Journal of NeuroInterventional Surgery最新文献

Background: Transcranial Doppler (TCD) is a non-invasive, bedside tool that allows for real-time monitoring of the patient's hemodynamic status following mechanical thrombectomy (MT). This systematic review and meta-analysis aims to evaluate the predictive value of TCD parameters following successful MT (Thrombolysis in Cerebral Infarction 2b-3).

Methods: In July 2024, we searched PubMed, Embase, and Scopus, to identify observational studies in which TCD parameters were measured within 48 hours of MT. Using random-effects models, we compared four TCD parameters (mean flow velocity (MFV), MFV index, pulsatility index (PI), and peak systolic velocity (PSV) among groups with vs without hemorrhagic transformation (HT) and favorable vs poor functional recovery (modified Rankin Scale 0-2 vs 3-6).

Results: Eleven studies comprising 1432 patients (59% male; mean age range: 63-73 years) were included. The MFV and MFV index were higher in patients with HT (Hedges' g=0.42 and 0.54, P=0.015 and 0.005, respectively). Patients with MFV index ≥1.3 showed a higher risk of all HT (RR 1.97; 95% confidence interval (CI) 1.28 to 3.03, P=0.002), symptomatic HT (RR 4.68; 95% CI 1.49 to 14.65, P=0.008), and poor functional status at 90 days (RR 1.65; 95% CI 1.27 to 2.14, P=0.029), respectively. There was no difference in mean PSV (P=0.1) and PI (P=0.3) among groups with and without HT.

Conclusion: This study underscores the prognostic value of the MFV index in predicting HT, symptomatic HT, and poor functional recovery after successful MT in the anterior circulation. Large-scale, multi-center studies are necessary to confirm these findings and to validate the MFV index as a reliable predictor for improving post-thrombectomy care.

Background: The choice of angiography system could influence the outcomes of mechanical thrombectomy (MT) in the treatment of acute ischemic stroke (AIS), but its impact is not yet well understood. This study aims to compare the clinical and technical outcomes of MT performed with single plane versus biplane angiography systems.

Method: We conducted a systematic review and meta-analysis, following PRISMA guidelines, by searching PubMed, Embase, Web of Science, and Scopus to include studies on patients with AIS who underwent MT with either single plane or biplane angiography up to May 4, 2024. The primary outcome was a favorable outcome defined as a modified Rankin Scale (mRS) score of 0-2 at 90 days after the procedure. Data were analyzed using a random-effects model and heterogeneity was assessed using the I² test and Q statistics.

Results: Five studies with a total of 1562 patients were analyzed. Of these, 68.4% were treated with biplane systems and 31.6% with single plane systems. Single plane angiography was associated with a significantly higher rate of favorable outcomes (OR 1.43; 95% CI 1.13 to 1.80; P<0.01). There were no significant differences in successful recanalization, periprocedural complications, procedure time, total fluoroscopy time, or contrast volume between the two systems.

Conclusion: While single plane angiography systems may offer slightly better outcomes in MT for AIS, both systems appear equally effective in most clinical and technical perspectives, suggesting that system selection may be more dependent on availability and procedural requirements rather than inherent superiority. Our findings may encourage clinicians to use single-plane angiography in settings where the biplane angiography suite availability is limited, but it should be noted that this observation may have been influenced by selection bias, particularly since the larger studies included in our meta-analysis did not observe this effect in adjusted analyses for potential confounder factors.

Introduction: Mechanical thrombectomy is a highly effective treatment for acute ischemic stroke (AIS) caused by large vessel occlusions (LVO). However, our understanding of the pathophysiology of AIS is still limited, particularly regarding the ischemic microenvironment distal to the occlusion.

Aim: To investigate the relationship between the intracerebral blood pressure (BP) distal to an LVO and clinical and imaging parameters.

Methods: In this single-center prospective study, intracerebral BPs proximal and distal to the occluding clot were measured during thrombectomy in patients with AIS of the anterior circulation caused by LVO. BPs were correlated with imaging parameters and clinical data using Spearman's rank correlation and linear regression.

