Journal of NeuroInterventional Surgery最新文献

Background: Dual antiplatelet therapy (DAPT) is critical for safe flow diversion (FD), yet unlike the extensive coronary literature, FD remains less common and lacks strong evidence to guide DAPT choice. Clopidogrel's variable responsiveness has pushed clinicians towards platelet function testing and more potent agents. In 2023, our institution adopted universal prasugrel-based DAPT, and this study compares outcomes across clopidogrel, ticagrelor, and prasugrel.

Methods: We present a retrospective review of all intracranial aneurysms treated with the Pipeline Embolization Device (PED) between July 2021 and July 2024 using a prospectively maintained database. Primary outcomes were thromboembolic and hemorrhagic complications, occlusion rates, and functional outcomes (modified Rankin Scale (mRS)). Secondary analyses were conducted based on surface modification.

Results: A total of 243 FD procedures were performed in 229 patients (mean age 55.2 years; 84.3% women) treating 265 aneurysms. DAPT regimens included ticagrelor (38.7%), clopidogrel (31.7%), and prasugrel (29.6%). At median 12-month follow-up, 97.8% of patients achieved favorable functional outcomes (mRS ≤2), with no differences between regimens. No significant differences in aneurysm occlusion (complete/near-complete in 86.4%) were found between the DAPT regimens. Thromboembolic (4.1%) and hemorrhagic (4.9%) complications did not differ significantly; notably, all intracranial hemorrhages occurred in ticagrelor-treated patients. Retreatment rates were significantly higher in non-surface-modified versus surface-modified PEDs (8.3% vs 0.9%, P=0.01).

Conclusions: Prasugrel showed comparable safety and occlusion outcomes relative to clopidogrel and ticagrelor. Our findings underscore a critical gap in the evidence base and highlight the urgent need for multicenter registries and prospective trials to establish standardized, data-driven DAPT protocols for intracranial FD.

Introduction: Partially thrombosed intracranial aneurysms (PTIAs) are rare, complex, and have a distinct natural history compared with non-thrombosed aneurysms. PTIAs show increased rates of recurrence despite angiographic intraluminal occlusion following endovascular treatment (EVT). Our single-center experience, along with a systematic review, identifies presenting features, rates of angiographic occlusion, complications, recurrence, and retreatment.

Methods: A single-center retrospective review of consecutive patients with PTIA using imaging-based inclusion criteria was performed. Rates of angiographic occlusion, complications, recurrence, and retreatment were evaluated. In conjunction, a systematic review was conducted in accordance with PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols) guidelines through PubMed, Scopus, and Google Scholar searches for studies on EVT of PTIA. After pooling patients undergoing EVT, presenting features and rates of occlusion and retreatment were assessed.

Results: Between 2018 and 2023, 22 PTIAs met imaging-based inclusion criteria. Eighteen underwent EVT: four coiling, two stent-assisted coiling, 11 flow diversion (FD), and one FD-assisted coiling. Mass effect was the most common symptom to herald diagnosis (8/18, 44.4%). Of 12 patients with adequate follow-up, 58% had near-complete or complete occlusion, 22% recurred, and 22% were retreated. For the systematic review, a total of 12 retrospective studies were included. In pooled analysis (n=259), including the present series, complete occlusion was achieved in 62%, 80%, 78%, and 100% for coiling±stent, Woven EndoBridge (WEB), FD, and parent vessel occlusion (PVO), respectively. Retreatment occurred in 51%, 54%, 15%, and 3% with coiling±stent, WEB, FD, and PVO, respectively.

Conclusion: PTIAs have a complex pathogenesis, poor natural history, and often undergo retreatment. The results suggest FD to be an increasingly utilized treatment option. Coil±stent and the WEB device appear to have poorer outcomes and higher retreatment rates. If able to tolerate, PVO remains a viable option with high occlusion and low retreatment rates.

Background: Randomized trials showed that endovascular thrombectomy (EVT) did not improve outcomes in medium vessel occlusion (MeVO) stroke compared with usual care. We investigated whether patients randomized to EVT who achieved near-complete/complete reperfusion had improved clinical outcomes compared with patients randomized to usual care.

