Journal of NeuroInterventional Surgery最新文献

Background and purpose: With the recent relaunch of Artisse 2.0, optimal sizing strategies for the device are still being refined. The official sizing chart covers only taller-than-wide aneurysms within a limited diameter range of 3.4-6 mm. To expand its applicability, we propose an intuitive sizing strategy emphasizing the importance of preserving the device's natural height.

Materials and methods: Patients treated with the Artisse 2.0 between November 2022 and October 2024 were retrospectively analyzed.

Results: Among 26 aneurysms treated over a 24-month period, 13 exhibited varying degrees of 'dog-ear' formation on post-deployment imaging. These cases showed greater width oversizing (+2.06 vs +1.29 mm, P<0.05) and height reduction (-1.83 vs -0.53 mm, P<0.05) compared with cases with complete neck coverage. Similarly, 9 out of the 16 aneurysms with at least one surveillance imaging failed to achieve complete angiographic occlusion. These cases were also associated with greater width oversizing (+1.72 vs +1.43 mm, P=0.47) and height reduction (-2.18 vs -0.81 mm, P=0.052).

Conclusion: In contrast to the Woven EndoBridge (WEB) device, excessive lateral compression and height reduction appear to undermine the stability of the Artisse 2.0. As a result, the device size for spherical or ovoid aneurysms can be determined using the '+1/-1' method, while the '+1/-0' approach is recommended for cylindrical aneurysms to improve neck coverage through height preservation. These proposed sizing strategies may serve as a practical interim solution until more clinical data and user experience become available.

Background: Flow diversion has revolutionized the management of intracranial aneurysms. This study aimed to evaluate the preliminary safety and efficacy profile of the novel Lattice flow diverter (LFD) in clinical applications.

Methods: We retrospectively analyzed consecutive patients with intracranial aneurysms who were treated with the LFD between June 2023 and May 2024. Based on the medical records and imaging data, we collected demographic characteristics, aneurysm features, procedural details, perioperative complications, clinical outcomes, and imaging results.

Results: This study comprised 105 patients (mean age, 55.4±9.04 years; 72.4% female) with 117 aneurysms, including 104 (88.9%) anterior circulation aneurysms. Procedural success was achieved in all patients (109 devices deployed). Adjunctive techniques included coiling in 39 aneurysms (33.3%) and balloon-assisted wall apposition in three cases (2.6%). The overall perioperative complication rate was 5.8%, with neurological complications (all ischemic events) occurring in 2.9% of cases. Clinical follow-up (mean 10.0±1.4 months) demonstrated preserved functional independence (modified Rankin Scale (mRS) score 0-2) in 98.0% of patients. Imaging follow-up (mean 6.6±1.6 months) revealed complete occlusion in 71.9% of aneurysms and adequate occlusion (Raymond-Roy class I/II) in 88.6%.

Conclusion: The LFD demonstrated favorable safety and efficacy characteristics for intracranial aneurysm treatment during short-term follow-up. Long-term outcomes require validation in multicenter prospective cohort studies.

Background: Hemorrhagic transformation after thrombectomy is associated with poor outcomes. This study aimed to assess post-thrombectomy angiographic signs and increased blood flow on transcranial Doppler as potential predictive factors for parenchymal hemorrhage after successful endovascular stroke treatment.

Methods: This cohort study included consecutive patients who underwent endovascular stroke treatment at a comprehensive stroke center with successful recanalization and 24-hour follow-up imaging available. Angiographic post-thrombectomy signs, including the blush sign, early venous filling, and punctate dilations, were retrospectively and blindly assessed. The mean blood flow velocity ratio of the recanalized artery was collected and compared with the contralateral artery, defining hyperperfusion as a ratio greater than 1.3. Control 24-hour CT scans were reviewed, and hemorrhagic transformation was classified. Unadjusted and clinical variable-adjusted logistic regression analyses were performed.

Results: A total of 362 patients were included in the analysis, with 28 (7.7%) presenting with parenchymal hemorrhage. The blush sign (adjusted OR 3.6, 95% CI 1.3 to 9.4, P=0.01), early venous filling (adjusted OR 6.1, 95% CI 1.9 to 20.0, P=0.003), a combination of both signs (adjusted OR 7.9, 95% CI 2.0 to 30.8, P=0.003), and Doppler-assessed hyperperfusion (adjusted OR 5.9, 95% CI 1.1 to 31.5, P=0.038) were independent predictors of parenchymal hemorrhage. A model incorporating these three variables presented an area under the curve of 0.82 (95% CI 0.67 to 0.99, P<0.001), indicating excellent predictive accuracy for identifying parenchymal hemorrhage following successful thrombectomy.

Conclusion: Angiography and transcranial Doppler ultrasonography may provide early signs that accurately predict parenchymal hemorrhage following successful recanalization.

Background: The ability to differentiate intracranial atherosclerotic disease (ICAD) related large vessel occlusion (LVO) from embolism is critical for stroke management. We hypothesized that the mismatch ratio derived from the automated computed tomography perfusion (CTP) could predict underlying ICAD.

