Journal of NeuroInterventional Surgery最新文献

Background: Patients with idiopathic intracranial hypertension (IIH) represent a unique population in whom mechanical shunting can be challenging. Endovascular cerebrospinal fluid shunting via the eShunt system has emerged as a potential alternative, but it is not currently approved for this indication, and its feasibility in IIH remains unknown.

Methods: In this retrospective, single center study, radiographic images of consecutively treated patients with shunt responsive IIH were assessed. Radiographic parameters involving the inferior petrosal sinus (IPS) and cerebellopontine angle (CPA) cistern were measured. We also examined whether the presence of a ventricular shunt at the time of imaging influenced radiographic candidacy, given the plausibility of cisternal changes after shunting.

Results: Of 53 patients (median age 41 years, 81.1% women), 24 (45.2%) were previously shunted before MRI imaging. The average CPA cisternal depth was 4.8±1.8 mm (right) and 4.9±2.1 mm (left); IPS size 3.5±0.7 mm (right) and 3.4±0.8 mm (left). The average off-axis angle trajectory from the IPS to the cistern was 128.6±9.8° (right) and 125.2±9.3° (left). In our final model, pre-existing ventricular shunt was not independently associated with endovascular shunting candidacy (OR 2.01, 95% CI 0.65 to 6.40; P=0.227). Overall, endovascular shunting was feasible in at least one side for 55% of patients, increasing to as high as 74% when assessment was based only on venous anatomy.

Conclusion: In this study, a sizeable proportion of patients with IIH were radiographic candidates for endovascular shunting, regardless of the presence of a pre-existing supratentorial shunt.

Mechanical thrombectomy (MT) is an established and guideline-endorsed treatment for acute ischemic stroke (AIS) due to large vessel occlusion. Intravenous thrombolysis (IVT) with alteplase remains the first-line therapy within the approved time window, often used alone or as a bridging strategy before MT. However, both interventions have been systematically understudied in pregnant patients, as this population has been excluded from most pivotal clinical trials. This systematic review critically evaluates the procedural feasibility, safety, and maternal-fetal outcomes of MT in pregnant patients experiencing AIS. A comprehensive literature search using PubMed, Embase, and Web of Science yielded 16 studies encompassing 26 cases. In 20 of these, the occlusions involved the M1 segment of the middle cerebral artery, with 58% receiving combined IVT and MT, and 42% undergoing MT alone. Successful reperfusion (TICI 2b-3) was attained in 84% of cases. The median times were 120 min from onset to hospital arrival, 92 min from arrival to puncture, and 330 min from onset to recanalization. Favorable maternal outcomes (mRS 0-1) were observed in 91% of cases at follow-up, and no direct MT-related fetal mortalities occurred. Radiological protection practices, though inconsistently reported, commonly included abdominal shielding and optimized fluoroscopic protocols. Despite limited high-level evidence, MT in pregnancy appears technically feasible and clinically beneficial, warranting prompt multidisciplinary coordination and robust imaging protocols. Future prospective research is essential to better define safety parameters and optimize guidelines for this vulnerable subgroup of patients.

Background: Infectious intracranial aneurysms (IIAs) are highly morbid vascular lesions, and the comparative effectiveness of medical management (MM), surgery, and endovascular treatment (EVT) remains uncertain.

Objective: To perform a systematic review and network meta-analysis comparing the three main interventions for IIAs: MM, open surgery, and EVT.

Methods: A systematic review and frequentist network meta-analysis were conducted. Studies comparing MM, open surgery, and EVT in patients with IIAs were included. The primary outcome was treatment success, defined according to study-specific definitions and operationally harmonized as the absence of treatment failure. Secondary outcomes included mortality, rupture or re-rupture, recurrence, neurological deficits, and complications. Random-effects models estimated odds ratios (ORs) with 95% confidence intervals (CIs). Treatment ranking was assessed using P scores, and heterogeneity was quantified using I².

