Journal of NeuroInterventional Surgery最新文献

Background: Unruptured intracranial aneurysms (IAs) that become symptomatic have been associated with instability.

Objective: To investigate the relationship between irregular pulsation on four-dimensional CT angiography (4D-CTA) and aneurysm wall enhancement (AWE) on vessel wall MRI (VW-MRI), and to evaluate their ability to identify symptomatic IAs.

Methods: This retrospective study included consecutive patients with IAs who underwent 4D-CTA and VW-MRI between March 2018 and May 2023. IAs were categorized as asymptomatic and symptomatic. The presence of irregular pulsation was identified on 4D-CTA video. Qualitative and quantitative AWE were evaluated. Univariate and multivariate analyses were used to identify the parameters associated with symptoms.

Results: 192 patients with 216 aneurysms (167 asymptomatic and 49 symptomatic) were included. IAs with irregular pulsation had significantly higher wall enhancement index (WEI) than IAs without irregular pulsation (median (IQR), 0.5 (0.2-1.1) vs 0.2 (0.0-0.6), P<0.001). Symptomatic IAs had significantly higher WEI than asymptomatic IAs (median (IQR), 0.7 (0.3-1.5) vs 0.2 (0.0-0.5), P<0.001), and more irregular pulsations (79.6% vs 25.1%, P<0.001). Both irregular pulsation (OR=6.86; 95% CI 2.62 to 17.96; P<0.001) and WEI (OR=2.56; 95% CI 1.14 to 5.71; P=0.022) were independently associated with symptoms. Combination of irregular pulsation and WEI achieved the highest area under the curve of 0.86 in identifying symptomatic aneurysms compared with irregular pulsation or WEI alone (P<0.001 and P=0.002, respectively).

Conclusion: In a large cohort of patients with unruptured IAs who underwent 4D-CTA and VW-MRI, both irregular pulsation and WEI were independently associated with symptoms. Such measures could identify IAs at higher risk of growth or rupture.

Background: Mechanical thrombectomy (MT) significantly improves outcomes in patients with acute ischemic stroke due to large vessel occlusion. There is limited understanding of how the site of hospital readmission after MT influences patient outcomes. Addressing this gap may be important for optimizing post-MT care and improving long-term outcomes for stroke patients.

Methods: We conducted a retrospective cohort analysis using data from the Nationwide Readmissions Database, focusing on acute ischemic stroke patients who underwent MT between 2016 and 2019. Multivariable Cox regression and Fine and Gray competing risks models were used to assess the impact of readmission site on patient outcomes, including mortality and the likelihood of discharge to home.

Results: The analysis included 18 330 patients readmitted within 90 days post-MT, with 63.7% readmitted to index hospitals and 36.3% to non-index hospitals. Readmission to the index hospital was not significantly associated with mortality but was linked to a higher likelihood of discharge to home (subdistributed HR 1.22, 95% CI 1.13 to 1.32, P<0.001), a lower likelihood of longer hospital stay (OR 0.81, 95% CI 0.72 to 0.90, P<0.001), and lower hospital cost (β = -3345.25, 95% CI -5786.46 to -904.04, P=0.007).

Conclusion: This nationwide analysis suggests that for acute ischemic stroke patients treated with MT, readmission to index hospitals within 90 days is associated with a higher likelihood of home discharge, shorter length of stay, and lower hospital cost. Further research is warranted to better understand the underlying causes of these disparities and to enhance continuity of care for this vulnerable patient population.

Background: Endovascular arterial embolization (EAE) is an effective treatment for severe epistaxis refractory to conservative management with nasal packing. However, contemporary real-world data are lacking, as are data on head-to-head comparisons of EAE versus nasal packing alone.

Methods: This was a retrospective cohort study of the Nationwide Readmissions Database (NRD) from 2016 to 2021 in the United States. Patients with severe epistaxis treated with nasal packing alone or EAE with or without nasal packing were included and followed for 180 days. Propensity score matching (PSM) for demographics, comorbidities, and hemorrhage risk factors was performed to balance patient characteristics. Primary outcome was recurrent epistaxis. Secondary outcomes include rates of non-routine hospital discharge (indicating short-term morbidity or mortality) and ischemic stroke.

