Journal of NeuroInterventional Surgery最新文献

Background: Automated machine learning (ML)-based large vessel occlusion (LVO) detection algorithms have been shown to improve in-hospital workflow metrics including door-to-groin time (DTG). The degree to which care team engagement and interaction are required for these benefits remains incompletely characterized.

Methods: This analysis was conducted as a pre-planned post-hoc analysis of a randomized prospective clinical trial. ML-based LVO detection software was implemented at four comprehensive stroke centers (CSCs) from January 1, 2021, to February 27, 2022. Patients were included if they underwent endovascular thrombectomy for LVO acute ischemic stroke. ML software utilization was quantified as the total number of active users and the ratio of the number of comments to the number of patients analyzed by the software by site per week. Primary outcome was the reduction in DTG relative to pre-ML implementation by hospital utilization level. Data are expressed as median (IQR).

Results: Among 101 patients who met the inclusion criteria, the median age was 71 years (IQR 59-79), with 48.5% being female. CSC 4 had the greatest number of total active users per week (32.5 (27.5-34.5)), and comment-to-patient ratio per week (5.8 (4.6-6.9)). Increased ML software utilization was associated with improvements in DTG reduction. For every 1 unit increase in the comment-to-patient ratio, DTG time decreased by 2.6 (95% CI -5.09 to -0.13) min, while accounting for site-level random effects. Number of users-to-patient was not associated with a reduction in DTG time (β=-0.22, 95% CI -1.78 to 1.33).

Conclusions: In this post-hoc analysis, user engagement with software, rather than total number of users, was associated with site-specific improvements in DTG time.

Background: Newly diagnosed glioblastoma (ndGBM) remains one of the most challenging malignancies to treat. Since the majority of patients experience tumor recurrence (rGBM) after first-line therapy, advancements in both initial and salvage treatments are essential.

Objective: We report our single-center experience on the feasibility and safety of superselective intra-arterial cerebral infusion (SIACI) with bevacizumab or cetuximab after osmotic blood-brain barrier disruption (oBBBd).

Methods: Partial results of three distinct trials (anonymized for blinded review) were analyzed. All patients were histopathologically confirmed to have either ndGBM or previously diagnosed ndGBM that progressed to rGBM despite standard therapy and had aKarnofsky Performance Status (KPS)≥70. All patients were admitted on the same day of the surgery, and the intervention followed similar steps in all included patients. Under general anesthesia, after oBBBd with mannitol, patients received SIACI.

Results: Between October 2014 and March 2024, 70 patients with a mean age of 56.2±12.4 years (range: 19-78) underwent successful treatment, encompassing 139 SIACIs and 246 infusions. All planned SIACIs were completed successfully. Forty-one patients with rGBM received bevacizumab-SIACI, 7 with ndGBM bevacizumab-SIACI, and 22 with ndGBM cetuximab-SIACI. In 133 of 139 SIACIs (95.7%), patients were discharged home with a length of stay of 1 day. The incidence of patients who experienced procedure-related and drug-related adverse events was 11.4% and 8.6%, respectively. No procedure-related deaths occurred.

Conclusion: In our single-center experience, comprising the largest cohort of bevacizumab or cetuximab SIACI treatment for rGBM and ndGBM, this promising and cutting-edge intervention is highly feasible and safe.

Background: Studies have been conducted to explore the potential predictive indicators of unfavorable outcomes in patients with acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). However, few studies have proposed a comprehensive predictive model combined with clinical baseline data and ancillary examination before surgery.

Method: In a retrospective study, we collected data on 823 patients with AIS-LVO who had undergone endovascular therapy (EVT); 562 patients who achieved successful revascularization with complete clinical and prognostic information were incorporated into the study. Those patients with a 90-day modified Rankin Scale (mRS) score of 0-2 were defined as having a favorable outcome, while a score of 3-6 represented an unfavorable outcome or futile reperfusion. To build up a predictive model, we applied multivariate logistic regression stepwise backward selection to decide which factors are supposed to be the components of the predictive model. Final model validity was testified by the variance inflation factor test and the Hosmer-Lemeshow (HL) goodness of fit test. The ultimate efficacy was supported by an area under the curve (AUC) value in both training groups and validation groups.

Results: 562 patients were enrolled in our study and divided into the training group and verification group in a ratio of 7:3. Factors of baseline data with P<0.1 in univariate logistic regression analysis were enrolled as the potential risk variables to conduct stepwise backward selection. The model was constructed by eight variables; higher mRS score (adjusted OR (aOR) 93.64, 95% CI 12.05 to 727.82, P<0.01), age >80 years (aOR 91.11, 95% CI 1.36 to 6116.36, P<0.05), National Institutes of Health Stroke Scale (NIHSS) >14 (aOR 0.15, 95% CI 0.02 to 0.99, P<0.05), operation history (aOR 8.13, 95% CI 1.32 to 50.20, P<0.05), creatinine (aOR 1.10, 95% CI 1.04 to 1.17, P<0.01), and neutrophil count (aOR 1.07, 95% CI 1.01 to 1.13, P<0.05) were associated with poor outcomes.