Results: 25 patients were included. A significant correlation was found between the mean arterial pressure (MAP) distal to the occlusion and the baseline Alberta Stroke Program Early CT Score (Spearman r=0.503, P=0.014) and baseline National Institutes of Health Stroke Scale score (r=-0.439, P=0.036). No significant correlation was observed between the MAP distal to the occlusion and collateral scores (eg, MAP vs American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology score (r=0.307, P=0.165) or modified Rankin Scale (mRS) score (pre-mRS vs 90-day mRS; r=0.013, P=0.952)). Systemic MAPs did not correlate with the MAP distal to the clot (eg, R²=0.029, P=0.593).

Conclusion: The intracerebral BP measured in the ischemic vasculature distal to the LVO correlates with the extent of the ischemic core and the clinical severity at baseline, but not with collateral scores, systemic BPs, or functional outcome. These results shed light on the pathophysiology of BP mechanisms in AIS and can be the basis for further research in this field.

Background: The management of acute ischemic stroke due to isolated posterior cerebral artery occlusion (iPCAO) remains a topic of debate. This study investigates the efficacy and safety of endovascular treatment (EVT) versus best medical treatment (BMT) in patients with iPCAO.

Methods: A systematic search was conducted across electronic databases including PubMed, Embase, and the Cochrane Library. Controlled studies comparing EVT and BMT in patients with iPCAO were selected. The primary efficacy outcome assessed was excellent outcome, defined as a modified Rankin Scale (mRS) score of 0-1. The primary safety outcome was symptomatic intracranial hemorrhage (sICH). Secondary outcomes included functional independence (mRS 0-2), early neurological improvement (ENI), and mortality rates. Statistical analyses were conducted using random effects models.

Results: Eleven retrospective cohort studies involving 1811 patients with EVT and 2871 patients with BMT were analyzed. Compared with BMT, EVT was associated with a higher likelihood of an excellent outcome (adjusted OR (aOR) 1.33, 95% CI 1.14 to 1.54) and ENI (aOR 1.66, 95% CI 1.39 to 1.98), but no significant difference in functional independence (aOR 1.02, 95% CI 0.88 to 1.18). Compared with BMT, EVT may not be associated with an increased risk of sICH in patients with iPCAO (aOR 1.34, 95% CI 0.60 to 3.02) or mortality (aOR 1.31, 95% CI 0.83 to 2.08), although heterogeneity was high.

Conclusions: EVT may improve the likelihood of an excellent outcome and ENI in patients with iPCAO. However, the potential risks of sICH and mortality warrant consideration. Randomized trials are required to establish the definitive efficacy and safety of EVT in this patient population.

Background: Ticagrelor, a P2Y12 inhibitor, offers a rapid onset and consistent platelet inhibition, making it a viable alternative for dual antiplatelet therapy (DAPT). The optimal ticagrelor dose for neurointerventional procedures, however, remains unclear. We report our experience with ticagrelor 60 mg twice daily plus aspirin 81 mg daily compared with the standard aspirin and clopidogrel regimen for intracranial stenting.

Methods: We conducted a retrospective analysis of a prospectively maintained database, identifying consecutive patients who underwent intracranial stenting for aneurysm treatment or intracranial atherosclerosis. Patients received either ticagrelor 60 mg with aspirin or aspirin with clopidogrel 75 mg daily. Primary outcomes included peri-procedural ischemic and/or hemorrhagic events within 30 days. Secondary outcomes were the median P2Y12 reaction unit and in-stent stenosis rates at 6-month follow-up.

Results: Among 119 patients, 59 received ticagrelor and 60 (50.4%) received clopidogrel. Baseline characteristics including age and gender were comparable between the two groups, although the ticagrelor group had a higher proportion of African-American patients. The majority of patients underwent aneurysm treatment (n=105; 88.23%), while the remainder received stenting for intracranial atherosclerosis (n=14; 11.77%). No ischemic events occurred in either group and intracranial hemorrhage rates were comparable (1.7% in both groups). The median P2Y12 reaction unit was significantly lower in the ticagrelor group (69 vs 126, P<0.001). In-stent stenosis rates were lower with ticagrelor (5% vs 21%).

Conclusion: Ticagrelor 60 mg for DAPT in intracranial stenting is safe and effective. Larger prospective studies may be required to validate these findings.

Background: Middle meningeal artery embolization (MMAE) is a safe and effective treatment for chronic subdural hematoma (cSDH); however, the appropriate level of postoperative care is unknown.

Objective: To evaluate whether elective MMAE for cSDH could be safely performed in an outpatient setting.