Results: 25 160 patients admitted to hospital for severe epistaxis were included; 754 (3.3%) underwent EAE. After PSM, 1542 patients remained in the conservative management group, and 743 remained in the EAE group. Overall, the risk of epistaxis readmission was lower after EAE compared with conservative management (HR 0.47, 95% CI 0.26 to 0.87, P=0.016); the 180-day epistaxis readmission rate was 4.6% and 10.6%, respectively (P=0.024). EAE was significantly associated with lower rates of non-routine discharge (22.1% vs 28.9%, P=0.026), despite a higher rate of ischemic stroke (1.6% vs 0.4%, P=0.017).

Conclusions: For patients with severe epistaxis, EAE is associated with a significant reduction of epistaxis recurrence rates as well as lower rates of patient morbidity compared with nasal packing alone, despite a small but significant increase in risk of ischemic stroke.

Background: Cerebrospinal fluid (CSF) loss in spontaneous intracranial hypotension (SIH) is accompanied by volume shifts between the intracranial compartments. This study investigated tricompartimental and longitudinal volume shifts after closure of a CSF leak.

Methods: Patients with SIH and suitable pre-therapeutic and post-therapeutic imaging for volumetric analysis were identified from our tertiary care center between 2020 and 2023. The Bern SIH score was calculated. Pre-interventional and post-interventional volumetry encompassed the CSF, parenchymal and venous compartments (ie, venous sinus and choroid plexus volumes).

Results: In total, 32 patients with SIH (49.7±16.0 years, 22 women) met inclusion criteria. The mean SIH score decreased between baseline (4.5±2.7) and early (2.7±2.3, <7 days after intervention), and also late follow-up (1.4±1.7, follow-up ≥7 days) after leak closure. This was accompanied by a significant increase in ventricular volume from 22.1 to 25.0 mL (P=0.01) at early follow-up, and 23.9 mL at later follow-up (P=0.080). In contrast, venous sinus volumes decreased from 13.8 to 9.6 mL (P=0.016) at early follow-up, and 10.0 mL (P=0.007) at late follow-up. No significant change in mean choroid plexus, total gray or total white matter volume was observed.

Conclusions: Closure of a spinal CSF leak leads to an early increase in ventricular CSF volume and a decrease in venous sinus volume. The results reflect the long-term convergence of the SIH score to normal values and indicate that permanent closure of a CSF leak induces a stable recompensation of the intracranial compartments without involving significant volume shifts within the cerebral parenchyma.

Background: Venous vascular malformations (VVMs) are congenital vascular anomalies, often impacting quality of life due to discomfort, swelling, and functional impairments. This study evaluates the efficacy of bleomycin sclerotherapy as a treatment for symptomatic VVMs of the tongue.

Methods: We conducted a retrospective review of all patients treated with this method in our institution between 2004 and 2024. Sclerotherapy procedures were performed under general anesthesia in the neuroangiography suite with fluoroscopic guidance using a negative subtraction technique. Outcomes were assessed through subjective patient reports and magnetic resonance imaging (MRI) where available.

Results: In total, 140 percutaneous bleomycin sclerotherapy procedures were performed on 36 patients (aged 19-80) with tongue VVMs. On average, patients required 2.06±1.8 treatment sessions and 2.29±1.4 procedures per session. The average interval between treatment sessions was 28.6±19.4 months. Per procedure, the total units of bleomycin injected was 11.2±3.9 mg/mL (2-15 mg/mL). Results revealed that 93.8% of procedures yielded subjective symptom improvement. Follow-up imaging was available in 14 patients and confirmed lesion reduction in nine (64.3%). Post-procedural complications were minimal, with transient swelling as the most common.

Conclusion: Percutaneous bleomycin sclerotherapy presents an effective, well-tolerated treatment for tongue VVMs, offering significant symptom relief. To our knowledge, this study represents the largest retrospective series of bleomycin sclerotherapy for tongue VVMs to date. Our findings support bleomycin sclerotherapy as a valuable option for managing VVMs in this challenging anatomical site.

