Journal of NeuroInterventional Surgery最新文献

Background: The angiographic shape of an occlusion, like the clot meniscus sign and the claw sign, has been reported to potentially impact the recanalization rate and clinical outcome in patients undergoing mechanical thrombectomy for acute ischemic strokes.

Method: Following PRISMA guidelines, a systematic literature search was conducted across PubMed, Scopus, Embase and Web of Science databases. Patients were grouped into clot meniscus/claw sign positive and negative groups based on the definitions obtained from each study. Primary outcomes included technical success, with a meta-analysis performed using a random-effects model to calculate proportions and odds ratios (OR) with 95% confidence intervals (Cl).

Results: We included seven studies recruiting 1572 patients. The results indicated that the positive and negative groups had comparable first-pass effect (OR 1.95; 95% CI 0.76 to 5.01; P=0.167) and final recanalization (OR 1.36; 95% CI 0.81 to 2.27; P=0.248) rates. However, the rate of having a favorable functional outcome was significantly higher in the positive group than in the negative sign group (OR 1.91; 95% CI 1.25 to 2.92; P<0.003). Within the sign-positive population, the use of contact aspiration was associated with a significantly higher rate of recanalization compared with using a stent retriever (OR 0.18; 95% CI 0.07 to 0.49; P<0.001). This result did not translate into a clinical impact, as both stent retriever and contact aspiration showed comparable rates of functional independence at 3 months (OR 0.22; 95% CI 0.02 to 2.33; P=0.210).

Conclusion: The presence of the clot meniscus/claw sign is not associated with recanalization outcomes after thrombectomy. However, it might be a good sign to predict which thrombectomy technique might be associated with better recanalization, although current evidence may need further confirmation.

Background: Acute ischemic stroke (AIS) often leads to significant morbidity and mortality. Mechanical thrombectomy (MT) is an effective intervention for large vessel occlusion strokes. However, hemorrhagic transformation (HT) remains a critical post-procedural complication. This study investigates the relationship between basal ganglia infarction (BGI) and the risk of HT, particularly focusing on hemorrhagic infarction (HI) and parenchymal hematoma (PH).

Methods: Data from the DIRECT-MT trial were analyzed. Patients were categorized based on the presence of BGI identified on initial non-contrast CT. HT was classified into HI and PH following the Heidelberg criteria. Multivariate logistic regression, propensity score matching (PSM), and inverse probability of treatment weighting (IPTW) were used to assess the association between BGI and HT.

Results: Among 607 patients, 273 had BGI. BGI was associated with a higher risk of HT, specifically PH. The incidence of PH in the BGI group was 20% compared with 11% in the non-BGI group. Adjusted analyses, including PSM and IPTW, confirmed the significant association between BGI and PH with an adjusted odds ratio (aOR) of 2.51 (95% CI 1.49 to 4.22, P<0.001). However, no significant association was found between BGI and HI.

Conclusions: BGI significantly increases the risk of PH following MT for AIS, underscoring the need for tailored therapeutic strategies in managing these patients. No significant correlation was observed between BGI and HI. Future research should explore the underlying mechanisms and validate these findings across diverse populations to improve patient outcomes.

Background: Hyperintense acute reperfusion marker (HARM) refers to delayed enhancement in the subarachnoid or subpial space on post-contrast fluid attenuated inversion recovery (FLAIR) images. HARM is a measure of blood-brain barrier breakdown, which has been correlated with poor outcomes in patients with acute ischemic stroke with large vessel occlusion (AIS-LVO). We hypothesized that unfavorable venous outflow (VO) would be correlated with HARM after thrombectomy treatment of AIS-LVO.

Objective: To determine whether poor VO is associated with HARM on follow-up MRI after stroke in patients with AIS-LVO.

Methods: Patients with AIS-LVO from the prospective CRISP2 and DEFUSE2 studies with a baseline CT angiography (CTA) scan and a follow-up MRI with FLAIR sequence were screened for enrollment. VO was measured on the baseline CTA scan using the cortical venous opacification score (COVES). HARM was determined on FLAIR sequences at the follow-up MRI. The primary outcome was the occurrence of HARM between those with good VO (VO+; COVES 3-6) and bad VO (VO-; COVES 0-2).