Results: Thirteen observational studies were included. In an exploratory network meta-analysis, both EVT (OR=2.51; 95% CI 1.22 to 5.15) and surgery (OR=7.29; 95% CI 2.00 to 26.55) were associated with higher odds of treatment success compared with MM. EVT was associated with a lower risk of aneurysm rupture or re-rupture compared with MM (OR=0.42; 95% CI 0.18 to 0.96), whereas no statistically significant differences were observed between EVT and surgery. Given the non-randomized nature of the evidence and methodological heterogeneity across studies, these findings should be interpreted with caution.

Conclusions: EVT and surgery were associated with higher odds of treatment success compared with MM, whereas EVT was additionally associated with a lower risk of rupture or re-rupture. These findings should be interpreted cautiously given the observational nature of the available evidence.

Idiopathic intracranial hypertension (IIH) is a complex and increasingly prevalent disorder that results in significant morbidity despite a broad array of available treatments. While lifestyle modifications, pharmacologic agents, and surgical interventions can produce meaningful short-term symptomatic improvements, long-term outcomes are poor, characterized by high rates of symptom recurrence. Weight loss remains the only disease-modifying therapy, though sustained reductions in weight are rarely achieved outside of bariatric surgery. In addition, a subset of patients is not overweight, limiting applicability. Pharmacologic therapies such as acetazolamide, topiramate, and glucagon-like peptide-1 (GLP-1) receptor agonists offer benefits but are limited by the side effect profile and poor efficacy. Surgical approaches often address only a portion of IIH's multifactorial pathophysiology, and recurrent symptoms may arise from persistent venous hypertension or new venous stenoses. This review evaluates the current evidence on medical and surgical treatment failures in IIH, emphasizing unresolved questions in disease pathogenesis and the need for personalized therapeutic approaches that advance the development of more durable treatment options.

Background: A study was undertaken to investigate the relationship between the vascular access route and the occurrence of diffusion-weighted imaging (DWI) lesions as well as puncture site complications in patients undergoing elective endovascular treatment (EVT) for cerebral aneurysms.

Methods: This retrospective single-center study included all consecutive patients who underwent elective EVT of unruptured cerebral aneurysms via transradial (TRA) or transfemoral (TFA) access between January 2024 and April 2025. Postprocedural MRI was assessed for new DWI lesions. Univariable and multivariable regression analysis was performed to identify predictors for DWI lesions.

Results: A total of 199 patients (50.3% TRA, 49.7% TFA) were included. New DWI lesions were detected in 53% of patients. There was no difference in the rates of silent or symptomatic DWI lesions between the two groups (60% vs 50%, P=0.15; and 5% vs 10%, P=0.19, respectively). In a multivariate regression analysis, higher age (aOR 1.04 per year, 95% CI 1.01 to 1.06, P=0.009), longer procedure time (aOR 1.01 per minute, 95% CI 1 to 1.02, P=0.023), and the use of adjunctive techniques such as stent- and balloon-assisted coiling (aOR 6.96, 95% CI 1.73 to 27.99, P=0.006) were independent predictors of postprocedural DWI lesions, while no association was found for the access route. Puncture site complications were comparable between TFA and TRA groups (TRA 3% vs TFA 8%, P=0.12).

Conclusion: TRA is a safe and feasible alternative to TFA for elective EVT. The risk of postprocedural DWI lesions is primarily influenced by patient age and procedural complexity rather than access route. These findings support the use of TRA in appropriately selected patients, particularly when vascular anatomy or patient preference favors this approach.

Background: New ischemic cerebral infarction (NICI) on diffusion-weighted imaging (DWI) is frequently observed after stent-assisted coiling.

Objective: To investigate whether preoperative statin use reduces NICI volume and whether the effect depends on baseline low-density lipoprotein cholesterol (LDL-C).

Methods: We retrospectively analyzed 490 patients with intracranial aneurysms who underwent stent-assisted treatment at multiple centers. Based on preoperative statin use, patients were classified into statin (n=269) and non-statin (n=221) groups. NICI volume was quantified on postoperative DWI. Multivariable linear regression was used to identify predictors of log-transformed NICI volume, including an interaction term between statin use and LDL-C >3.4 mmol/L.