Background: Thrombus enhancement sign (TES) has emerged as a potential imaging biomarker in patients with acute ischemic stroke (AIS) undergoing endovascular thrombectomy (EVT).

Objective: To evaluate the prognostic value of TES on 90-day mortality and functional outcomes.

Methods: We conducted a prospective, two-center study involving 323 patients with AIS treated with EVT. TES was assessed by CT angiography (CTA) using thin-slab maximum intensity projection. The primary outcome was 90-day mortality; secondary outcomes included functional outcomes measured by the modified Rankin Scale (mRS). Subgroup, mediation, and sensitivity analyses were conducted to assess the predictive value of TES across different clinical factors.

Results: TES positivity was identified in 228 (70.6%) patients. TES-positive patients had a 90-day mortality rate of 25.0%, compared with 9.5% in TES-negative patients. TES was significantly associated with 90-day mortality in both univariate analysis (OR=4.275, 95% CI 1.765 to 10.350, P=0.001) and multivariate model 3 (adjusted OR=3.821, 95% CI 1.449 to 10.075, P=0.007). TES was also associated with 90-day mRS score 0-2 (OR=0.500, 95% CI 0.305 to 0.819, P=0.006) in univariate analysis.

Conclusion: TES is an independent predictor of 90-day mortality and poor functional outcomes in patients with AIS treated with EVT. TES can potentially serve as a valuable imaging biomarker for identifying high-risk patients.

Background: Previous studies suggest that it may be inappropriate to determine treatment strategies solely based on the degree of stenosis for patients with intracranial atherosclerotic stenosis (ICAS). In order to better risk stratify patients with ICAS, we developed a novel non-invasive fractional flow (FF) calculation technique based on intracranial angiography (Angio-FF) to assess the hemodynamics for patients with ICAS. This study aims to investigate the difference in FF between symptomatic and asymptomatic patients with ICAS and its potential optimal threshold.

Methods: A total of 124 patients with ICAS with severe intracranial stenosis who had undergone cerebral angiography were recruited. According to the time of onset, the patients were divided into a symptomatic ICAS group (n=78) and an asymptomatic ICAS group (n=46). The Angio-FF of each group was collected and compared. Receiver-operating characteristic curve (ROC) analysis was performed to assess the discriminative ability of Angio-FF to predict hemodynamics for ICAS.

Results: Compared with the asymptomatic ICAS group, the symptomatic ICAS group had a significantly lower Angio-FF (0.75 (0.66-0.85) vs 0.85 (0.77-0.89), P<0.001). The optimal cut-off value of Angio-FF for distinguishing symptomatic ICAS from asymptomatic ICAS was 0.785 (sensitivity 71.74%, specificity 57.69%).

Conclusions: Patients with Angio-FF <0.7853 may be more prone to intracranial ischemic events. Angio-FF of 0.7853 can serve as a boundary for whether patients with ICAS exhibit clinical symptoms.

Background: Transverse sinus stenosis (TSS) and sigmoid sinus wall anomalies (SSWAs) are the most common causes of pulsatile tinnitus (PT). While these conditions may co-occur, they usually require different management approaches. This study aims to evaluate whether TSS stenting alone, without targeted treatment of SSWAs, is sufficient to resolve PT in patients presenting with PT, TSS, and SSWAs.

Methods: We conducted a retrospective study of consecutive patients diagnosed with PT, TSS, and SSWAs who underwent transvenous endovascular treatment between September 2020 and January 2024. The primary outcome was treatment success at 3 months, defined as complete resolution of baseline PT. Secondary outcomes included treatment success at 24 hours and 1 year, PT recurrence within 1 year, and major complications.

