Journal of NeuroInterventional Surgery最新文献

Background: Previous studies have indicated that a subset of patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO) experience spontaneous recanalization (SR), but the prognosis and factors associated with SR in these individuals are not well characterized.

Methods: We conducted a post hoc secondary analysis of the Study of Endovascular Therapy in Acute Anterior Circulation Large Vessel Occlusive Patients with a Large Infarct Core (ANGEL-ASPECT) trial. SR in the medical management group was defined as a modified arterial occlusive lesion (AOL) grade of 2 or 3 on computed tomography angiography (CTA) or magnetic resonance angiography (MRA) at 36 hours (±12 hours).

Results: SR was detected in 67 out of 184 patients (36.4%) in the medical management (MM) group. The median age of patients was 67 years (interquartile range (IQR) 58-72), and 48 (71.6%) were male. The adjusted odds ratio (aOR) for 90-day modified Rankin Scale (mRS) score shift toward better outcomes of the MM with SR group vs the MM without SR group was 1.83, with marginally significant difference (95% confidence interval (CI) 0.992 to 3.36; P=0.053). No significant difference was found between the MM with SR group and EVT recanalization group (aOR 1.45; 95% CI 0.86 to 2.43; P=0.16) with similar findings in the inverse probability treatment weighting analysis (OR 0.85; 95% CI 0.49 to 1.48; P=0.57). Multivariable regression analysis showed that hypertension, atherothrombotic stroke and higher clot burden score were factors associated with SR.

Conclusions: SR in medically managed patients with acute large ischemic stroke caused by LVO was associated with good functional outcome. An improved understanding of SR patients may be helpful to develop therapeutic strategy in patients with large infarct due to LVO in anterior circulation.

Trial registration number: NCT04551664.

Background: We investigate the association of imaging biomarkers extracted from fully automated body composition analysis (BCA) of computed tomography (CT) angiography images of endovascularly treated acute ischemic stroke (AIS) patients regarding angiographic and clinical outcome.

Methods: Retrospective analysis of AIS patients treated with mechanical thrombectomy (MT) at three tertiary care-centers between March 2019-January 2022. Baseline demographics, angiographic outcome and clinical outcome evaluated by the modified Rankin Scale (mRS) at discharge were noted. Multiple tissues, such as muscle, bone, and adipose tissue were acquired with a deep-learning-based, fully automated BCA from CT images of the supra-aortic angiography.

Results: A total of 290 stroke patients who underwent MT due to cerebral vessel occlusion in the anterior circulation were included in the study. In the univariate analyses, among all BCA markers, only the lower sarcopenia marker was associated with a poor outcome (P=0.007). It remained an independent predictor for an unfavorable outcome in a logistic regression analysis (OR 0.6, 95% CI 0.3 to 0.9, P=0.044). Fat index (total adipose tissue/bone) and myosteatosis index (inter- and intramuscular adipose tissue/total adipose tissue*100) did not affect clinical outcomes.

Conclusion: Acute ischemic stroke patients with a lower sarcopenia marker are at risk for an unfavorable outcome. Imaging biomarkers extracted from BCA can be easily obtained from existing CT images, making it readily available at the beginning of treatment. However, further research is necessary to determine whether sarcopenia provides additional value beyond established outcome predictors. Understanding its role could lead to optimized, individualized treatment plans for post-stroke patients, potentially improving recovery outcomes.

Background: The safety and efficacy of endovascular thrombectomy (EVT) for large vessel occlusion (LVO) strokes associated with infective endocarditis (IE) compared with medical management (MM) is unclear.

Methods: In this nationwide analysis of hospitalizations in the United States, we assessed the outcomes of EVT versus medical management (MM) for patients with LVO and IE. Primary outcome was routine home discharge with self-care. Secondary outcomes include home discharge, in-hospital mortality, intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH). Propensity score matching (PSM) was performed to adjust for confounders. Additional multivariable adjustments were performed for doubly robust analyses.

Results: 2574 patients were identified; 656 (25.5%) received EVT. After PSM, the rate of routine discharge was significantly higher for patients with EVT compared with MM (14.6% vs 8.5%, p=0.021), and patients with EVT had significantly higher rate of home discharge (34.5% vs 26.5%, p=0.041), lower rate of in-hospital death (14.8% vs 25.2%, p=0.002), and lower rate of ICH (15.8% vs 23.1%, p=0.039). EVT was not associated with a different rate of SAH compared with MM (11.2% vs 7.9%, p=0.17). These associations remained unchanged with additional multivariable adjustments.

