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: Data about the safety and the efficacy of flow diversion for distal anterior cerebral artery (DACA) aneurysms are limited. We present the largest multicenter analysis evaluating the outcomes of flow diversion in unruptured DACA aneurysm treatment.

Methods: Databases from 39 centers were retrospectively reviewed for unruptured DACA aneurysms treated with flow-diverting stents. Demographics, clinical presentation, radiographic characteristics, procedural complications, and outcomes were assessed.

Results: A total of 168 patients with 168 unruptured DACA aneurysms were treated between January 2018 and December 2022. One hundred and twenty-five were women (74.4%) and the median age was 61 (IQR 52-67) years. The most common morphology was saccular (91.7%), with branch involvement in 61.9% of cases. Median parent vessel diameter was 1.9 mm (IQR 1.7-2.2) and stents were successfully deployed in 99.4% of cases. In 96.4% a single stent was implanted, while 3.6% of cases required two stents. Median imaging follow-up was 16.5 (IQR 7-24) months. At last follow-up the rate of occlusion (O'Kelly-Marotta scale C or D) was 82.1%. Symptomatic thromboembolic or hemorrhagic complications occurred in 5.3% of patients and the mortality rate was 0.6%. The rate of retreatment was 1.2%.

Conclusions: Flow-diverting stents are a reasonably safe and effective treatment option for unruptured DACA aneurysms.

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: The increasing availability of neuroimaging tests has led to a rise in the identification of incidental unruptured intracranial aneurysms (UIAs). Their management is under debate, with no consensus on their follow-up strategy, which can cause anxiety in patients. Our aim is to evaluate the impact of diagnosis and imaging follow-up on daily activities and quality of life.

Methods: A multicenter cross-sectional study was carried out in patients with UIAs undergoing watchful waiting. Exclusion criteria were history of stroke, renal polycystic disease, symptomatic aneurysms, intervention or scheduled for intervention. The patients completed an anonymous 36-question survey about their habits and perceived quality of life after diagnosis through a validated questionnaire (PROMIS).

Results: We obtained 73 responses from 183 patients identified in eight hospitals (40%), 68 of which were included in the study (50 women (74%), median (IQR) age 62 (55-70) years). Forty-nine patients (72%) underwent at least one imaging follow-up per year. Forty-two patients (63%) found follow-up tests reassuring and 12 (18%) experienced concern about the results. Nineteen patients (28%) reported adopting a healthier lifestyle since diagnosis, while 13 (19%) acknowledged a negative impact on their daily activities. Forty-six (68%) admitted avoiding or conditioning at least one activity or situation from a list. PROMIS scores were similar to those of the general reference population. Overall, 77% rated their quality of life as 'good' or better.

Conclusions: The diagnosis of UIAs seems to influence the activities of the majority of patients. However, follow-up yielded more benefit in the form of healthier lifestyles than harm to daily activities, without detriment to their perceived quality of life.

Background: Arteriovenous shunts below conus medullaris (AVS-BC) are understudied, particularly those associated with spinal dysraphism. This study aimed to refine the classification and management of AVS-BC.

Methods: A retrospective analysis of patients with AVS-BC from two centers over two decades was performed, focusing on clinical presentations, angioarchitecture, and treatment outcomes. AVS-BC was classified into eight subtypes based on angioarchitecture, dural relation, and spinal dysraphism presence. Treatment efficacy was evaluated using changes in the modified Aminoff and Logue's Scale and the modified Denis Pain and Numbness Scale.

Results: The cohort included 140 patients (85.0% male) with a median onset age of 54 years (IQR 47-62). Spinal dural arteriovenous fistula was the most prevalent subtype (32.1%). AVS-lipoma (58.8%) and AVS with spina bifida/meningocele (75.0%) were mainly located in S3-S5, while others were above S2 (p<0.001). Most AVS-BCs were supplied by the internal iliac artery (37.1%) and drained intradurally (96.4%). Venous lakes were common in spinal epidural arteriovenous fistula (88.2%) and paravertebral arteriovenous fistula (100.0%). Larger drainage veins (>2.0 mm) were found in paravertebral arteriovenous fistula (PVAVF) (50.0%) and AVS with spina bifida/meningocele (AVS-SBD) (50.0%) (p=0.012). Embolization was the preferred treatment (50.7%), achieving a 97.1% anatomical cure rate. Despite functional improvements, 25% experienced deterioration during a median follow-up of 47 months (IQR 20-113).

