Journal of NeuroInterventional Surgery最新文献

Background: First-pass effect (FPE) is crucial for better outcomes in mechanical thrombectomy (MT) for acute large vessel occlusions. However, its frequency and predictors in vertebrobasilar artery occlusion (VBAO) remain unclear.

Objective: To conduct a comprehensive systematic review and meta-analysis to assess the incidence of FPE in MT for VBAO and its impact on key clinical outcomes. Additionally, to explore potential predictors of achieving FPE, addressing critical knowledge gaps and providing evidence to optimize treatment strategies for patients with VBAO.

Methods: A systematic literature search was performed in PubMed, EMBASE, Web of Science, and the Cochrane Library up to November 1, 2024. Studies evaluating FPE in patients with acute VBAO undergoing MT were included. The prevalence of FPE was estimated using a meta-analysis of proportions, and associations with clinical outcomes and predictive factors were assessed using pooled ORs with random-effects models.

Results: Twenty studies involving 4315 patients met inclusion criteria. The overall prevalence of FPE in patients with VBAO was 41% (95% CI 33% to 50%). FPE was significantly associated with improved 90-day outcomes (modified Rankin Scale (mRS) score 0-2: OR=2.00, 95% CI 1.45 to 2.75; mRS score 0-3: OR=2.33, 95% CI 1.78 to 3.04), reduced risk of symptomatic intracranial hemorrhage (OR=0.49, 95% CI 0.27 to 0.87), and lower mortality (OR=0.43, 95% CI 0.32 to 0.57). The results showed that significant positive predictors of FPE included female sex, atrial fibrillation, cardioembolic or unknown stroke etiology, mid- or distal basilar artery occlusion, contact aspiration techniques, and the use of larger catheters. Conversely, negative predictors were identified as a history of hypertension, hyperlipidemia, prior stroke or transient ischemic attack, higher baseline NIHSS scores, prolonged procedure time, and the use of general anesthesia.

Conclusion: Achieving FPE in acute VBAO is strongly associated with improved clinical outcomes. Important clinical, procedural, and anatomical factors related to FPE were identified, aiding clinical decisions and thrombectomy techniques.

Percutaneous biopsy of petrous apex lesions is technically challenging due to deep skull base anatomy and proximity to critical neurovascular structures.1-5 In this technical video 1, we present a cone beam CT-guided biopsy using a contralateral subzygomatic transclival approach, initially described under CT guidance.6 The minimally invasive route provides a safe, direct trajectory to the petrous apex while preserving the internal carotid artery. The step-by-step workflow includes cone beam CT-based trajectory planning, fluoroscopic guidance, and coaxial bone sampling using an 11-gauge biopsy needle. Two clinical cases are demonstrated: one revealing metastatic breast cancer and another confirming Erdheim-Chester disease. Both procedures were completed without complications and allowed definitive histopathological diagnosis. This approach expands the interventional neuroradiologist's toolkit for skull base access and represents a valuable alternative to open surgical biopsy in selected patients, combining precision, safety, and diagnostic efficacy. neurintsurg;18/3/893/V1F1V1Video 1Cases presentation.

Background: Medium vessel occlusion (MVO) mechanical thrombectomy (MT) has shown promising outcomes and safety profiles, comparable to those of large vessel occlusion thrombectomy.

Objective: To assess the efficacy and safety of the CatchView Mini (CVM) stent retriever (Balt, Montmorency, France) in patients with acute stroke with proximal and distal MVO (pMVO vs dMVO), respectively.

Methods: We analyzed retrospective data of consecutive patients with MVO who underwent MT with the CVM stent retriever. We categorized occlusions into pMVO group (segments A1, M2, and P1) versus dMVO group (segments A2, A3, M3, P2, and P3). Demographic, clinical, angiographic, and clinical outcome data (National Institute of Health Stroke Scale score at 24 hours and modified Rankin Scale (mRS) score at 3 months) were compared. The first pass effect (FPE) was defined as that which achieved modified Thrombolysis in Cerebral Infarction (mTICI) 2c-3 after a single device pass.

Results: A total of 196 patients were included (44.3% female, median (IQR) age 74 (67-84) years), of whom 151 (77%) had pMVO and 45 (23%) dMVO. FPE was achieved in 108 (55.1%) patients, and final successful reperfusion (mTICI 2c-3) was attained in 156 (79.6%) cases, with up to two passes in 78% of patients. Rescue MT was performed in 24 (12.2%) patients. The dMVO group had a higher FPE rate (84.4% vs 46.3%; P<0.001), fewer number of passes, and lower symptomatic hemorrhage rate (0% vs 0.6%; P=0.009) than the pMVO group. Around 75% of patients in both groups achieved similar favorable outcomes (mRS score 0-2) at 3 months.

