Journal of NeuroInterventional Surgery最新文献

Background: Early literature on the Woven EndoBridge (WEB) device reported 80-90% adequate aneurysm occlusion but low complete occlusion (40-55%). It is uncertain whether residual or recurrent aneurysms require re-treatment to prevent future rupture.

Objective: To systematically review the literature to meta-analyze occlusion and complication rates after re-treatment of these aneurysms.

Methods: PubMed and EMBASE were queried for 're-treatment' of 'recurrent' or 'residual' aneurysms treated with the WEB device. Studies reporting strategies and outcomes were included. Patient and aneurysm characteristics, outcomes, and complications were extracted. Meta-analyses were conducted on variables reported by three or more studies.

Results: We included 15 studies of 220 patients (220 aneurysms) with a mean age of 57.8 years (95% CI 55.1 to 60.7 years). At baseline, 42.8% (95% CI 35% to 51%) of aneurysms were ruptured, had a mean 8.6 mm dome (95% CI 7.3 to 10 mm) and a mean 5.2 mm neck (95% CI 4.7 to 5.7 mm), and 69.85% were at bifurcations (95% CI 47.63% to 85.51%). At mean 11.2 months' follow-up (95% CI 8 to 15.6 months), 75.9% (95% CI 66.1% to 83.5%) had residual dome filling, predominantly from incomplete occlusion in 84.7% of cases (95% CI 66.6% to 93.9%). Endovascular management was used in 82.5% (95% CI 72.6% to 89.3%) of recurrences, with stent-assisted or flow diverter-assisted coil embolization being used in 42.4% (95% CI 32.7% to 52.8%). Overall, complication rates were 8.9% (95% CI 4.9% to 15.6%) thromboembolic and 8% (95% CI 4.3% to 14.2%) device-related. Complete angiographic occlusion after re-treatment was achieved in 64.1% (95% CI 52.6% to 74.2%), of patients, with 15.2% (95% CI 8.8% to 24.9%) requiring additional re-treatment.

Conclusion: Our review reports excellent safety and modest occlusion outcomes with re-treatment of recurrent or residual aneurysms post-WEB embolization. Outcomes with observational management of residual or recurrent aneurysms are lacking, questioning the requirement for re-treatment. Endovascular strategies demonstrated excellent safety and additional re-treatment rates, highlighting their expanding role in post-WEB recurrences.

Background: Numerous scoring systems have been developed to individualize estimation of functional outcome after endovascular thrombectomy (EVT) of acute ischemic stroke. The aim of our study was to assess their utility for clinical practice based on a large cohort from real-world care of EVT.

Methods: For 13 082 patients included in the German Stroke Registry Endovascular Treatment (GSR-ET) (July 2015 to December 2021), we calculated the following prognostic tools: pre-interventional PRE-, Totaled Health Risks in Vascular Events - Endovascular therapy (THRIVE-EVT)- and Computed Tomography for Late Endovascular Reperfusion (CLEAR) scores and post-interventional MR PREDICTS@24 hours and BET-score. Area under the receiver operating characteristic curve (AUC) analyses in the total cohort and pre-defined subgroups were performed to determine each tool's prognostic value for good functional outcome (modified Rankin Scale (mRS) 0-2) and mortality at 90-day follow-up.

Results: All pre-interventional tools achieved a moderate prognostic value for predicting good functional outcome (PRE: AUC (95% confidence interval): 0.757 (0.747-0.768), THRIVE-EVT: 0.751 (0.740-0.761), CLEAR: 0.731 (0.72-0.742)), had a higher predictive value than the admission National Institute of Health Stroke Scale ((NIHSS); 0.705 (0.694-0.716), all P<0.001), but were inferior to the NIHSS 24 hours after EVT (0.864 (0.855-0.872), all P<0.001). Predictive capacity for mortality was less accurate (AUC range: 0.697-0.729). Subgroup analyses revealed that the PRE-score was most robust at predicting good functional outcome, whereas the THRIVE-EVT score was superior in predicting mortality. Post-interventionally, MR PREDICTS@24 hours yielded high predictive accuracy for good functional outcome and mortality (both AUC >0.85), superior to 24-hour NIHSS for all subgroups, except patients <50 years of age.