Methods: Patients with acute ischemic stroke (AIS) and LVO from prospective registry databases who underwent CTP were included in the derivation cohort (n=1100). The mismatch ratio, calculated as the ratio of the hypo-perfused volume to the infarct core volume by software, was defined. Receiver Operating Characteristic (ROC) analysis was performed to assess the predictive performance of the mismatch ratio for ICAD, and logistic regression analysis was used to identify independent predictors of LVO associated with underlying ICAD. External validation was conducted using cohorts from two other stroke centers (n=385).

Results: In the derivation cohort, 390 patients were classified as ICAD and 720 as embolism. The ICAD group had a higher mismatch ratio (9.8 vs 3.6, P<0.001). The mismatch ratio outperformed age and National Institutes of Health Stroke Scale (NIHSS) score in predicting ICAD (area under the curve (AUC), 0.77 vs 0.36 vs 0.28, P<0.001). The ROC curve had a best cut-off of 7.1 for predicting ICAD, which was an independent predictor of ICAD-related occlusion (adjusted odds ratio (aOR) 5.43, 95% CI 3.68 to 8.03), with 68% sensitivity and 76% specificity. These results were validated in an external cohort (AUC=0.78; 95% CI, 0.73 to 0.83).

Conclusion: The perfusion mismatch ratio may be an optimal and simple predictor of anterior circulation ICAD- related LVO before endovascular treatment (EVT). When this ratio was ≥7.1, ICAD was five times more likely than embolism.

Background: Despite successful reperfusion after endovascular therapy (EVT), over 50% of patients with large vessel occlusion (LVO) and large core infarction fail to achieve favorable functional outcomes, termed 'futile recanalization'. This study aimed to identify predictors and develop a scoring system to predict futile recanalization in patients with LVO and large core infarction undergoing EVT.

Methods: Patients were selected from the Acute Anterior Circulation Large Vessel Occlusive Patients With a Large Infarct Core (ANGEL-ASPECT) trial. Futile recanalization was defined as a modified Rankin Scale (mRS) score of >3 at 90 days despite successful reperfusion (extended Thrombolysis in Cerebral Infarction scale ≥2b). Participants were divided into futile (mRS >3) and no-futile (mRS ≤3) recanalization groups. Multivariable logistic regression was used to develop the predictive scale, with model performance assessed via a receiver operating characteristic (ROC) curve and Hosmer-Lemeshow test.

Results: Of 146 patients, 74 had futile recanalization. A six-item scale (0-6 points) was developed, including gender, age, systolic blood pressure, admission National Institutes of Health Stroke Scale score, blood glucose, and neutrophil-to-lymphocyte ratio. The scale showed good predictive performance (area under the ROC curve (AUC) 0.806, 95% CI 0.737 to 0.876) and good calibration (Hosmer-Lemeshow test, P=0.837). The optimal cut-off value of the scale was ≥3 points with 81% sensitivity, 70% specificity, and 76% accuracy.

Conclusions: The pre-EVT scale could effectively predict 90-day futile recanalization before EVT, providing a valuable tool for clinical decision-making and risk stratification in patients with LVO and large core infarction.

Background and purpose: Endovascular treatment (EVT) has become the standard of care for selected adult patients with large vessel occlusion (LVO), but its efficacy in pediatric patients remains limited. This study aimed to assess the clinical outcomes of EVT in pediatric patients with LVO and compare it with medical management.

Methods: The Chinese Pediatric Ischemic Stroke Registry (CPISR) is a multicenter, prospective observational study. Eighty-five centers across 20 provinces in China reported functional outcomes for children aged between 28 days and 18 years presenting with arterial ischemic stroke (AIS) caused by LVO who received either EVT or medical treatment. The primary outcome was the pediatric modified Rankin Scale (mRS) score at 90 days. Secondary outcomes included excellent outcome (pediatric mRs 0-1), favorable outcome (pediatric mRs 0-2) and 90-day mortality. Propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) were employed to address imbalances across groups. A meta-analysis integrating the currently available evidence was performed to systematically compare the two groups.

Results: In this study, 64 patients with LVO were finally included in this analysis. After PSM, EVT was associated with increased odds of improved shift pediatric mRS scores (OR 3.20, 95% CI 1.03 to 9.97) and excellent outcome (OR 10.0, 95% CI 1.10 to 90.59). There was no significant difference in 90-day mortality between EVT and medical management groups (OR 1.70, 95% CI 0.10 to 28.43). Meta-analysis also demonstrated the superiority of EVT over medical treatment, showing better mRS shift at 90 days (OR 2.56, 95% CI 1.44 to 4.54), a high possibility of excellent outcome (OR 4.44, 95% CI 1.90 to 10.33) and favorable outcome (OR 2.16, 95% CI 1.15 to 4.05).

Conclusion: This matched-control study and meta-analysis showed that EVT was associated with better functional outcomes in pediatric patients with LVO. These findings support the use of EVT as a treatment approach for pediatric patients with LVO.