Conclusion: For patients with LVO stroke and IE, EVT was associated with significantly higher odds of favorable hospitalization outcomes and lower odds of ICH compared with MM.

Background: A higher number of recanalization attempts reduces the efficacy of endovascular thrombectomy (EVT) for acute ischemic stroke secondary to large vessel occlusion (LVO). We assessed the impact of switching EVT techniques after a failed first pass on procedural and clinical outcomes.

Methods: This multicenter international study, conducted between January 2013 and December 2022, included patients undergoing EVT for anterior circulation LVO (internal carotid artery or M1 segments) with failed first pass recanalization. Propensity score matching identified a 1:1 matched cohort of patients in whom EVT technique was changed after a failed first pass and those with the same technique repeated. The primary outcome was successful recanalization at second attempt defined as Thrombolysis in Cerebral Ischemia (TICI) score of 2B or higher. Secondary outcomes were 90-day modified Rankin Score (mRS) and postprocedural hemorrhage.

Results: Among 2167 patients, converting to an alternative technique after a failed first pass was associated with higher odds of successful recanalization (adjusted OR (aOR)=1.5, p=0.041), and higher odds of mRS 0-2 at 90 days (aOR=1.6, p=0.005) without additional risk of symptomatic hemorrhage (p=0.379). Using a propensity score matched cohort of 490 patients, technique conversion at second attempt increased odds of successful recanalization at second attempt (aOR=1.32, p=0.006) and 90-day mRS 0-2 (aOR=1.38, p=0.008).

Conclusions: Early conversion to an alternative EVT technique after a failed first pass recanalization in patients with AIS is associated with better technical success and clinical outcomes.

Background: To evaluate the stand-alone efficacy and improvements in diagnostic accuracy of early-career physicians of the artificial intelligence (AI) software to detect large vessel occlusion (LVO) in CT angiography (CTA).

Methods: This multicenter study included 595 ischemic stroke patients from January 2021 to September 2023. Standard references and LVO locations were determined by consensus among three experts. The efficacy of the AI software was benchmarked against standard references, and its impact on the diagnostic accuracy of four residents involved in stroke care was assessed. The area under the receiver operating characteristic curve (AUROC), sensitivity, and specificity of the software and readers with versus without AI assistance were calculated.

Results: Among the 595 patients (mean age 68.5±13.4 years, 56% male), 275 (46.2%) had LVO. The median time interval from the last known well time to the CTA was 46.0 hours (IQR 11.8-64.4). For LVO detection, the software demonstrated a sensitivity of 0.858 (95% CI 0.811 to 0.897) and a specificity of 0.969 (95% CI 0.943 to 0.985). In subjects whose symptom onset to imaging was within 24 hours (n=195), the software exhibited an AUROC of 0.973 (95% CI 0.939 to 0.991), a sensitivity of 0.890 (95% CI 0.817 to 0.936), and a specificity of 0.965 (95% CI 0.902 to 0.991). Reading with AI assistance improved sensitivity by 4.0% (2.17 to 5.84%) and AUROC by 0.024 (0.015 to 0.033) (all P<0.001) compared with readings without AI assistance.

Conclusions: The AI software demonstrated a high detection rate for LVO. In addition, the software improved diagnostic accuracy of early-career physicians in detecting LVO, streamlining stroke workflow in the emergency room.

Background: A direct aspiration first pass technique (ADAPT) has emerged as a fast, safe, and efficacious method for treating acute large vessel occlusion. However, successful clot aspiration is not guaranteed in every ADAPT procedure. We have observed that when the catheter effectively ingested the clot, the catheter tip displayed a distinct fluttering motion, referred to herein as tip flutter. Thus this study aimed to assess whether this catheter tip flutter can be used as a sign of successful clot aspiration.

Methods: This retrospective study included 231 consecutive patients admitted to our institution due to acute ischemic stroke and treated with ADAPT between October 2018 and November 2023. We obtained baseline and procedural data from all patients. Additionally, we assessed the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy of the tip flutter in predicting clot aspiration.

Results: The incidence of embolus translocation was significantly higher in the tip flutter positive group than in the tip flutter negative group (P<0.001). Also, hyperdense artery presentation was more prevalent in the positive group (P<0.001), whereas the clot burden score was higher in the negative group (P=0.002). Clot aspiration in the first pass occurred in 83 (96.5%) and 37 (25.5%) patients in the positive and negative groups, respectively (P<0.001). Multivariable logistic regression analysis showed the tip flutter sign (OR 1.09, 95% CI 0.16 to 1.29; P<0.001) was an independent predictor of successful clot aspiration. Sensitivity, specificity, PPV, NPV, and accuracy of the tip flutter for predicting clot aspiration were 69.2%, 97.3%, 96.5 %, 74.5%, and 82.7%, respectively.