Conclusion: Pre-interventional scoring tools predict functional outcome after EVT better than stroke severity alone. Post-interventionally, the MR PREDICTS@24 hours tool adds predictive value to the 24-hour NIHSS as a single prognostic feature. Multivariate prognostic tools incorporating (post-)procedural information enable individualization of prognosis assessment after EVT under routine-care conditions.

Background: This study assessed caliber and flow changes of covered cortical middle cerebral artery (MCA) branches using the new Caliber-Flow Status Scale (CFSS), postoperative diffusion-weighted imaging (DWI) lesions, and clinical outcome following flow diverter (FD) treatment of MCA aneurysms.

Methods: This single-center retrospective study collected data from patients treated with FD between January 2016 and March 2024, including patient characteristics, aneurysm features, postoperative DWI lesions, and clinical outcomes. Vessel status was assessed using CFSS: 1a (normal caliber and flow), 1b (normal caliber, reduced flow), 2a (reduced caliber, normal flow), 2b (reduced caliber and flow), and 3 (occlusion).

Results: Thirty-nine patients with 41 aneurysms with 63 covered MCA branches were included. Immediately after FD deployment, 63.5% of covered branches retained normal caliber and flow (CFSS 1a) while the remaining branches with compromised caliber and flow (CFSS >1a) showed significant improvement following tirofiban administration. Intraoperative thromboembolic complications led to occlusion in three branches, all restored after tirofiban without clinical symptoms (P=0.003). At 6 months, 79% of covered branches showed normal flow with or without caliber reduction (CFSS 1a/2a). DWI lesions showed no significant correlation with caliber and flow changes and clinical symptoms.

Conclusions: FD treatment for MCA aneurysms leads to significant but primarily asymptomatic CFSS changes in covered cortical branches within the first 6 months. Intra-arterial tirofiban effectively improves vessel status in branches with higher CFSS (>1a). CFSS is valuable for tracking these changes and underscores the importance of long-term follow-up.

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.

Background: Endovascular stenting is a promising treatment for patients with idiopathic intracranial hypertension (IIH) and venous sinus stenosis (VSS). However, data on the impact of stenosis type on clinical outcomes of patients undergoing stenting treatment remain limited. This prospective cohort study aimed to compare post-stenting outcomes in patients with IIH and intrinsic versus extrinsic VSS.

Methods: Patients with IIH and VSS undergoing stenting at a tertiary hospital in China were enrolled consecutively from 2017 to 2023. Based on digital subtraction angiography, high-resolution MRI, and intravascular ultrasound findings, patients were categorized into two groups: intrinsic or extrinsic stenosis. At 6 months post-stenting, clinical outcomes including cerebrospinal fluid (CSF) pressure, headache, visual impairment, and papilledema were recorded. Multivariable regression models were used to explore the relationship between stenosis type and clinical outcomes.

Results: In total, 92 patients were included, 60 with intrinsic stenosis and 32 with extrinsic stenosis. At 6 months, the intrinsic group had lower CSF pressure (median 180 vs 210 mmH₂O, β coefficient -31.8, 95% CI -54.0 to -9.6) and a higher rate of complete symptom resolution (81.7% vs 40.6%, OR 8.88, 95% CI 2.60 to 30.30) than the extrinsic group. Additionally, 36.8% (95% CI 10.5% to 77.2%) of the effect of stenosis type on complete symptom resolution at 6 months was mediated through reduction in CSF pressure.

Conclusion: This single-center study suggested that patients with IIH and intrinsic VSS had lower CSF pressure and better symptom recovery compared with those with extrinsic VSS at 6 months post-stenting. Further validation in other centers and populations is needed.

Trial registration number: ChiCTR.org.cn, ChiCTR-ONN-17010421.

Background: Vertebral hemangiomas are incidental and typically, asymptomatic lesions of the spine, present in 10-12% of the population. However, aggressive vertebral hemangiomas (AVHs) can compromise the spinal canal, leading to spinal cord or nerve root compression, and require timely treatment to prevent permanent neurological deficits. Surgical management is challenging owing to the high vascularity of AVHs, and carries a significant risk of perioperative blood loss. Intraosseous ethanol injection is commonly used for sclerotization, but may not adequately deal with epidural components.