Methods: This was a multicenter, retrospective study of patients with cSDH who underwent elective MMAE. Patients were categorized as either inpatient (admitted for ≥1 night of hospitalization after MMAE) or outpatient (discharged on the same day of MMAE). Patient demographics, radiological data, procedural details, and follow-up data were collected. The primary endpoint was periprocedural complications, and secondary outcomes included emergency department (ED) visits or unplanned readmission within 24 hours, 1-7 days, and 8-30 days after MMAE.

Results: Elective MMAE procedures were carried out in 190 patients, of which 45.3% (n=86) were outpatient procedures and 54.7% (n=104) inpatient. There were 7 (3.7%) periprocedural complications (one outpatient, six inpatient; P=0.12). Five patients presented to the ED and were readmitted within 24 hours of MMAE (three outpatient, two inpatient). Six patients presented to the ED 1-7 days after MMAE (three outpatient, three inpatient); three were subsequently admitted (one outpatient and two inpatient). Nine patients presented to the ED 8-30 days after MMAE (two outpatient and seven inpatient); three were subsequently readmitted (all inpatient). No elective outpatient MMAE resulted in a readmission attributable to the procedure within the examined time frame.

Conclusion: Elective MMAE can be safely performed as an outpatient procedure without increased risk of postprocedural adverse events in most eligible patients with cSDH.

Background: Arteriovenous malformations (AVMs) are uncommon cerebral lesions that can cause significant neurological complications. Surgical resection is the gold standard for treatment, but endovascular embolization and stereotactic radiosurgery (SRS) are viable alternatives.

Objective: To compare the outcomes of endovascular embolization versus SRS in the treatment of AVMs with Spetzler-Martin grades I-III.

Methods: This study combined retrospective data from 10 academic institutions in North America and Europe. Patients aged 1 to 90 years who underwent endovascular embolization or SRS for AVMs with Spetzler-Martin grades I-III between January 2010 and December 2023 were included.

Results: The study included 244 patients, including 84 who had endovascular embolization and 160 who had SRS. Before propensity score matching (PSM), complete obliteration at the last follow-up was achieved in 74.5% of the SRS group compared with 57.8% of the embolization group (OR=0.47; 95% CI 0.26 to 0.48; P=0.01). After propensity score matching, SRS still achieved significantly higher occlusion rates at last follow-up (78.9% vs 55.3%; OR=0.32; 95% CI 0.12 to 0.90; P=0.03).Hemorrhagic complications were higher in the embolization group than in the SRS group, although this difference did not reach statistical significance after PSM (13.2% vs 2.6%; OR=5.6; 95% CI 0.62 to 50.47; P=0.12). Similarly, re-treatment rate was higher in the embolization group (10.5% vs 5.3%; OR=2.11; 95% CI 0.36 to 12.31; P=0.40) compared with the SRS group.

Conclusion: Our findings indicate that SRS has a significantly higher obliteration rate at last follow-up compared with endovascular embolization. Also, SRS has a higher tendency for fewer hemorrhagic complications and lower re-treatment rate. Further prospective studies are needed.

Background: Post-recanalization target vessel re-occlusion (TVR) following endovascular thrombectomy (EVT) is a known complication of the procedure, and it is associated with worse long-term functional outcomes. The incidence and factors that contribute to TVR are not well understood, particularly within the immediate timeframe following EVT.

Methods: A prospective, multicenter study was performed across four comprehensive stroke centers on adult patients undergoing EVT for acute large vessel occlusion. Modified Thrombolysis in Cerebral Infarction (TICI) score was recorded at the end of the standard procedure, and another TICI score was recorded 10 min later to evaluate for TVR.

Results: 167 patients underwent EVT for a large vessel occlusion, 93.4% of which were in the anterior circulation. Twenty-seven patients (16.2%) had a change in their TICI score 10 min after EVT, with 19 of these patients (70%) having a worsening in their score. Of the total sample, 13% had their post-procedure care altered by any intervention, and 8% underwent further endovascular interventions due to the change in reperfusion over the 10 min time period. Functional independence (modified Rankin Scale score 0-2) at 90 days was observed in 31% of the entire cohort and in 21% of patients with a worse TICI score at 10 min.

Conclusions: This is the first study to prospectively assess for TVR in the immediate timeframe following EVT. One in six patients had a change in their TICI score, and one in 11 patients had additional intervention. Accordingly, neurointerventionalists should consider integrating angiographic evaluation at 10 min following EVT.