Conclusions: In this study, we found that tip flutter was a reliable indicator of successful clot aspiration during ADAPT.

Background: Temporary clipping (TC) is an essential adjunct in cerebral aneurysm (CA) surgery. Despite appearing insignificant to the surgeon under the microscope, TC may cause parent vessel injury. Intraoperative diagnostic cerebral angiography (ioDCA) is crucial for assessing aneurysm occlusion and parent vessel integrity. We aimed to assess sequelae of TC evident on immediate ioDCA.

Methods: Elective CA clippings with ioDCA in a hybrid operating room from January 2020 to June 2023 were reviewed. Microsurgical and angiographic assessments were performed to identify post-TC parent vessel alterations. Outcomes were compared between TC and non-TC-groups.

Results: Collectively, 107 patients underwent 111 craniotomies for clipping of 127 CAs. TC was used in 59/111 cases (53.2%) for treatment of 66/127 CAs (51.9%). CA size and neck were significantly larger in the TC group than in the non-TC group (p<0.001). Parent vessel vasospasm at the site of the previous temporary clip location was evident on 3D rotational angiography in 12/59 (20.3%) TC cases. Clip adjustment rates after ioDCA were similar between groups (TC 13.6% vs non-TC 8.2%, p=0.328). In the TC group compared with the non-TC group, the rates of symptomatic radiographic ischemia and functional decline at discharge were significantly higher (p=0.022 and p=0.045, respectively). However, functional status at follow-up was comparable (p=0.620).

Conclusions: TC during CA surgery can cause significant yet microsurgically occult vasospasm in the parent vessel, potentially contributing to symptomatic ischemia and early functional decline. Intraoperative angiography is crucial for detecting this issue, highlighting both its importance and the risks associated with TC.

Background: Distal occlusions associated with incomplete reperfusion (expanded Thrombolysis in Cerebral Infarction,

Methods: Retrospective registry analysis of patients undergoing endovascular therapy between July 2020 and December 2022, with available immediate post-interventional FPDCT and 24 hours follow-up perfusion imaging. Persistent hypoperfusion was defined as a perfusion deficit at 24 hours directly corresponding to the area of incomplete reperfusion on final angiography run. The DOT sign was defined as a punctiform or tubular hyperdense signal increase on FPDCT indicative of a residual occlusion. Association between the DOT sign (present/absent) with the occurrence of persistent hypoperfusion and poor outcome (modified Rankin scale (mRS) score 3-6) was evaluated using logistic regression analysis.

Results: Of 292 patients included (median age 73 years; 47% female), 209 had incomplete reperfusion. Among patients with incomplete reperfusion, 61% had a present DOT sign and 46% had persistent hypoperfusion. In the overall cohort, but also within each eTICI stratum, a present DOT sign was associated with persistent hypoperfusion on 24±12 hours follow-up perfusion imaging (adjusted odds ratio (aOR) 4.8, 95% confidence interval (CI) 2.0 to 12.3 for patients with eTICI 2 a-2c). A present DOT sign was also associated with poor outcome (aOR 2.6, 95% CI 1.1 to 6.2).

Conclusion: Patients with

Background: The aim of this study is to assess the feasibility of identifying the hemodynamic status of intracranial atherosclerotic stenosis (ICAS) using angio-based fractional flow (FF) calculated from a single angiographic view, with wire-based FF as the reference standard.

Method: The study retrospectively recruited 100 ICAS patients who underwent pressure wire measurement and digital subtraction angiography. The AccuICAD software was used to calculate angio-based FF, with the wire-measured value serving as the reference standard for evaluating the accuracy, consistency, and diagnostic performance of angio-based FF.

Results: The mean±SD value of wire-based FF was 0.77±0.18, while the mean value of angio-based FF was 0.77±0.19. A good correlation between angio-based FF and wire-based FF was evident (r=0.90, P<0.001), with good agreement (mean difference 0.00±0.08). The diagnostic accuracy of angio-based FF and percent diameter stenosis (DS%) were 93.23% versus 72.18%, 91.73% versus 72.93%, and 89.47% versus 78.95% for predicted wire-based FF thresholds of 0.70, 0.75, and 0.80, respectively. The area under the curve (AUC) values for angio-based FF and DS% were 0.975 versus 0.822, 0.970 versus 0.814, and 0.943 versus 0.826 at the respective thresholds, respectively.

Conclusion: The FF calculated from a single angiographic view can be considered an effective tool for functional assessment of cerebral arterial stenosis.