Methods: Post-hoc analysis of ESCAPE-MeVO, which randomized patients with MeVO stroke to undergo EVT in addition to usual care or usual care only. Reperfusion grade in EVT patients was assessed with the MeVO expanded Thrombolysis in Cerebral Infarction (meTICI) score. Regression analyses were used to compare clinical outcomes between EVT patients with near-complete/complete (meTICI 2c-3) reperfusion and usual care patients, and the association between reperfusion grade and clinical outcomes in EVT patients.

Results: Overall, 253 of 255 (99.2%) patients randomized to EVT had final meTICI scores, of whom 133 (52.2%) achieved meTICI 2c-3 reperfusion. Infarct volumes were lower in EVT meTICI 2c-3 patients than in usual care patients, but there were no significant differences between EVT meTICI 2c-3 and usual care patients for 90-day modified Rankin Scale (mRS) score (adjusted common OR 1.17, 95% CI 0.79 to 1.75). Higher final meTICI scores were associated with improved 90-day mRS and lower infarct volumes in EVT patients.

Conclusion: Although higher reperfusion grade was associated with smaller infarct volumes, there was no statistically significant difference in 90-day mRS between patients achieving meTICI 2c-3 and those receiving usual care.

Background: Randomized trials have not shown a clear benefit of endovascular therapy (EVT) for medium vessel occlusion (MeVO) strokes. We aimed to identify subgroups in which successful recanalization provides meaningful clinical benefit.

Methods: We retrospectively analyzed prospectively recorded consecutive patients with MeVO stroke treated with EVT at two comprehensive stroke centers. Successful recanalization was defined as expanded Thrombolysis in Cerebral Infarction (eTICI) 2b-3. The treatment effect was calculated as the difference in 90-day functional independence (modified Rankin Scale score 0-2) between recanalized and non-recanalized patients. Predicted infarct core on admission was calculated on non-contrast CT using AI-based software (AI-ICV; Methinks AI) and on CT perfusion (cerebral blood flow (CBF) <30%; IschemiaView). The hypoperfused volume (Tmax >6 s) was also obtained and the perfusion mismatch ratio was calculated (Tmax >6 s - CBF <30%)/Tmax >6 s). The treatment effect was analyzed in the overall cohort and after applying enrichment strategies based on clinical and imaging variables. Optimal cutoffs were identified by maximizing the added treatment effect while retaining ≥40% of the cohort.

Results: Among 232 EVT-treated patients (mean age 76.1±12.3 years; median (IQR) National Institutes of Health Stroke Scale (NIHSS) score 9 (6-14)), the recanalization rate was 84.9%. The overall treatment effect was +33.3% (recanalized 53.3% vs non-recanalized 20.0%). Enrichment strategies increased the treatment effect: age ≤80 years (+13.8%), AI-ICV ≤9 mL (+9.9%), and NIHSS score ≥10 (+6.7%). Combining age, NIHSS, and AI-ICV criteria increased the treatment effect to 61.9% for an added value of +33.6%.

Conclusions: In MeVO stroke, the benefit of successful recanalization is substantial and can be further enhanced through pragmatic enrichment using readily available clinical and imaging variables, supporting refined patient selection and future trial design focused on enriched subgroups.

Background: The SpineJack system is a minimally invasive device designed to restore vertebral height and stability in vertebral compression fractures (VCFs). This systematic review and meta-analysis evaluates its clinical efficacy, safety, and potential advantages over conventional treatments.

Methods: A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. PubMed, Embase, and Scopus were searched on July 20, 2024, for original clinical studies involving adult patients with VCFs treated using the SpineJack system. Studies reporting quantitative outcomes such as pain (Visual Analog Scale, VAS), disability (Oswestry Disability Index, ODI), and vertebral body height (VBH) restoration were included. Data were pooled using random-effects models, and publication bias was assessed through funnel plots and regression analysis.

Results: 18 studies comprising 1482 patients (930 treated with SpineJack) met the inclusion criteria. Fracture etiologies included osteoporotic, traumatic, and pathologic. Meta-analysis demonstrated significant reductions in pain (VAS standardized mean difference (SMD) 2.26, 95% CI 1.68 to 2.84, P<0.001) and disability (ODI SMD 3.64, 95% CI 2.91 to 4.38, P<0.001). Restoration of anterior VBH (SMD 1.45, 95% CI 1.12 to 1.78, P<0.001, I²=0%), and middle VBH (SMD 3.93, 95% CI 1.51 to 6.34, P=0.001) were both significant. Reported complications were infrequent and primarily minor.