Objective: To carry out a staged treatment with an image-guided puncture and ethanol injection of the epidural component in 12 patients.

Methods: We retrospectively analyzed 12 patients with symptomatic AVHs who underwent targeted epidural ethanol injection followed by vertebral body cement augmentation, between 2017 and 2024, at three tertiary hospitals. Data collection included pre- and post-treatment imaging and clinical outcomes.

Results: Among 12 patients (mean age 50, women 50%), all had extensive epidural involvement and were symptomatic, including spinal cord compression and pain. Reduction in size of more than 75% of the epidural hemangioma was achieved in 8 cases, with 11 patients experiencing complete symptom resolution. Laminectomy was performed in 3 cases, while corpectomy was avoided in all cases. Two patients had neurological worsening, with one achieving complete resolution and the other having mild residual impairment after rehabilitation due to a small spinal cord ischemic lesion. No other major complications occurred.

Conclusion: Direct epidural ethanol injection provides a minimally invasive alternative to surgery, such as corpectomy, including rapid size reduction of the compressive epidural component, and potentially, prevents retrograde flow into arterial collaterals. Adding vertebroplasty enhances vertebral stability.

Background: Intrasaccular devices have broadened treatment options for wide necked aneurysms. This study presents the preliminary experience with the Artisse 2.0 device.

Methods: Innovative NeurovaScular Product SurveIllance REgistry (INSPIRE) is a non-randomized, multicenter, real world clinical study with treatment arms for aneurysms (INSPIRE-A) and acute ischemic stroke (INSPIRE-S). This interim analysis included 87 patients enrolled from November 2022 to April 2024 in the INSPIRE-A Artisse cohort across 16 Europoean centers. Procedures followed standard clinical care, with 6 months of follow-up. Safety and efficacy endpoints included major stroke, neurological death, serious adverse events (SAEs), aneurysm occlusion, and retreatment rates. An independent core laboratory assessed imaging, and all SAEs were reviewed by a clinical events committee. The Artisse steering committee provided independent oversight of the data.

Results: The Artisse device achieved an overall successful implantation rate of 96.6% (84/87), with satisfactory placement rates of 98.7% (74/75) for unruptured and 88.9% (8/9) for ruptured aneurysms. Following the procedure, 46.2% of unruptured aneurysm patients were receiving antiplatelet therapy (APT), predominantly aspirin monotherapy, while no ruptured aneurysm patients received APT. Device related SAE rate was 1.3% (1/87), and the overall stroke rate was 2.3% (2/87), including both ruptured and unruptured aneurysms. At 6 months, 80.0% (28/35) of patients with unruptured aneurysms showed complete obliteration, with no recurrences or retreatments.

Conclusions: Preliminary experience with the Artisse 2.0 device demonstrated high technical success, favorable safety, and efficacy in aneurysm obliteration at 6 months. Larger studies with longer follow-up periods are needed to confirm these findings.

Background: We aim to share our experience of transradial access (TRA) for cerebral angiography and intervention in five patients ranging from 6 days to 7 months of age.

Methods: In this institutional review board-approved, retrospective case series, we reviewed all patients who underwent TRA for cerebral angiography with and without intervention. We describe three techniques for radial artery cannulation, namely: (1) bareback; (2) with a micropuncture sheath; and (3) with an intravenous catheter. Demographic, clinical, procedural, and imaging data were abstracted from the patients' medical records.

Results: From September 2019 to August 2023, five patients (median age and weight, 24 days (range 6-218 days) and 4.2 kg (range 3.2-6.2 kg)) underwent TRA for cerebral angiography. Four patients underwent diagnostic cerebral angiography, two via left TRA and two via right TRA. One patient was definitively treated with endovascular embolization for an arteriovenous fistula. Median procedural length was 1.5 hours (range 1-2.2 hours) and median effective skin dose was 88.7 mGy (range 48.8-140.3 mGy). No procedures required conversion to femoral artery access to obtain diagnostic quality imaging or to facilitate intervention. No complications related to the accessed radial artery were recorded.