Conclusions: The CVM device appears effective and safe for pMVO and dMVO thrombectomy.

Background: Large and giant intracranial aneurysms pose treatment challenges. The benefit-risk balance of flow diverters (FDs) alone versus FDs with coiling remains unclear. This study aimed to compare these two strategies.

Methods: This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A comprehensive search of PubMed, Embase, Scopus, Cochrane, and Web of Science was performed up to October 2024. Studies comparing FDs with or without adjunctive coiling in large/giant intracranial aneurysms were included. The primary outcome was complete aneurysm occlusion, defined by the Raymond-Roy Occlusion Classification. Additional outcomes included procedural and postprocedural complications. Data were analyzed using a random effects model.

Results: 15 studies with 1130 patients were analyzed, with 557 in the FD alone group and 573 in the FD+coiling group. The meta-analysis revealed that FD+coiling significantly improved complete aneurysm occlusion rates (OR 1.59, 95% CI 1.06 to 2.40, P=0.03). While overall ischemic complications were significantly lower in the FD alone group, a sensitivity analysis showed no significant difference (OR 0.49, 95% CI 0.20 to 1.23, P=0.13). Subgroup analysis of fusiform aneurysms showed no significant difference in complete aneurysm occlusion rates (OR 1.10, 95% CI 0.50 to 2.40, P=0.82). Procedural and hemorrhagic complications did not differ significantly, and no publication bias was detected in the results.

Conclusions: Combining FDs with coiling improved complete aneurysm occlusion rates in large and giant saccular intracranial aneurysms, although the impact on complications remains controversial. Further investigation into the benefit-risk ratio of this combined approach is warranted.

Objective: Fractional flow (FF) reserve has been developed as a gold standard for coronary intervention. Intracranial FF is also a valuable hemodynamic index to assess the severity of narrowing in intracranial atherosclerotic stenosis (ICAS). This study aims to investigate the predictive value of FF in assessing restenosis following endovascular treatment in patients with symptomatic ICAS.

Methods: This retrospective study recruited 67 patients with symptomatic ICAS who received intracranial stenting between March 2019 and January 2024. FF was measured by dedicated software (AccuICAD) before and after stenting. During follow-up, patients were categorized into two groups based on the occurrence of in-stent restenosis (ISR): ISR group and non-ISR group. Multivariate regression analysis and Kaplan-Meier survival analysis were performed to identify the predictive factors for ISR.

Results: Post-FF was significantly different between the ISR and non-ISR groups (0.84±0.09 vs 0.92±0.06, respectively, P<0.01). Univariate and multivariate Cox regression analyses identified post-FF (HR 0.0, 95% CI 0.0 to 0.08, P=0.005) and smoking (HR 3.06, 95% CI 1.02 to 9.19, P=0.047) as the two predictors of ISR. Receiver operating characteristic curve analysis confirmed the predictive value of post-FF for ISR (AUC=0.783, 95% CI 0.645 to 0.920, P=0.003), with a cut-off value of 0.94. Kaplan-Meier survival analysis further demonstrated that patients with a post-FF value >0.94 had a significantly lower incidence of ISR (P=0.001).

Conclusion: In this study, post-FF effectively predicted ISR, providing an intraoperative evaluation value for stenting in ICAS.

Background: Robotic neurointerventions have demonstrated promising initial clinical results. Claims of enhanced precision during robotic navigation have been reported, but objective quantification of such precision is limited. Precision during intracranial navigation and device deployment is crucial in neurovascular interventions, and lack of precision can lead to intraprocedural complications. This study compared quantitative metrics of precision in manual and robotic procedures using a virtual simulator.

Methods: Using three different simulated aneurysm procedures with different levels of difficulty (easy, medium, and hard), 12 operators with different levels of experience were assigned a defined task for each case. Each procedure was performed both manually and under robotic assistance. Precision was assessed using the length of translations and the total degree of rotations of the microwire and microcatheter needed to complete the assigned tasks, as well as recorded safety metrics. Results were compared between the manual and robotic groups.

Results: We analyzed 78 procedures (robotic, n=34; manual, n=34) performed by 12 operators with various levels of neurointerventional surgical experience (high, n=5; low, n=7). For the difficult case, operators used significantly less microwire translations when operating with robotic assistance (38.7 cm vs 108.4 cm, P=0.023). There were no significant differences for the easy and medium cases. Safety metrics and procedural times were not significant different.

Conclusions: Operators demonstrated increased precision during microwire navigation when using robotic assistance to navigate a difficult aneurysm in a controlled simulated experimental set-up compared with manual navigation.

