Journal of NeuroInterventional Surgery最新文献

Background: The Pipeline Flex embolization device with Shield technology (PED Shield, Medtronic, Irvine, CA, USA) is a flow diverter designed to reduce thrombogenicity through phosphorylcholine surface modification. Although in vitro and in vivo studies have demonstrated the thrombogenicity reducing effects of this technology, its effectiveness in real-world clinical practice remains unclear. This study aims to compare the number of post-procedure diffusion-weighted imaging (DWI)-positive lesions between PED Flex(Medtronic, Irvine, CA, USA) and PED Shield to assess the impact of surface modification.

Methods: This retrospective cohort study included patients with unruptured intracranial aneurysms treated with PED Flex or PED Shield between April 2016 and March 2024 at a single institution. Propensity score matching was performed to control for confounders, and the number of post-procedure DWI-positive lesions was evaluated as the primary outcome.

Results: In total, 148 procedures (132 patients, 138 aneurysms) were included, with 68 (46%) treated with PED Flex and 80 (54%) with PED Shield. Propensity score matching resulted in 47 matched pairs. After matching, the median number of post-procedure DWI-positive lesions was nine (interquartile range (IQR): 3-17) in the PED Flex group and three (IQR: 1-6) in the PED Shield group, with a significantly lower number in the PED Shield group (regression coefficient β = -10.70 [95% confidence interval (CI): -16.23 to -5.16), P<0.001).

Conclusion: After adjusting for confounders, the PED Shield group had significantly fewer post-procedure DWI-positive lesions than the PED Flex group, suggesting that phosphorylcholine surface modification technology may reduce thrombogenicity in real-world clinical practice.

Background: The presence of a coincident intracranial aneurysm (CIA) on the target vessel of patients undergoing mechanical thrombectomy (MT) for acute ischemic stroke (AIS) poses challenges, as the benefits and risks of the procedure in this scenario remain unclear. This study aimed to evaluate the efficacy and safety of MT in AIS cases with a CIA on the target vessel.

Methods: We retrospectively analyzed data from 14 stroke centers in France and Switzerland between January 2015 and January 2023. We identified AIS cases with CIA on the target vessel treated with MT. The control population was constituted from the ETIS registry (Endovascular Treatment in Ischemic Stroke), including AIS patients treated with MT in the same centers during the same period, and were matched (1:4) on age (±1 year) and sex. The primary outcome was favorable functional status at 3 months, defined as a modified Rankin Scale (mRS) score ≤2 or equal to pre-stroke mRS.

Results: A total of 104 MT-treated patients with at least one CIA on the target vessel and 416 MT-treated patients without CIA were analyzed. Despite an aneurysm rupture occurring in 5.8% of cases, no significant differences were observed in favorable functional outcome at 3 months between the CIA and control groups (42.4% vs 41.0%; adjusted OR 1.20, 95% CI 0.72 to 1.97). Similarly, recanalization rates (modified Thrombolysis In Cerebral Infarction (mTICI) ≥2b at end of MT) did not differ significantly (90.0% vs 85.9%; adjusted OR 1.75, 95% CI 0.77 to 3.95).

Conclusion: MT is an effective option for AIS patients, even with CIA on the target vessel, but the risk of rupture underscores the need for procedural planning. Future studies should further explore size and location criteria to optimize patient selection and orientation.

Background: Endovascular embolization has been reported in limited case series and case reports as a minimally invasive option for managing refractory epilepsy, particularly in cases where traditional surgical interventions are high risk.

Objective: To explores the feasibility, safety, and outcomes of endovascular embolization in pediatric patients with intractable epilepsy due to varied etiologies.

Methods: This retrospective case series includes four pediatric patients with medically refractory epilepsy, who underwent staged endovascular embolization at a tertiary care center between 2022 and 2024. Patients were selected based on contraindications to conventional surgical approaches and failure of at least two anti-seizure medications. Outcome measures included seizure frequency reduction, functional improvements, and procedure-related complications. Follow-up duration ranged from 10 to 15 months after the last embolization.

Results: The cohort included four patients aged 2 to 9 years, and a total of 12 embolization procedures were performed. Three patients achieved freedom from seizures, while one undergoing a palliative procedure showed meaningful improvement in seizure frequency. No patients required rescue surgery, and none experienced hydrocephalus or neurologically unexpected complications during the follow-up period. Postprocedural deficits were similar to functional hemispherectomy outcomes. Parents and clinicians reported substantial developmental and functional improvements across multiple domains.

Conclusions: Endovascular embolization is a promising minimally invasive strategy for pediatric patients with refractory epilepsy, particularly when anatomical or medical considerations preclude traditional surgery. Further research is warranted to refine patient selection criteria and assess long-term efficacy compared with established surgical approaches. This series expands the potential applications of endovascular techniques in epilepsy management.

Background: The cumulative impact of radiation dose reduction strategies in acute hospital settings remains underreported. This study quantifies and compares cumulative radiation exposure in patients with ruptured intracranial aneurysms before and after implementing dose reduction strategies.