Results: 121 patients were included; 60.3% (n=73) had VO+ and 39.7% (n=48) had VO-. Patients with VO- had higher presentation National Institutes of Health Stroke Scale scores (18 (IQR 12-20) vs 12 (IQR 8-16) in VO+; P<0.001). Middle cerebral artery M1 segment occlusions were more common in VO- patients (65% vs 43% VO+; P=0.028). VO- patients also had a larger pre-treatment ischemic core (23 (4-44) mL vs 12 (3-22) mL in VO+; P=0.049) and Tmax >6 s volumes (105 (72-142) mL vs 66 (35-95) mL in VO+; P<0.001). VO- patients were more likely to develop HARM after thrombectomy (31% vs 10% in VO+; P=0.003). On multivariable regression analysis, VO- (OR=3.6 (95% CI 1.2 to 10.6); P=0.02) and the presence of any ICH (OR=3.6 (95% CI 1.2 to 10.5); P=0.02) were independently associated with the occurrence of HARM.

Conclusions: In patients with AIS-LVO, VO- correlated with HARM on post-thrombectomy MRI.

Background: This study aimed to elucidate the safety and efficacy of mechanical thrombectomy using the Versi Retriever in patients with acute ischemic stroke (AIS).

Methods: This was a prospective, multicenter, single-arm study conducted at 10 institutes in Japan from December 2018 to March 2021 on mechanical thrombectomy using the Versi Retriever in patients with AIS. The primary efficacy outcome was the modified Rankin scale (mRS) 0-2 at 90 days after the procedure. The primary safety outcome was mortality within 90 days after the procedure.

Results: Fifty-eight patients with a mean age of 72.7 years were enrolled in the study. The primary efficacy outcome of mRS 0-2 at 90 days was 62.0% (95% CI 47.2-75.3%) in patients within 8 hours of stroke onset. The rate of immediate reperfusion of Thrombolysis in Cerebral Infarction (TICI) grade 2b-3 using the Versi Retriever in three passes was 78.0% (64.0-88.5%). The rate of final reperfusion of TICI 2b-3 was 100% (92.9-100%). The primary safety outcome of mortality within 90 days was 8.0% (2.2-19.2%) in patients within 8 hours of AIS onset. The incidence of intracranial hemorrhage within 24 hours was 12.0% (4.5-24.3%) for symptomatic cases and 32.0% (19.5-46.7%) for asymptomatic cases.

Conclusion: The Versi Retriever proved to be a safe and effective option for mechanical thrombectomy in patients with AIS.

Background: Intravenous (IV) tenecteplase is increasingly being used in lieu of alteplase for acute ischemic stroke. We sought to study the influence of IV tenecteplase versus IV alteplase on the efficacy of first line thrombectomy strategy.

Methods: This was a secondary analysis of the Alteplase versus Tenecteplase (AcT) trial. We included anterior and posterior circulation stroke patients in whom a thrombectomy was attempted. We compared outcomes for stent retriever as first line strategy versus contact aspiration alone, and interactions with thrombolysis type. We examined angiographic outcomes (extended final thrombolysis in cerebral infarction (eTICI) 2c-3 after first-pass, eTICI 2b-3 and eTICI 2 c-3 on final angiography), and clinical and safety outcomes. Mixed effect regression analyses with interaction terms were performed. All outcomes were assessed and analyzed by blinded adjudicators.

Results: Among 506 patients who received thrombectomy, 435 were included (222 (51.0%) IV tenecteplase, 213 (49.0%) IV alteplase). A stent retriever was used as the first line endovascular thrombectomy (EVT) approach in 288 (66.2%), and aspiration in 147 (33.8%) patients. There was no difference in rates of final eTICI 2c-3 between groups (57.0% with stent retriever vs 61.9% with aspiration; P=0.35). There was, however, a significant interaction (P=0.02) between thrombolysis type and first line EVT strategy for final eTICI 2c-3, where tenecteplase was associated with higher odds of final eTICI 2c-3 with aspiration (adjusted OR (aOR) 2.29, 95% CI 1.10 to 4.75), but not with stent retriever (aOR 0.63, 95% CI 0.38 to 1.04). No significant interaction between thrombolysis and first line strategy was found for the other angiographic, clinical or safety outcomes.

Conclusion: IV tenecteplase before EVT may enhance reperfusion with first line aspiration.

Trial registration number: NCT03889249.

Background: Surveys are increasingly used in neurointervention to gauge physicians' and patients' attitudes, practice patterns, and 'real-world' treatment strategies, particularly in conditions for which few, or no evidence-based, recommendations exist. While survey-based studies can provide valuable insights into real-world problems and management strategies, there is an inherent risk of bias.