Results: Median infarct volume was significantly lower in the statin group (1.39 (IQR 0.87-1.92)) than in the non-statin group (1.83 (IQR 1.48-2.47); P<0.001). After multivariable adjustment, statin use remained independently associated with smaller NICI volume (B = -0.382; 95% CI -0.488 to -0.277; P<0.001). Subgroup analysis showed consistent reductions in both statin+normal LDL-C and statin+high LDL-C subgroups (both P<0.001). No interaction was observed between statin use and LDL-C level (P=0.147), suggesting consistent protection regardless of lipid status. Smoking (B=0.407; P<0.001), higher body mass index (B=0.040; P<0.001), and female sex (B=0.130; P=0.033) were independent predictors of larger infarct volume.

Conclusions: Preoperative statin therapy significantly reduced NICI volume after stent-assisted aneurysm treatment, independently of LDL-C, suggesting possible neurovascular protection through pleiotropic mechanisms beyond lipid lowering.

Background: Intracranial aneurysms (IAs) are more prevalent and rupture at smaller sizes in adults with sickle cell disease (SCD), compared with the general population, but evidence regarding treatment outcomes remains limited.

Objective: To evaluate the safety and efficacy of coil embolization for unruptured IAs in adults with SCD.

Methods: We retrospectively reviewed consecutive adults with homozygous sickle cell disease (HbSS) who underwent elective coil embolization for unruptured IAs between 2010 and 2023. Clinical, hematological, procedural, and radiological data were analyzed. Primary endpoints were immediate and long term angiographic occlusion and periprocedural complications. Durable occlusion was defined as Raymond-Roy Occlusion Classification class I-II at the last follow-up.

Results: 25 patients with HbSS (median age 50 years; 76% women) with 35 aneurysms were treated. All patients received exchange transfusion to sickle hemoglobin <30%. Immediate Raymond-Roy Occlusion Classification class I-II occlusion was achieved in 33 of 35 lesions (94%; 95% CI 81% to 98%). Two complications (5.7%) occurred: one intraprocedural aneurysm perforation resulting in death 2 days after treatment and one transient ischemic event without permanent deficit. At a median follow-up of 60 months (range 12-156), durable occlusion was observed in 94% (33/35; 95% CI 81% to 98%), with two retreatments. All surviving patients were independent (modified Rankin Scale score of 0-2) at the last follow-up.

Conclusions: Preventive coil embolization for unruptured IAs in adults with HbSS achieved high rates of durable occlusion with an overall acceptable safety profile in carefully selected cases when applied selectively within expert centers using a standardized hematologic optimization protocol.

Background: Vertebral compression fractures (VCFs), characterized by middle column involvement, osteonecrotic clefts, split morphology, or pedicle fractures, pose biomechanical challenges that reduce the effectiveness of conventional vertebroplasty and kyphoplasty. We evaluated the feasibility, safety, and clinical outcomes of the Calibrated Screw Technique (CAST), a minimally invasive approach combining percutaneous pedicle screw fixation and targeted cement augmentation, in patients with complex VCFs.

Methods: We retrospectively analyzed 147 consecutive patients (155 vertebral levels; mean age 80.1 years), primarily with osteoporotic fractures (80.6%), treated using CAST. Demographic, clinical, and radiographic data were collected at baseline, and at 1 and 6 months. Pain intensity was measured by the numeric rating scale (NRS), and patient perceived outcomes were assessed using patient global impression of change (PGIC). Radiographic outcomes included refracture rates at treated vertebrae, incidence of new fractures, and kyphotic angle correction in mobile fractures.

Results: CAST was technically feasible in all cases without major complications. Mean NRS scores improved significantly from 7.7 before the procedure to 3.6 at 1 month and 2.7 at 6 months (P < 0.0001). At the 1 month follow-up, 55.3% of patients reported feeling 'extremely' or 'much improved' on PGIC, increasing to 69.8% at 6 months. Radiographically, only one asymptomatic refracture occurred at 1 month (0.8%) and none at 6 months. New fracture incidence decreased from 13.8% at 1 month to 4.2% at 6 months.