Results: Thirty-three patients with PT, TSS, and SSWAs underwent 38 procedures. Among these, 14 cases (36.8%) had dehiscence alone, 3 cases (7.9%) with diverticulum alone, and 20 cases (52.6%) involved both dehiscence and diverticulum. Stenting alone was performed in 25 cases (65.8%), stent-assisted coiling in 9 cases (23.7%), and coiling alone in 4 cases (10.5%). The primary outcome of complete resolution of PT at 3 months was achieved in 86.1% (31/36) of cases, with partial resolution in an additional 13.9% (5/36) of cases. There was no difference in outcomes between cases of isolated stenting and those involving coiling or stent-assisted coiling.

Conclusion: Transverse sinus stenting alone, without dedicated treatment of SSWAs, resolves PT in patients with TSS and SSWAs. These results support the growing evidence that SSWAs are secondary to TSS in patients with PT and/or idiopathic intracranial hypertension, suggesting that additional interventions like coiling or surgery of SSWAs may be unnecessary.

Background: The time to maximum (Tmax) profile based on computed tomography perfusion (CTP) provides a quantitative assessment of cerebral hemodynamic compromise. We aimed to delineate the Tmax profile in stroke patients with symptomatic intracranial atherosclerotic stenosis (ICAS) and to investigate its predictive role in stroke recurrence after optimal medical treatment.

Methods: Consecutive patients with ischemic stroke within 30 days attributed to 50%-99% ICAS were prospectively enrolled. Baseline tissue volume at different perfusion parameter thresholds based on CTP was automatically calculated using the Rapid Processing of Perfusion and Diffusion (RAPID) software. All patients received optimal medical treatment. The primary outcome was a composite of stroke in the territory of qualifying artery or vascular death within 1 year.

Results: Among 204 patients with symptomatic ICAS, the median volume of Tmax >4 s, Tmax >6 s, and relative cerebral blood flow (rCBF) <30% were 61 mL, 0 mL, and 0 mL, respectively. The 1 year rate of primary outcome was 16.2% (33/204). Tmax >4 s volume was significantly associated with the primary outcome (per 10 mL increase, adjusted hazard ratio (HR), 1.028 (1.008-1.049), P=0.005). The optimal cut-off value of Tmax >4 s volume for predicting the primary outcome was 83 mL. Patients with Tmax >4 s volume >83 mL had a higher risk of the 1 year primary outcome than those with Tmax >4 s volume ≤83 mL (adjusted HR, 7.346 (3.012-17.871), P<0.001), after adjusting for degree of stenosis and stroke mechanisms.

Conclusion: Tmax >4 s volume is a promising perfusion parameter to define hemodynamic compromise in patients with symptomatic ICAS. Patients with a larger volume of Tmax >4 s are likely to have a higher risk of stroke recurrence despite optimal medical treatment.

Background: Timely treatment within the therapeutic window is critical for patients with stroke. This study adopts a risk-averse optimization approach to maximize the likelihood of receiving treatment within this window.

Methods: We developed an optimization model using data from a citywide stroke registry (July 1, 2019 to December 31, 2020). The model included scene locations, data from 10 stroke centers, Cincinnati Prehospital Stroke Scale (CPSS) scores, prehospital times, and in-hospital processing times for endovascular thrombectomy (EVT) in patients with large vessel occlusion (LVO) stroke and intravenous thrombolysis (IVT) in patients with non-LVO stroke. Transport times were calculated using Google Maps and hospital delivery was determined through mathematical programming. We compared the Risk-Averse strategy against four other prehospital strategies (Nearest, Mothership, Optimistic, and Pessimistic strategies) using Monte Carlo simulations for 726 patients.

Results: The Risk-Averse strategy consistently outperformed others for patients with LVO stroke, with 82.0% (95% CI 79.8% to 84.1%) receiving EVT within 6 hours, representing a 4.8% increase over the Mothership strategy and a 13.7% increase over the Nearest strategy. The average time to EVT was 268.1 min (95% CI 258.3 to 278.5). For patients with non-LVO stroke, 80.6% (95% CI 80.0% to 81.6%) received IVT within 4.5 hours, with no significant differences between strategies.

Conclusions: The Risk-Averse hospital selection strategy significantly improves EVT rates for patients with LVO stroke without delaying IVT for those with non-LVO stroke.