Conclusions: The refined AVS-BC classification revealed significant angioarchitectural variations. Tailored treatment strategies, especially embolization, resulted in high anatomical cure rates, though post-treatment deterioration warrants further investigation.

Background: The posterior communicating artery (PComA) is among the most common intracranial aneurysm locations, but flow diverter (FD) treatment with the widely used pipeline embolization device (PED) remains an off-label treatment that is not well understood. PComA aneurysm flow diversion is complicated by the presence of fetal posterior circulation (FPC), which has an estimated prevalence of 4-29% and is more common in people of black (11.5%) than white (4.9%) race. We present the FD-PComA in-silico trial (IST) into FD treatment performance in PComA aneurysms. ISTs use computational modeling and simulation in cohorts of virtual patients to evaluate medical device performance.

Methods: We modeled FD treatment in 118 virtual patients with 59 distinct PComA aneurysm anatomies, using computational fluid dynamics to assess post-treatment outcome. Boundary conditions were prescribed to model the effects of non-fetal and FPC, allowing for comparison between these subgroups.

Results: FD-PComA predicted reduced treatment success in FPC patients, with an average aneurysm space and time-averaged velocity reduction of 67.8% for non-fetal patients and 46.5% for fetal patients (P<0.001). Space and time-averaged wall shear stress on the device surface was 29.2 Pa averaged across fetal patients and 23.5 Pa across non-fetal (P<0.05) patients, suggesting FD endothelialization may be hindered in FPC patients. Morphological variables, such as the size and shape of the aneurysm and PComA size, did not affect the treatment outcome.

Conclusions: FD-PComA had significantly lower treatment success rates in PComA aneurysm patients with FPC. We suggest that FPC patients should be treated with an alternative to single PED flow diversion.

Background: This study investigates the efficacy and safety of bridging intravenous thrombolysis (IVT) before endovascular therapy (EVT) compared with EVT alone in patients with large infarction core.

Methods: We conducted a comprehensive search of PubMed, EMBASE, and the Cochrane Library from January 2015 to June 2024. Included studies involved patients with acute ischemic stroke with an Alberta Stroke Program Early CT Score of ≤5 or an ischemic core volume of ≥50 mL. Studies were required to provide either 90-day modified Rankin Scale (mRS) score, reperfusion, symptomatic intracranial hemorrhage (sICH), or 90-day mortality.

Results: Nine observational studies with 2641 patients were analyzed. The IVT+EVT group had a higher rate of 90-day functional independence (mRS 0-2; OR 1.56, 95% CI 1.31 to 1.87; adjusted OR (aOR) 1.43, 95% CI 1.21 to 1.68) and 90-day functional outcome (mRS 0-3; OR 1.34, 95% CI 1.11 to 1.62; aOR 1.18, 95% CI 1.02 to 1.37) compared with EVT alone. There was no significant difference in successful reperfusion (OR 1.01, 95% CI 0.62 to 1.64; aOR 1.07, 95% CI 0.74 to 1.54) and 90-day mortality (OR 0.86, 95% CI 0.73 to 1.02; aOR 0.89, 95% CI 0.77 to 1.04) between the two groups. Moreover, patients who received IVT+EVT had a higher rate of sICH (OR 1.30, 95% CI 1.03 to 1.64; aOR 2.21, 95% CI 1.22 to 4.01).

Conclusions: In patients with large infarction core, bridging IVT before EVT is associated with favorable functional outcomes compared with EVT, even though bridging therapy entails a higher risk of sICH. Further trials are needed to confirm these findings.