Journal of NeuroInterventional Surgery最新文献

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.

Background: Current clinical decision tools for assessing the risk of symptomatic intracranial hemorrhage (sICH) in patients with vertebrobasilar artery occlusion (VBAO) who received endovascular treatment (EVT) have limited performance. This study develops and validates a clinical risk score to precisely estimate the risk of sICH in VBAO patients.

Methods: The derivation cohort recruited patients with VBAO who received EVT from the Posterior Circulation IschemIc Stroke Registry in China. Based on the posterior circulation-Alberta Stroke Program Early CT Score (pc-ASPECTS) evaluation method, the cohort was further divided into non-contrast CT (NCCT) and diffusion weighted imaging (DWI) cohorts to construct predictive models. sICH was diagnosed according to the Heidelberg Bleeding Classification within 48 hours of EVT. Clinical signature was constructed in the derivation cohort using machine learning and was validated in two additional cohorts from Asia and Europe.

Results: We enrolled 1843 patients who underwent EVT and had complete data. pc-ASPECTS of 1710 patients was evaluated on NCCT and 699 patients on DWI. In the NCCT cohort, 1364 individuals made up the training set, of whom 101 (7.4%) developed sICH. In the DWI cohort, the training set consisted of 560 individuals, with 44 (7.9%) experiencing sICH. Predictors of sICH were: glucose, pc-ASPECTS, time from estimated occlusion to groin puncture (EOT), poor collateral circulation, and modified Thrombolysis in Cerebral Infarction (mTICI) score. From these predictors, we derived the weighted poor collateral circulation-EOT-pc-ASPECTS-mTICI-glucose (PEACE) score. The PEACE score showed good discrimination in the training set (area under the curve (AUC)_NCCT=0.85; AUC_DWI=0.86), internal validation set (AUC_NCCT=0.81; AUC_DWI=0.82), and two additional external validation set (Asia: AUC_NCCT=0.78, AUC_DWI=0.80; Europe: AUC_NCCT=0.74, AUC_DWI=0.78).

Conclusion: The PEACE score reliably predicted the risk of sICH in VBAO patients who underwent EVT.

Background: The recently completed Early Minimally Invasive Removal of Intracerebral Hemorrhage (ENRICH) trial demonstrated a benefit for endoport-mediated evacuation within ≤24 hours for lobar hemorrhages but not for basal ganglia hemorrhages (BGH). We performed an exploratory evaluation of the Stereotactic Cerebral Underwater Blood Aspiration (SCUBA) technique for BGH evacuation.

Methods: We reviewed data from patients presenting to an urban health system with BGH who underwent SCUBA evacuation according to institutional guidelines. Three cohorts were then created: (1) all patients with BGH evacuation using the SCUBA approach; (2) patients with BGH evacuation using SCUBA within ≤24 hours and with ENRICH-defined intraventricular hemorrhage (IVH) selection criteria; and (3) SCUBA evacuation within ≤24 hours, ENRICH-defined IVH, and intracerebral hemorrhage (ICH) volumes of ≥30 mL. Key outcomes included evacuation percentage, residual hematoma volume ≤15 mL, and 6-month modified Rankin Scale (mRS) score of 0-3.

Results: Sixty-eight patients with BGH underwent SCUBA. Median preoperative ICH volume was 35 mL and median postoperative volume was 1.3 mL for a median evacuation percentage of 97%, with 90% achieving ≤15 mL residual volume. For 19 patients in cohort 2 and 12 patients in cohort 3, median evacuation percentages were 98% and 100% of patients had ≤15 mL residual volume in both groups. A good outcome was achieved in 53% and 50% of patients, respectively.

Conclusions: SCUBA evacuation for BGH in patients who otherwise meet ENRICH criteria suggests superior 6-month outcomes compared with ENRICH BGH patients (utility-weighted mRS 0.51 vs 0.34). A randomized clinical trial is warranted to prospectively evaluate SCUBA evacuation within 24 hours in patients with spontaneous BGH.

Background: Endovascular transvenous embolization (TVE) was developed as a curative technique for brain arteriovenous malformations (bAVMs) with small nidi and a single draining vein. We describe a partial transvenous embolization technique (pTVE) as an intermediate embolization session to decrease hemorrhagic complications of larger nidi with multiple venous outlets.

Method: We reviewed our single-center database of bAVMs treated endovascularly between January 2023 and March 2024. Six consecutive patients underwent 10 sessions of pTVE for ruptured AVMs.

Results: The median age of patients was 24.5 years. The median nidus size was 5 cm (range 4-6 cm). Three patients had grade III lesions according to the Spetzler-Martin classification, two were grade IV, and one was grade V. Four patients had draining veins with multiple efferent veins with each collecting vein, one patient had multiple efferent veins with one collecting vein, and one patient had one efferent vein with a long bifurcation. pTVE achieved partial occlusion in all cases without any hemorrhagic complications. One patient had the AVM totally occluded with two sessions of pTVE. Decision-making was facilitated by creating subcategories of venous angioarchitecture and detailing the technical particularities in the corresponding category.

Conclusion: We described a novel treatment technique of transvenous embolization as an adjunct strategy for large bAVMs.