Conclusion: The SpineJack system provides a safe and effective minimally invasive option for VCF management, yielding considerable improvements in pain relief, functional recovery, and vertebral height restoration. Additional high-quality studies are warranted to further define its comparative advantages and long-term outcomes.

Background: Acute ischemic stroke due to large-vessel or medium-vessel occlusion is often treated with aspiration thrombectomy. Delivery-assist catheters (DAsCs) are a new class of tapered support catheters designed to facilitate navigation of large-bore aspiration catheters through tortuous anatomy.

Objective: To perform a meta-analysis to evaluate the procedural efficacy and safety of DAsC-assisted aspiration thrombectomy.

Methods: A PRISMA-guided systematic review identified studies using DAsCs during aspiration thrombectomy for large- or medium-vessel occlusions. We extracted data on successful reperfusion; first pass effect (FPE), defined as modified Thrombolysis in Cerebral Infarction (mTICI) ≥2b (FPE≥2b) and mTICI≥2c (FPE≥2); use of adjunctive devices; and symptomatic intracranial hemorrhage (sICH). Pooled event rates with 95% CIs were calculated using a random-effects meta-analysis of proportions.

Results: 14 studies were identified with 720 patients. Pooled successful reperfusion was 95% (95% CI 91 to 97%) for final mTICI ≥2b and 71% (95% CI 59% to 81%) for final mTICI ≥2c. FPE ≥2c was achieved in 51% (95% CI 43% to 59%) of cases, while FPE ≥2b was 65% (95% CI 54% to 75%). Adjunctive rescue devices were used in 23% (95% CI 17% to 30%) of procedures. Puncture-to-recanalization time was 26.1 min on average. The rate of sICH was 1% (95% CI 0% to 3%), and 44% (95% CI 39% to 50%) of patients had a 90-day modified Rankin Scale score of 0-2.

Conclusions: In pooled analysis, DAsC-assisted aspiration thrombectomy demonstrated high first pass efficacy and low hemorrhagic rates across single-arm studies. This meta-analysis supports DAsCs as a safe adjunct to aspiration thrombectomy. Prospective comparative studies are warranted to evaluate technical performance and safety relative to standard aspiration techniques.

Background: Endovascular treatment of intracranial aneurysms has significantly advanced, with the Woven EndoBridge (WEB) device emerging as a promising option for wide-necked aneurysms. The latest iteration, WEB-17, allows for delivery through a smaller microcatheter but has a reduced number of wires in comparison with the previous WEB-21 system.

Objective: To evaluate the safety and efficacy of WEB-17 in ruptured aneurysms.

Methods: A retrospectively analyzed single-center study of a prospectively maintained registry including 200 patients with ruptured intracranial aneurysms treated with either the WEB-21 or WEB-17 system. Procedural complications, including rebleeding and vasospasm, were analyzed and compared between the two cohorts. Postoperative follow-up assessed aneurysm occlusion rates and clinical outcomes.

Results: The WEB-17 system was used in 65% of cases, while WEB-21 was used in 35%. No significant differences were found in baseline patient characteristics. In addition, no significant differences were found between periprocedural complications, aneurysmal rebleeds, and delayed cortical ischemia. However, there were more aneurysm remnants and more retreatments with the WEB-17.

Conclusion: Both WEB systems demonstrated good safety and efficacy in the treatment of ruptured intracranial aneurysms. The WEB-17 system, however, demonstrated significantly lower complete occlusion rates and a trend towards increased retreatment rates. Further studies are required to confirm long-term outcomes or to detect smaller group differences.

Background: Intracranial atherosclerotic stenosis (ICAS) is a leading cause of ischemic stroke, often requiring endovascular treatment in cases refractory to medical therapy. Stent angioplasty is the most common intervention, but it carries risks such as restenosis and thromboembolic events. Drug-coated balloons or drug-eluting balloons (DCB/DEBs) have emerged as a promising alternative, delivering antiproliferative agents without permanent implantation. This study aims to compare clinical and procedural outcomes of DCB/DEBs versus stent angioplasty in patients with symptomatic ICAS.

