group had a lower incidence of tinnitus (5.9% vs 27.5%, P=0.015), worse initial best corrected visual acuity (0.22 vs 0, in logMAR, P=0.000), worse preoperative MD (-8.64 vs -3.05, P=0.000) and higher trans-stenotic gradient pressure (19.5 vs 16, P=0.002) and total cranial gradient pressure (TCGP) (25.75 vs 18, P=0.000), lower ganglion cell complex (GCC) thickness (90.5 vs 99, P=0.005), higher focal loss volume percentage (2.35 vs 0.84, P=0.002) and global loss volume percentage (4.87 vs 1.8, P=0.012) of GCC. Multivariate analysis showed that worse preoperative MD and higher TCGP (OR 45.61, 95% CI 5.21 to 399.48; P=0.001 and OR 8.45, 95% CI 1.60 to 44.67; P=0.012, respectively) were associated with an increased risk of poorer MD outcomes at the 6-month follow-up.

Conclusion: This study found that worse preoperative MD and higher TCGP at baseline may be associated with poorer visual outcomes after stenting treatment.

Background: Temporomandibular joint replacement (TMJR) can result in large volume blood loss (BL) from the underlying internal maxillary artery (IMA). Pre-operative IMA embolization has been utilized to reduce intra-operative BL, but prior studies are limited to small case series.

Methods: Adult patients undergoing pre-operative IMA embolization for TMJR between June 2014 and September 2024 at a single institution were included. Electronic medical records were reviewed for demographic information, treatment details, and outcomes. Historical controls were identified via citations and PubMed searches.

Results: Pre-operative IMA embolization was performed in 73 patients (108 sides) undergoing TMJR. Coils were used in 96% of the patients, with a median of three coils used per side (interquartile range (IQR) 3-4). Middle meningeal artery (MMA) was occluded in 26% of the sides completed. There was one intra-procedural complication of a self-limited retrograde femoral artery dissection. Median operative BL/side during TMJR was 100 mL (IQR 50-181). There were no embolization-related complications in hospital or at follow-up (median follow-up of 12 months (IQR 4-24)). Using the BL per side beyond the third quartile of the historical controls as the definition of excessive BL, the embolized cohort contained half the number of patients with excessive BL (12.5%) compared with the historical cohort (25.0%).

Conclusion: Pre-operative IMA embolization is safe and may be effective at reducing BL and excessive hemorrhage during TMJR. A randomized controlled trial is needed to ascertain its benefits compared with the conventional approach.