Background: The endovascular clip system (eCLIPs), a unique extra-saccular device for treatment of wide necked bifurcation aneurysms (WNBAs), was evaluated in the French eCLIPs efficacy and safety study (EESIS-FR). This paper summarizes the patient demographics, procedural characteristics, and 30 day adverse event (AE) data.

Methods: The EESIS-FR trial was a prospective study from 18 centers, enrolling 123 adults with WNBAs at the carotid (CT) and basilar (BT) termini. The study protocol was approved by a central ethics committee, had independent adjudication of AEs by a Clinical Events Committee, and had independent core laboratory adjudication of effectiveness outcomes.

Results: Mean age was 55.0±1.2 years (19-78 years); 73% were women. 43% and 57% of the aneurysms were located at BT and CT, respectively. Mean neck length was 4.8 mm, neck depth 4.2 mm, dome height 5.4 mm, and dome width 6.3 mm. Successful implantation was achieved in 115 cases (93%). Implant time averaged 36 min. Three primary safety events (2.4%) occurred within the first 30 days, all at the index procedure: subarachnoid hemorrhage (SAH) due to a distal guidewire perforation, death from SAH due to rupture of the aneurysm, and spinal cord infarction caused by an occlusive access catheter. Five minor strokes (4.1%) and three transient ischemic attacks (2.4%) occurred, all of which were procedurals. None of these patients had a modified Rankin Scale score of >2 at 30 days. No patient had further ischemic or hemorrhagic events beyond the periprocedural period to 30 days.

Conclusion: eCLIPs treated WNBAs at BT and CT, with procedural safety and technical success similar to those with intrasaccular devices.

Background: Interhospital transfers of stroke patients to higher levels of care for endovascular treatment (EVT) are common. Optimizing transfer times may help improve overall reperfusion times. We sought to model and compare the ground travel times for health system-affiliated and nearest EVT-capable stroke center transfers and examine associated factors in the four largest cities in the USA: New York City (NYC), Los Angeles (LA), Chicago, and Houston.

Methods: We identified EVT-capable centers (defined as comprehensive, thrombectomy-capable, and primary plus stroke centers) and their health system-affiliated hospitals for each city. For each affiliated hospital, we used a Monte Carlo simulation to model ambulance travel times to its system EVT-capable center as well as the nearest EVT-capable center. We subsequently analyzed hospital service area variables associated with prolonged (extra travel time to affiliated hospital >20 min) transfers.

Results: The total travel time (mean (SD), min) to an affiliated versus nearest EVT-capable center was 29.9 (10.2) versus 14.4 (2.0) (P<0.001), with only ~7% of the nearest EVT-capable centers sharing affiliation with the transferring center. The travel times were significantly greater in LA compared with Houston and NYC (P<0.001). Finally, hospital service areas with a greater proportion of patients over 50 years of age and teaching hospital status were associated with potentially reduced extra transfer time.

Conclusion: This study characterized theoretical stroke transfer networks in the four largest US cities and showed that affiliated-hospital system transfers may increase overall transfer times compared with transferring to the nearest EVT-capable center.

Background: Endovascular thrombectomy (EVT) is now the standard treatment for patients with large cerebral infarcts. However, the benefit of intravenous thrombolysis before EVT (IVT+EVT) in this setting is uncertain.

Methods: We conducted a post hoc analysis of the Large Stroke Therapy Evaluation (LASTE) trial, which randomized patients with large infarcts (Alberta stroke program early CT score (ASPECTS) ≤5) to EVT plus medical care or medical care alone. Among those assigned to EVT, patients were divided into two groups: IVT+EVT and EVT alone. The main outcome was the shift analysis of the 3 month modified Rankin Scale (mRS) score. Safety outcomes included parenchymal hemorrhage (PH) and symptomatic intracranial hemorrhage (sICH).

Results: Among 159 patients allocated to EVT, 55 received IVT+EVT and 104 EVT alone. Patients in the IVT+EVT group had lower National Institutes of Health Stroke Scale (NIHSS) scores (median 19 (IQR 17-22) vs 22, (19-24) p=0.003), were less often anticoagulated (3.6% vs 27.9%, p<0.001) and shorter onset-to-imaging time (median 148 (91-280) vs 200 (123-311); P=0.024). Both groups had similar rates of ASPECTS 0-2 (50.9% vs 55.8%; P=0.56). There was no significant difference in 3 month functional outcome between IVT+EVT and EVT alone (generalized OR 1.22 (95% CI 0.85 to 1.74); P=0.28) or sICH (RR 1.72 (95% CI 0.65 to 4.48); P=0.27). Pre-EVT recanalization was higher in the IVT+EVT group (RR 15.1 (95% CI 1.9 to 117.9); P<0.001). Mortality rates did not differ significantly.

Discussion: In patients with very large infarcts, IVT+EVT was not associated with better functional outcome than EVT alone, despite higher pre-EVT recanalization rates. Safety outcomes were comparable. Randomized trials are warranted to clarify the role of IVT in this high-risk population.

Trial registration number: NCT03811769.