Conclusions: In this study, CAST provided a safe, technically feasible, and durable solution for stabilization and pain relief in complex VCFs unsuitable for conventional augmentation, highlighting its value for challenging VCFs.

Background: Dynamic internal jugular vein (IJV) stenosis is increasingly recognized in patients with cerebral venous outflow disorders (CVD). Although the hemodynamic effects of dynamic jugular stenosis have been characterized, its role in disease remains undefined. This study evaluated the safety and early outcomes of IJV stenting for symptomatic rotational stenosis.

Methods: This retrospective, single-institution study included adult patients that underwent IJV stenting for dynamic, symptomatic IJV stenosis between 2023 and 2025. Inclusion required dynamic venography demonstrating >75% rotational IJV stenosis and ≥6 mmHg trans-stenotic pressure gradient. Demographic, procedural, and clinical data were analyzed. Symptom severity was assessed using the Cerebral Venous Disorder Symptom Severity (CVDSS) scale and the Headache Impact Test (HIT-6).

Results: Sixteen patients (mean age 37.1 years, 75% female) were included. All underwent successful IJV stent placement without periprocedural complications. The median trans-stenotic pressure gradient improved from 7 mmHg (range 6-18) to 1 mmHg (range 0-9) after stenting. CVDSS scores improved from 13.5 (11.0-16.0) to 8.5 (4.75-12.0) at peak improvement (p<0.001), with sustained improvement (10.5 (8.0-12.3), p<0.001) at a median follow-up of 10.1 months. Median HIT-6 scores decreased from 65.5 (64.0-67.3) to 61.0 (57.0-64.0) (p<0.001). Thirteen patients reported meaningful symptom improvement at last follow-up, and 88% were satisfied with their decision to pursue stenting.

Conclusion: Jugular vein stenting in refractory CVD patients with severe, symptomatic rotational IJV stenosis is technically feasible and associated with meaningful clinical improvement in patients though partial symptom recurrence is common. Optimal patient selection and procedural expertise are essential to maximize patient safety and efficacy.

Background: The periprocedural management of antithrombotic medications in patients with chronic subdural hematoma (cSDH) after middle meningeal artery embolization (MMAE) or surgical evacuation is uncertain.

Methods: A systematic review was conducted across Medline, Embase, and Web of Science databases. We pooled proportions and risk ratios (RRs) for the meta-analysis with the corresponding 95% CIs. Systemic and intracranial (including recurrence) bleeding complications and thromboembolic events were evaluated.

Results: Of the 16 included studies with 4606 patients, 1784 were receiving antithrombotic medications. Antithrombotic therapy was resumed in 1231 patients (69.0%). Bleeding complications were similar between patients in whom antithrombotic therapy was resumed (14.1%, 95% CI 9.7% to 20.2%) and in those in whom it was discontinued (15.4%, 95% CI 7.4% to 29.3%). After MMAE, patients had similar rates of bleeding events (12.1%, 95% CI 4.9% to 27.0%) to patients with overall treated cSDH, and recurrence (RR 2.28, 95% CI 0.46 to 11.37) and reoperation (RR 1.07, 95% CI 0.40 to 2.917) risks were similar between the resumed and discontinued groups. Thromboembolic complications were significantly higher in the discontinued group (12.6%, 95% CI 6.5% to 23.0%) than in the resumption group (3.5%, 95% CI 1.8% to 6.9%). Earlier resumption (1 week to 1 month) was associated with a lower thromboembolic risk without increasing bleeding complications.

Conclusions: Post-procedural antithrombotic resumption may reduce thromboembolic events without significantly increasing bleeding risk. Early resumption of antithrombotics post-MMAE appears to be safe, although further data are required to confirm this observation. Future studies should aim to better define patient characteristics influencing decision-making in this context.