Methods: This retrospective study included 166 patients with subarachnoid hemorrhage (SAH) due to ruptured intracranial aneurysms, comparing two time periods: pre-adjustment (July 2012-March 2013) and post-adjustment (January 2017-March 2022) of dose reduction strategies. Radiation doses from imaging modalities, including X-ray, computed tomography (CT), and angiography, were collected. Cumulative radiation dose (CRD) and cumulative effective dose (CED) were calculated and compared between the two periods.

Results: Angiography accounted for the largest share of the CRD in clipping and coiling procedures (about 75% and 95%, respectively), whereas its contribution to the CED was lower in clipping and coiling procedures (about 20 and 60%, respectively), reflecting differences in radiation weighting for biological effects. Significant reductions in both mean CRD and CED were observed in the post-period for both clipping and coiling procedures, with reductions of approximately 40% and 30% in CRD (P<.001 and P=0.013) and 45% and 35% in CED (P< .001 and P=0.002), respectively.

Conclusion: The implementation of radiation dose reduction strategies significantly decreased both cumulative radiation and effective doses, highlighting the importance of continuous optimization to enhance patient safety without compromising diagnostic and therapeutic efficacy.

Background: The present study reports a multicenter experience of using hydrophilic polymer-coated (HPC) flow diverters (FDs) with prasugrel single antiplatelet therapy (SAPT) to treat posterior circulation aneurysms (PCAs).

Methods: A prospectively maintained database was retrospectively reviewed to identify all cases of intracranial PCA treated with HPC-coated FDs under SAPT (prasugrel). The clinical presentation and outcomes, periprocedural and postprocedural complications, and degree of occlusion at follow-up (FU) were evaluated.

Results: A total of 74 patients were treated (45.9% female). Ischemic complications were experienced by two patients (2.7%) and were dependent on the use of FDs. No cases of aneurysm rupture or hemorrhagic complications related to antiplatelet therapy or the FD treatment were recorded. The rate of complete occlusion was 77.9% in the early FU period (3-6 months) and 90.3% in the initial 12-month period.

Conclusion: In this single-arm retrospective study, HPC-coated FDs with prasugrel SAPT were associated with high safety in the treatment of ruptured and unruptured PCA and high occlusion rates at early- and mid-term FU.

Background: The development of safe and effective endovascular devices is dependent on accurate simulation of anticipated use environments during preclinical testing. We sought to optimize and evaluate the human 'live cadaver' neurovascular model for the purpose of testing radial access catheters. We aimed to assess the realism of our model during simulated neurointerventional procedures as well as explore and characterize potential challenges of radial access catheters.

Methods: A human 'live cadaver' model was developed from a cadaveric specimen consisting of the head, neck, bilateral upper limbs, and thorax. Catheters were inserted into the heart and thoracic aorta. Blood-mimicking fluid made by 0.7% carboxymethyl cellulose + 0.25% sodium propionate was circulated through the vasculature using an external peristaltic pump. Bilateral radial access was obtained using 7F sheaths. Experienced neurointerventionists (n=5) were provided with a questionnaire using a validated 5-point Likert scale and tasked with assessing the model's radial artery, aortic arch, and carotid/vertebral arteries on the parameters of anatomical accuracy, roadmap angiography, device manipulation, haptic feedback, comparison to clinical cases, radio-opacity of devices, and overall similarity to actual patients. Challenging mechanisms were identified and described by evaluation of fluoroscopic and endoscopic videos.

Results: A total of six cadavers were used. Formalin-fixed arteries showed mechanical properties comparable to those of fresh human arteries, including maximum stretch and increased tensile strength/stiffness. The contrast angiographies revealed no obstruction in the micro- or macro-vasculature. Overall similarity scores for arms (radial, brachial, axillary, and subclavian arteries) were 34.6±2.3 out of 40, for aortic arch 30.3±5.4 out of 40, and for carotid/vertebral artery access 33.0±4.2 out of 40. We identified three distinct challenges associated with market radial access catheters: (1) torque build-up followed by sudden release and whipping; (2) catheter tip entry into ulcerated or nodular aortic atheroma preventing free motion; and (3) catheter catching at a septum-like structure at the medial edge of the brachiocephalic trunk; the latter two result in herniation of the system into the arch even with favorable aortic arch angles.

Conclusions: The model provided a reliable and accurate human radial and aortic vasculature simulation, allowing for the evaluation of catheter performance and identification of challenging mechanisms likely to occur in clinical settings. These findings suggest that the modified human live cadaveric model could be a valuable testing platform to support the development of next-generation transradial systems for improved clinical performance.

Background: Despite high recanalization rates with endovascular thrombectomy (EVT) for large vessel occlusions, functional outcomes remain suboptimal. This study investigates whether adjunctive intra-arterial (IA) thrombolysis following successful EVT can improve patient outcomes.

Methods: A systematic review and meta-analysis was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. We searched Medline, Embase, Web of Science, and Cochrane databases. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for functional and safety outcomes.