Conclusion: We established an estimation model for invalid reperfusion in AIS-LVO patients and constructed the nomogram for individualized predictions. The AUC of the training group and validation group were both 0.96, with excellent HL and decision curve analysis, presenting excellent clinical prediction efficiency and application potential.

Background: Complete recanalization (CR, modified Treatment in Cerebral Ischemia (mTICI) score of 2c or better) is associated with favorable outcomes after endovascular thrombectomy (EVT) for stroke patients. However, the degree of inter-proceduralist differences in CR rates is unknown, and whether higher CR rates are being achieved by performing more passes or by focusing on first-pass effectiveness is also unclear.

Methods: This was a multicenter retrospective study of anterior circulation large vessel occlusion stroke patients in the United States from 2016 to 2022. Patients treated by proceduralists with at least 50 cases were included. CR rates for each proceduralist were assessed and proceduralists were divided into tertiles. First-pass effect (FPE, defined as CR after one pass) and the number of passes for patients treated by the top tertile of proceduralists were compared with the bottom tertile. Mediation analyses were conducted to assess causal links between CR rates and number of passes or FPE.

Results: A total of 1096 EVTs performed by 11 proceduralists were identified. CR rates were highly variable across providers (43.1% to 75.3%, p<0.001). Patients treated by the top tertile were more likely to experience FPE (OR 1.99, 95% CI 1.49 to 2.67, p<0.001) and did not undergo more passes (p=0.69) compared with the bottom tertile. Higher rates of FPE among patients was a significant mediator of higher odds of CR among patients treated by the top tertile (p<0.001).

Conclusions: Angiographic outcomes among EVT proceduralists are highly variable. Proceduralists who achieve higher rates of CR are doing so with higher rates of FPE, not more passes.

Background: Left ventricular assist devices (LVADs) are used as definitive therapy or as a bridge to heart transplant in patients with advanced heart failure. Thromboembolic complications such as acute ischemic stroke (AIS) are common among patients with LVAD support. This study aims to evaluate the current evidence on the efficacy and safety of mechanical thrombectomy (MT) in patients with AIS due to large vessel occlusions (LVO) and LVAD-support.

Methods: A comprehensive systematic review was conducted in PubMed, Embase, and Scopus to find observational studies with reports of ≥5 MTs in adult patients with LVAD support (PROSPERO registration code CRD42024597541). Rates of successful and complete reperfusion, favorable functional outcomes at 90 days (modified Rankin Scale (mRS) 0-2 or equal to pre-stroke mRS), mortality at 90 days, any intracerebral hemorrhage (ICH) and symptomatic ICH (sICH) were pooled using generalized linear mixed models.

Results: Eight studies were included with data from 51 patients and 62 MTs. The rate of successful reperfusion was 87.4% (95% CI 62.5% to 96.6%) and complete reperfusion rate was 57.3% (95% CI 35.1% to 76.9%). Rate of favorable functional recovery was 62.5% (95% CI 42.2% to 79.2%). Rate of sICH was 6.4% (95% CI 0.9% to 34.0%). Mortality rate was 16.7% (95% CI 7.1% to 34.7%). Between 25-40% of patients who were waiting for a heart transplant before their stroke received a heart transplant after MT.

Conclusions: MT for the emergent treatment of AIS in the setting of LVAD is relatively safe and efficacious for achieving successful reperfusion and good functional recovery.

Background: New generation flow-diverting stents have benefited from recent technological advances to reduce their thrombogenicity. This in vitro study is the first of its kind to compare multiple surface modified flow diverters with their bare metal counterparts.

Methods: A thrombin generation assay (TGA) was used to compare thrombin generation resulting from different stent types with glass beads (positive control) and plasma (negative control). Ten different stent types were studied, including a next-generation implant, Surpass Elite, with two different surface modifications. A thrombogram was generated from each of the 10 sample types, from which peak thrombin generation and time to peak (TTP) were obtained.

Results: Compared with the positive control and their bare metal counterparts, lower peak thrombin and longer TTP were obtained with most of the surface modified devices tested. Only the stent with an active heparin drug coating demonstrated lower peak thrombin and TTP than the negative control plasma.

Conclusion: Generally, surface modification resulted in lower thrombogenicity, as assessed by peak thrombin concentration and TTP, when compared with the unmodified version of the device. The device with an active heparin drug coating was significantly different from other surface modifications and plasma with respect to peak thrombin and TTP, though the implications of this should be investigated through future in vitro and in vivo studies.