Background: The aim of this study was to evaluate the preliminary experience of a combined middle meningeal artery embolization (MMAE) and burr hole evacuation approach for chronic subdural hematoma (cSDH) under a single anesthesia session.

Methods: We performed a retrospective review of all patients who underwent MMAE and burr hole surgery during the same admission at a single major academic institution between 2019 and 2024. Patients were dichotomized by those with both procedures performed under a single anesthesia session (combined) or two separate sessions (separate). Baseline demographics, comorbidities, and complications were compared. The primary outcomes were in-hospital and 90-day complication and reoperation rates.

Results: 103 patients were included in the study (median age 74 (67-81) years), with 33.9% in the combined cohort. Demographics, comorbidities, and radiographic characteristics were similar between the cohorts. While cumulative procedure times were similar (separate 85 (71-110) min vs combined 96 (82-127) min), total anesthesia time was significantly longer for patients with separate procedures (separate 225 (193-264) min vs combined 165 (145-183) min, P<0.001). There were no differences in the rates of access site complications, reoperation, stroke, or mortality between the cohorts. The combined cohort trended to have shorter length of stay (separate 6 (5-8) days vs combined 5 (4-7) days, P=0.058). There were no differences in complication or reoperation rates within 90 days.

Conclusion: The results of this study suggest that MMAE performed under a single anesthesia session with burr hole evacuation surgery is a safe and potentially resource-efficient approach for the management of cSDH.

Background: The Woven EndoBridge (WEB) device is a prevalent treatment for intracranial aneurysms. While many studies have assessed the obliteration rate post-WEB embolization, few have focused on long-term outcomes in partially thrombosed aneurysms.

Objective: To assess whether partially thrombosed aneurysms are at higher risk of recurrence or retreatment following WEB embolization compared with non-thrombosed aneurysms.

Methods: We evaluated data from 22 academic institutions, focusing on previously untreated cerebral aneurysms treated with the WEB device. Logistic regression was utilized to analyze factors predicting long-term aneurysm obliteration and retreatment necessity.

Results: Among 1303 patients, 26 presented with a partially thrombosed aneurysm. In the partially thrombosed group, the mean aneurysm maximal diameter was 10.7±4 mm with a neck ratio of 1.99±1.19 mm, larger than in the control group where the mean aneurysm maximal diameter was 6.81±2.37 mm with a neck ratio of 1.64±0.51 mm (P<0.001 for both maximal diameter and neck ratio). At the final follow-up, partially thrombosed aneurysms treated by the WEB device had a 38.5% retreatment rate, compared with 7.0% for non-thrombosed aneurysms (P<0.001). Among partially thrombosed aneurysms, the Raymond-Roy type IIIa/b occlusion rate was higher (38.5% vs 9.9%, P<0.001). On multivariate analysis, partially thrombosed aneurysms compared with non-thrombosed aneurysms had an increased rate of retreatment (OR 3.64, 95% CI 1.28 to 10.1).

Conclusion: Partially thrombosed aneurysms are associated with a poorer occlusion rate and a higher rate of retreatment following WEB embolization. For partially thrombosed aneurysms, the WEB device appears suboptimal as a first-line treatment, and therefore alternative techniques should be prioritized.

Background: Previous studies have demonstrated that successful reperfusion does not always correlate with long-term functional benefit in patients with acute ischemic stroke (AIS) treated via endovascular therapy (EVT). We evaluated patient characteristics and clinical outcomes in patients with AIS who underwent EVT with successful reperfusion resulting in either beneficial recanalization (BR) or futile recanalization (FR).

Methods: The authors conducted a single-institution retrospective, observational study of patients with AIS who underwent EVT between January 2019 and January 2024. Baseline characteristics, procedural details, and clinical metrics were reviewed, and FR predictors were identified.

Results: Of 441 subjects, 151 (34.24%) experienced FR, with this cohort displaying a higher mean blood glucose level on admission compared with the BR cohort (168±87.77 mg/dL vs 143±70.48 mg/dL; P=0.0029). Multivariable logistic regression analysis found blood glucose on admission to be a significant independent predictor of FR (P=0.0081). Hyperglycemia (glucose≥126 mg/dL) carried a twofold higher risk of FR (OR 2.088, 95% CI 1.399 to 3.137, P=0.0003), whereas glucose exceeding 300 mg/dL carried a threefold increased risk (OR 3.321, 95% CI 1.367 to 8.565, P=0.0093).

Conclusions: Rates of futile recanalization increased in a stepwise fashion as glucose levels on admission worsened in this study cohort. These findings suggest that early and rapid glucose management in patients with AIS undergoing EVT may improve outcomes and reduce the incidence of futile recanalization.

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.