Results: Seven trials (2131 patients) were included. IA thrombolysis was administered to 1081 (50.7%) patients. Patients receiving adjunctive IA thrombolysis had higher odds of excellent functional outcomes (modified Rankin Scale (mRS) 0-1) at 90 days (OR 1.44, 95% CI 1.21 to 1.72) compared with the EVT-alone group while maintaining similar rates of symptomatic intracerebral hemorrhage (sICH; OR 1.15, 95% CI 0.75 to 1.75). Subgroup analysis of excellent functional outcomes showed that the benefits of IA thrombolysis were primarily observed in specific patient populations: those treated with alteplase 0.225 mg/kg or tenecteplase 0.125 mg/kg, patients with lower expanded Thrombolysis in Cerebral Infarction (eTICI) scores, higher initial National Institutes of Health Stroke Scale (NIHSS), and those with cardioembolic etiology. Mortality rates and good functional outcomes (mRS 0-2) remained comparable between treatment groups.

Conclusion: Adjunctive IA thrombolysis following successful EVT may improve functional outcomes without added risk of sICH. Certain patient subgroups (those with lower recanalization rates, higher NIHSS, and cardioembolic etiology) and specific thrombolytic agents and dosages (alteplase 0.225 mg/kg, tenecteplase 0.125 mg/kg) appear to derive greater benefits from this approach. Further research is needed to validate these findings and refine patient selection.

Background: Studies suggest head positioning may impact cerebral venous outflow by creating dynamic stenosis in the internal jugular veins (IJVs) in susceptible individuals.

Objective: To examine the relationships between IJV pressure gradients and intracranial pressures, measured via lumbar puncture (LP), on head rotation in patients with cerebral venous outflow disorders (CVDs).

Methods: A retrospective chart review was conducted on consecutive adult patients suspected of having CVD who underwent diagnostic cerebral venous venography with rotational IJV venography and superior sagittal sinus (SSS) pressure measurements in multiple head positions followed immediately by LP in neutral and with rotation. Data on IJV pressures, SSS pressures, and LP opening pressure (OP) were collected and analyzed.

Results: In this sample of 70 patients, 9% developed moderate, 53% severe, and 30% occlusive rotational stenosis of the right IJV with 90 degree rightward rotation, resulting in mean jugular gradients of 5.5 mm Hg (SD 4.7). On head rotation, 59 (84%) patients experienced an increase in SSS pressures, and 67 (96%) experienced an increase in LP OP from neutral on head rotation (mean change 5.5 (SD 3.54) mm Hg). On average, for every 1 mm Hg increase in IJV trans-stenosis gradient, a 0.55 mm Hg increase in SSS pressure and a 0.27 cm H₂O increase in LP OP occurred.

Conclusion: In this sample of consecutive CVD patients, dynamic IJV stenosis pressure gradients predicted changes in SSS pressure and LP OP. As IJV pressure gradients increased, there was a near immediate increase in CSF pressure, roughly commensurate to the cervical gradients. These findings suggest that single position LP OP may only represent a snapshot of CSF pressure in a dynamic pressure system.

Background: A carotid web (CaW) is a non-atheromatous, shelf-like intraluminal projection, commonly affecting the internal carotid artery. It can be associated with embolic stroke, particularly in younger patients without traditional stroke risk factors. The natural history of CaW is not well-established. Several studies have reported on outcomes after interventional and medical therapy with variable results.

Objective: To synthesize the literature and report the clinical characteristics and management outcomes of patients with CaWs.

Methods: A systematic literature review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines.

Results: 33 studies comprising 737 patients (mean age 50.2 years, female 59.4%, African American 65%) with 835 CaWs were included. The majority of the CaWs were symptomatic (72.9%) with a mean National Institutes of Health Stroke Scale (NIHSS) admission score of 7.5. Atherosclerotic plaques and intramural thrombi were each present in 33% of patients. The classic atherosclerotic and stroke risk factors were prevalent as follows: hypertension 37.8%, diabetes 14.6%, smoking 21.7%, dyslipidemia 16.7%. In total, treatment outcomes were available for 376 patients with 448 symptomatic CaWs (227 medical, 221 interventional). Medical therapy consisted of antiplatelet or anticoagulation medications, while interventional treatment included carotid artery stenting (CAS), carotid endarterectomy (CEA), and internal carotid artery resection and primary anastomosis (ICRA). The interventional group was associated with a significantly lower risk of recurrent ischemic events compared with the medical group (interventional 0%, medical 36.1%; OR 14.18, 95% CI 3.17 to 63.46, P=0.001) over a mean follow-up of 21.2 months. The odds ratio of cerebral ischemic event recurrence was correlated with the need for thrombectomy at the first event and history of dyslipidemia.

Conclusions: Most CaWs were found during stroke work-up. Prevention of secondary ischemic events was superior in the interventional management group (CAS, CEA, ICRA) compared with the medical management group.