Objective: To assess key themes, sample characteristics, response metrics, and report frequencies of quality indicators of neurointerventional surveys.

Methods: A systematic review compliant with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was performed. The PubMed database was searched for neurointerventional surveys published between 2000 and 2023. Survey topics, design, respondent characteristics, and survey quality criteria suggested by the Consensus-Based Checklist for Reporting of Survey Studies (CROSS) were assessed and described using descriptive statistics. Response rates and numbers of participants were further assessed for their dependence on sample characteristics and survey methodologies.

Results: A total of 122 surveys were included in this analysis. The number of surveys published each year increased steeply between 2000 (n=1) and 2023 (n=14). The most common survey topics were stroke (51/122, 41.8%) and aneurysm treatment (49/122, 40.2%). The median response rate was 58.5% (IQR=30.4-86.3), with a median number of respondents of 79 (IQR=50-201). Sixty-eight of 122 (55.7%) surveys published the questionnaire used for data collection. Only a subset of studies reported response rates (n=89, 73%), data collection time period (n=91, 74.6%), and strategies to prevent duplicate responses (n=57, 46.7%).

Conclusion: Surveys are increasingly used by neurointerventional researchers, particularly to assess real-world practice patterns in endovascular stroke and aneurysm treatment. Adapting best-practice guidelines like the CROSS checklist might improve homogeneity and quality in neurointerventional survey research.

Background: This study aimed to perform a comprehensive pooled analysis of all published series involving pediatric patients with large vessel occlusion (LVO) undergoing endovascular treatment (EVT) to study the disease landscape including presentation, management, and outcomes.

Methods: The data used in this study were pooled from published literature on EVT for pediatric stroke spanning from 1980 to 2023. The relevant articles were carefully reviewed, and only those reporting at least one case of pediatric LVO undergoing EVT were included. Furthermore, pediatric patients with LVO who received EVT from the Chinese Pediatric Ischemic Stroke Registry database were also included. The primary outcome for this study was the unfavorable outcome after stroke. The risk factors influencing the outcomes of patients with pediatric stroke treated with EVT were analyzed using Cox proportional hazards models.

Results: A total of 221 pediatric patients who underwent EVT were included. During an average follow-up period of 6 months, 20.8% of patients had an unfavorable outcome. Multivariate Cox regression showed that patients with a higher Pediatric National Institutes of Health Stroke Scale (pedNIHSS) score (aHR=7.54, 95% CI 2.38 to 23.58) and unsuccessful reperfusion (aHR=5.84, 95% CI 2.86 to 11.93) were associated with an increased risk of unfavorable outcomes, while older age (aHR=0.27, 95% CI 0.09 to 0.82) was associated with a lower risk of unfavorable outcomes.

Conclusion: Following EVT treatment, a significant proportion of pediatric patients with LVO achieved favorable outcomes. However, factors such as the severity of the pedNIHSS score and unsuccessful reperfusion were found to be associated with a poorer prognosis.

Background: Accurately forecasting early neurological deterioration of ischemic origin (END_i) following medical management may aid in identifying candidates for thrombectomy. We aimed to develop and validate a nomogram to predict END_i in patients with mild large and medium vessel occlusion stroke intended for medical management.

Methods: Two hundred and forty-eight patients were enrolled (173 and 75 randomised into training and validation cohorts). The risk factors were identified using logistic regression analyses. A nomogram was constructed based on the risk factors identified. The discrimination, calibration, and clinical practicability of the nomogram were assessed using receiver operating characteristic curve (ROC) analysis, the Hosmer-Lemeshow test, and decision curve analysis (DCA), respectively.

Results: END_i was detected in 44 (17.7%) patients. Four predictors were identified in the training cohort and entered into the nomogram including age, symptom fluctuation characteristics, presence of core infarct, and occlusion site. ROC analysis showed that the area under the curve was 0.930 (95% CI 0.884 to 0.976) and 0.889 (95% CI 0.808 to 0.970) in the training and validation cohorts, respectively. The Hosmer-Lemeshow test yielded a mean absolute error of 0.025 and 0.038, respectively, for the two cohorts. The DCA showed that the nomogram model had superior practicality and accuracy across the majority of the threshold probabilities.

Conclusion: The proposed nomogram showed a favourable predictive performance for END_i in patients with mild large and medium vessel occlusion stroke intended for medical management. For such patients, immediate thrombectomy or at least intensive medical monitoring may be reasonable to avoid delays in rescue thrombectomy.