Conclusions: We have demonstrated that TRA in the neonate and infant is feasible. In our experience this technique is safe and effective for diagnostic cerebral angiography. Additionally, select intervention via TRA in this population may be possible as demonstrated by our single example of endovascular management of an intracranial fistula.

Background: Recent advances in mechanical thrombectomy for large vessel occlusion suggest that cyclical aspiration (CyA) may enhance clot ingestion and reduce embolic complications compared with static aspiration (StA). We aimed to identify the experimental conditions under which CyA outperforms StA.

Methods: A 3D-printed neurovascular model in a flow loop (137/89 mmHg, 72 bpm) simulated middle cerebral artery M1 segment (MCA-M1) occlusions with soft and stiff clot analogs. CyA (4.5 Hz and Δp=85-105 kPa) was performed with a dual-solenoid device coupled to a vacuum pump. Eighty experiments were randomized into four treatment arms combining aspiration patterns and 0.071″ and 0.088″ aspiration catheters: CyA-71, CyA-88, StA-71, and StA-88.

Results: The overall first pass recanalization (FPR) rate was 74% (59/80), with CyA significantly outperforming StA (92% vs 55%, p<0.001). CyA achieved the highest FPR with both 0.088″ and 0.071″ catheters (95% and 90%, respectively), whereas StA-71 achieved 80% and StA-88 30%.Induction of vessel collapse markedly reduced FPR rates (86.2% without collapse vs 20% with collapse, p<0.001). Under StA, collapse was more frequent with larger catheters (StA-088: 70% vs StA-71: 0%, p<0.001), but CyA significantly mitigated this effect (StA-88: 70% vs CyA-88: 5%, p<0.05). No significant differences were found in distal embolization rates.

Conclusions: 0.088″ catheters may be more effective for retrieving clots, except in cases of arterial collapse. CyA improves recanalization rates by reducing the risk of collapse associated with super-large bore catheters. A deeper understanding of catheter sizing and neurovascular anatomy could further optimize outcomes.

Background: Emergent carotid artery stenting (eCAS) is increasingly used in acute stroke due to tandem occlusion. However, the optimal timing for initiating dual antiplatelet therapy (DAPT) remains unknown. We analyze the effectiveness and safety of early versus delayed initiation of DAPT in a cohort of patients with acute stroke treated with eCAS.

Methods: Multicenter registry of patients treated with eCAS from 2019 to 2023. Main outcomes were stent occlusion/restenosis during follow-up, symptomatic intracranial hemorrhage (sICH) after DAPT, and good functional outcome at 3 months (modified Rankin scale (mRS) 0-2). Two timeframes for early DAPT initiation were considered: <12 hours after the procedure, and <24 hours. DAPT beyond 24 hours was considered as reference.

Results: 309 patients were included, 215 males (69.6%), mean (SD) age 67 (12.8) years. DAPT was initiated after eCAS in 270 patients (87.4%), <12 hours in 98 (36.3%), <24 hours in 198 (73.3%), and >24 hours in 72 (26.7%). At 3 months follow-up, stent occlusion/restenosis occurred in 25 patients (12.3%), and sICH after DAPT in 8 patients (3%); 141 (58%) achieved mRS 0-2. Early DAPT did not modify the risk of stent occlusion/restenosis: OR for DAPT <12 hours and DAPT <24 hours: 0.82 (95% CI 0.28 to 2.41) and 0.94 (95% CI 0.37 to 2.40), respectively, or sICH (OR 2.08 (95% CI 0.21 to 20.48) and 2.42 (95% CI 0.29 to 20.03)). Similarly, early DAPT did not improve the likelihood of mRS 0-2 (OR 1.76 (95% CI 0.92 to 3.69) and OR 1.30 (95% CI 0.74 to 2.28)).

Conclusions: In this study, early DAPT initiation following eCAS did not modify the risk of late stent occlusion/restenosis, sICH, or the chance of achieving a good outcome at 3 months.