Methods: A systematic review and meta-analysis was conducted according to PRISMA guidelines (PROSPERO: CRD42024616346). Six studies comprising 527 patients (233 DCB/DEB, 294 stenting) were included. Outcomes assessed included restenosis rates, periprocedural complications, and recurrent ischemic events.

Results: DCB/DEBs significantly reduced the risk of restenosis (RR 0.25; 95% CI 0.15 to 0.40; I²=0%) compared with stents. For periprocedural complications, no significant difference was observed (RR 0.65; 95% CI 0.32 to 1.33; I²=0%). In terms of recurrent ischemic events, DCB/DEBs were associated with a significant reduction (RR 0.30; 95% CI 0.13 to 0.67; I²=0%).

Conclusion: DCB/DEBs appear to offer significantly lower restenosis rates and fewer recurrent ischemic events compared with conventional stenting for symptomatic ICAS, without increasing periprocedural complications. While data on long-term outcomes remain limited, DCB/DEBs may represent a less invasive and potentially safer endovascular option. Further randomized trials are warranted to define its role in clinical practice.

Background and purpose: Durable outcomes with neurovascular stents require balancing antithrombotic performance with rapid endothelialization. We previously developed an amine-functionalized surface modification (Anti-thrombus formation, Endothelial-growth promotion, tissue Integration, and Surface; AEGiS Technology) with antithrombotic behavior. In this study we evaluated its pro-endothelialization properties and explore the mechanism.

Methods: Adsorption of extracellular matrix proteins from human plasma was profiled on AEGiS-modified versus control NiTi surfaces with an a priori focus on vitronectin. Human umbilical vein endothelial cell (HUVEC) adhesion was quantified by attached cell numbers and post-wash retention as a measure of adhesion strength. Migration and surface coverage were assessed in an in vitro endothelialization model designed to mimic stents on vessel walls. For translation, self-expanding stents bearing AEGiS or control coatings were deployed in a porcine model and endothelial coverage at 1 week was quantified by angiography and histology.

Results: The AEGiS surface selectively increased vitronectin adsorption compared with the control surface. Consistent with this shift, AEGiS supported greater HUVEC adhesion and stronger retention. In the endothelialization model, AEGiS accelerated coverage of the substrate compared with the control. In vivo, AEGiS-modified stents showed greater endothelial coverage at 1 week than control stents.

Conclusions: Amine functionalization enriched vitronectin adsorption and supported early endothelial coverage, indicating its potential to promote endothelialization of neurovascular stents.

Background: Accurate device sizing is crucial for successful flow diverter (FD) therapy in intracranial aneurysms. This study assesses the accuracy and clinical utility of the Ankyras virtual simulation software (Mentice AB, Gothenburg, Sweden) in predicting FD length across multiple device types and manufacturers.

Methods: We retrospectively analyzed 193 FDs (7 device types) deployed in 180 patients with 230 intracranial aneurysms. Simulation-based prediction of effective lengths (simulated length (SL)) and nominal manufacturer specifications (labeled length) were compared with measured in vivo lengths (measured length (ML)). Performance was evaluated using simulation accuracy (SA), absolute error (AE), relative error (RE), length ratio, and correlation analysis.

Results: Virtual simulation demonstrated good clinical usability, achieving a mean absolute deviation of only -1.38 mm at the proximal landing zone compared with ML. Simulation-based predictions showed significantly superior accuracy compared with nominal manufacturer specifications (SA 89.6±11.3% vs 81.8±13.7%, P<0.001), with mean AE reduced by 58% (-1.38 mm vs -3.34 mm) and mean RE by 42% (10.5% vs 18.2%). Strong correlations between SL and ML (r=0.900) validated predictive reliability across all tested device types. Centerline correction technology further enhanced parameters such as SA to 94.8±9.5%.

Conclusion: Virtual simulation-based prediction of effective FD length using the Ankyras software showed reliable and clinically meaningful results, enabling accurate estimations of the proximal landing zone and overall length. Ankyras, along with comparable simulation platforms, may provide considerable potential to facilitate FD selection and implementation, especially in anatomically complex cases.