Background: Blood urea/creatinine (U/Cr) ratio is considered to be an ideal biomarker of dehydration. We investigated the association between the U/Cr ratio trajectory and delayed cerebral ischemia (DCI) as well as functional outcome in aneurysmal subarachnoid hemorrhage (aSAH). Additionally, we explored the role of DCI as a mediator and its interaction with dehydration.

Methods: Consecutive aSAH patients were reviewed. A latent class growth mixture model (LCGMM) was applied to classify the dehydration trajectory over 7 days. Multivariate logistic regression was conducted to examine associations between dehydration trajectories, DCI, and poor outcome. Furthermore, causal mediation analysis combined with a four-way decomposition approach was employed to quantify the extent to which DCI mediates or interacts with dehydration in influencing poor outcomes.

Results: A total of 519 aSAH patients were included. By applying the LCGMM method, we categorized participants into three dehydration trajectory groups: low group (n=353), decreasing group (n=97), and high group (n=69). Multivariate analysis demonstrated that dehydration trajectory was independently associated with both DCI and poor outcome. The effect of dehydration trajectory on poor outcome was partially mediated by DCI, involving both pure mediation and mediated interaction. Specifically, the excess relative risk of DCI was decomposed into four components: controlled direct effect (66.42%), mediation only (16.35%), interaction only (6.09%), and mediated interaction (11.16%).

Conclusion: Among aSAH patients, dehydration trajectory was significantly associated with poor functional outcome, with DCI serving as a partial mediator through both direct and interaction effects.

Background: Transradial cerebral angiography (TRA) is a convenient but challenging procedure, particularly for selecting the left internal carotid artery (ICA) and vertebral artery.

Objective: To predict the selection of the left ICA using CT and MR images acquired before TRA.

Methods: Overall, 306 patients with TRA were enrolled and divided into either the group with success (264 patients) or the failure (42 patients) group. The following anatomical factors were measured: A1 (subclavian artery angle), A2 (right subclavian-innominate artery angle), A3 (innominate-left common carotid artery angle), D1 (aorta to right subclavian artery length), and D2 (innominate-to-left common carotid artery length).

Results: The median values for A1, A2, A3, D1, and D2 were 81.57° (IQR 69.26-94.14), 147.03° (125.73-161.09), 24.73 (15.85-37.72°), 34.73 mm (29.68-38.48), and 13.15 mm (11.33-15.64), respectively, with significant differences observed between the successful and failure groups in A3 (26.88° vs 15.50°; P<0.001), D1 (34.24 mm vs 37.62 mm; P<0.001), and D2 (12.78 mm vs 14.91 mm; P<0.001). The aortic arch type did not affect success (P=0.134), while patients in the failure group were significantly older (P<0.001). A predictive logistic regression model was developed, revealing differing factor impacts when controlling variables. The model (area under the curve 0.87) highlights data complexity and enables user-friendly prediction of left ICA-selective TRA success (https://je0000000342227505.shinyapps.io/icatra/).

Conclusion: This study demonstrated that the success of left ICA selective angiography can be predicted using aortic arch images, providing a basis for the extension of TRA.

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: Although recently presented randomized trials have failed to prove an overall benefit of mechanical thrombectomy (MT) for patients with medium vessel occlusions (MeVOs), questions remain unanswered, particularly regarding the technology and the role of dedicated small devices. This prospective multicenter, core lab reviewed registry study investigates the efficacy and safety of the APERIO Hybrid used as a first-line device for the treatment of MeVO patients.

Methods: Data from all MeVO patients who underwent MT with the APERIO or APERIO Hybrid¹⁷ as a first-line technique were prospectively included. The primary endpoint was the successful recanalization (Thrombolysis In Cerebral Infarction (TICI) 2b/3) after up to three passes with the APERIO without the use of a rescue technique and without any symptomatic intracranial hemorrhage (ICH).

Results: 134 patients were enrolled from 10 stroke centers. The primary endpoint was reached in 97 patients (81.5%, 95% CI 74.5% to 88.5%). In patients who failed the primary endpoint, TICI 2b/3 was reached with 4 to 6 APERIO passes in 4 patients (3.3%) and with other techniques in 18 patients (15%). Overall recanalization success was 95.8%. TICI 2b/3 with APERIO Hybrid was achieved after the first pass in 76 patients (63.9%), in 23 (19.3%) after 2 passes, and in 1 patient (0.8%) after 3 passes. Modified Rankin Scale (mRS) 0-2 at 90 days was reached by 79.0% of the patients. Symptomatic ICH occurred in no patients, asymptomatic ICH in 16 (13.5%), and subarachnoid hemorrhage in 15 patients (12.6%).

Conclusion: APERIO and APERIO Hybrid¹⁷ have been proven to be both safe and effective first-line devices for MT in MeVO stroke at different centers and with high rates of successful recanalization.