Neurointervention最新文献

Randomized clinical trials have established the clinical efficacy of mechanical revascularization compared to drug therapy. Successful reperfusion in mechanical thrombectomy is achieved in 53% to 83% of cases, often requiring multiple thrombectomies, which can prolong procedure times and potentially lead to worse outcomes and higher complication risks. The current body of literature suggests that the first pass effect (FPE) is of paramount importance. To achieve a higher FPE, a double stent retriever (DSR) technique is becoming more popular. This publication shares our experience, challenges, and learning journey in implementing DSR in our department.

Purpose: Delayed rupture (DR) can occur even after successful deployment of flow diverters (FDs). Although coiling is often added to reduce the risk of rupture in high-risk intracranial aneurysms, its effectiveness remains unproven. To assess current practice in Japan, a questionnaire was distributed to evaluate the effect of coiling on rupture prevention.

Materials and methods: A retrospective survey was sent to 124 institutions with qualified FD practitioners, receiving 76 responses (61%). A total of 5,527 patients treated with FDs were included in the study, and clinical records of 5,211 aneurysms were analyzed.

Results: DRs (excluding intraprocedural accidents) occurred in 36 cases (0.7%). Of 1,286 aneurysms treated with FD and coiling, 9 (0.7%) ruptured. Ruptured aneurysms in the FD with coiling group were located in the supraclinoid segment (4 cases), paraclinoid internal carotid artery (ICA) (3 cases), and basilar artery (2 cases), of which 7 were classified as giant (diameter >20 mm). In the FD-alone group, 55% (15/27) of ruptured aneurysms were located in the cavernous ICA. Time to rupture ranged from 1 to 2,220 days with no significant difference between groups, except for 1 exceptionally delayed case. Outcomes were worse in the FD with coiling group, where 67% (6/9) had a modified Rankin Scale score of 6. The DR rate was identical between the FD-alone and FD with coiling groups.

Conclusion: Coiling does not appear to prevent rupture after FD treatment. Aneurysms treated with coiling tended to be larger, to rupture earlier, and to have worse outcomes, probably due to selection bias. Routine loose coiling may provide psychological reassurance but lacks proven efficacy as a preventive measure.

We present a case of a patient in their 50s with a spinal epidural arteriovenous fistula (SEDAVF) at L2 level with intradural venous reflux. Initial transarterial embolization was attempted but failed due to vessel tortuosity and vasospasm. The second embolization was carried out with percutaneous puncture of the epidural venous sac under cone-beam computed tomography angiography (CBCTA) guidance. Following the complete obliteration of the fistula, resolution of the venous congestion and significant improvement of the patient's symptoms were achieved. This case highlights the utility of the percutaneous approach as an alternative treatment strategy for SEDAVFs when traditional endovascular routes are not feasible. Advanced imaging techniques, such as CBCTA, facilitate precise navigation and successful embolization.

Purpose: Procedure time (PT), defined as the time between groin access and vessel recanalization, is a recently recognized predictor of outcomes after endovascular thrombectomy (EVT) for acute ischemic stroke (AIS). However, the factors affecting PT and its potential value as a performance measure of AIS treatment remain unexplored.

Materials and methods: Using the Korean Stroke Registry, we compared patients who underwent EVT for AIS from 2018 to 2022 based on 60 minutes PT. We conducted multivariate analysis to investigate whether PT <60 minutes was associated with successful recanalization and good functional stroke outcomes. We also investigated factors that independently predicted PT ≥60 minutes. Furthermore, we determined the cutoff point for PT.

Results: We analyzed 4,703 patients (mean age: 69.5±11.9, 60.3% male) who underwent EVT. The mean PT was 54.6±36.7 minutes. Multivariate analysis revealed that PT <60 minutes independently predicted a good functional outcome as represented by modified Rankin Scale scores of 0-2 (adjusted odds ratio [aOR]: 1.40, 95% confidence interval [CI]: 1.22-1.59). PT <60 minutes was significantly associated with successful recanalization after adjusting for confounding variables (aOR: 1.66, 95% CI: 1.33-2.07). Moreover, after adjusting for covariates, age≥65 years (aOR: 1.20, 95% CI: 1.05-1.38), onset-to-door time (aOR: 1.03, 95% CI: 1.01-1.04), door-to-puncture time (aOR: 1.05, 95% CI: 1.03-1.06), posterior circulation stroke (PCS) (aOR: 1.13, 95% CI: 1.02-1.28), and smoking (aOR: 1.24, 95%CI: 1.09-1.45) independently predicted PT ≥60 minutes. Finally, the highest aOR for good stroke outcome was observed in the 60-minute cutoff model (aOR: 1.45, 95%CI: 1.27-1.67).

Conclusion: PT <60 minutes was significantly associated with good functional outcomes. Conversely, PT ≥60 minutes was associated with older age, PCS, smoking, prolonged onset-to-door and door-to-puncture time. Further studies are necessary to develop refining strategies for optimizing PT to improve stroke outcomes.

Artificial intelligence (AI), particularly deep learning, has demonstrated high diagnostic performance in detecting intracranial aneurysms on computed tomography angiography (CTA) and magnetic resonance angiography (MRA). However, the clinical translation of these technologies remains limited due to methodological limitations and concerns about generalizability. This scoping review comprehensively evaluates 36 studies that applied deep learning to intracranial aneurysm detection on CTA or MRA, focusing on study design, validation strategies, reporting practices, and reference standards. Key findings include inconsistent handling of ruptured and previously treated aneurysms, underreporting of coexisting brain or vascular abnormalities, limited use of external validation, and an almost complete absence of prospective study designs. Only a minority of studies employed diagnostic cohorts that reflect real-world aneurysm prevalence, and few reported all essential performance metrics, such as patient-wise and lesion-wise sensitivity, specificity, and false positives per case. These limitations suggest that current studies remain at the stage of technical validation, with high risks of bias and limited clinical applicability. To facilitate real-world implementation, future research must adopt more rigorous designs, representative and diverse validation cohorts, standardized reporting practices, and greater attention to human-AI interaction.

A 44-year-old female experienced a recurrence and enlargement of a basilar top aneurysm 2 years after initial treatment with a Woven EndoBridge (WEB) device. Retreatment using a new WEB device combined with a flow diverter (FD) via a semi-jail technique successfully obliterated the aneurysm without complications. Follow-up imaging at 4 months showed complete occlusion and favorable outcomes. This case suggests that combining WEB and FD may offer effective retreatment for complex, recurrent aneurysms, enhancing coverage and durability. Despite its technical challenges, this approach shows promise, though further long-term studies are needed to confirm its safety and wider applicability.

We report a rare case of a left internal mammary artery (LIMA) originating from the left thyrocervical trunk (TCT), which arose directly from the aortic arch. A patient in their 70s presented with bilateral distal internal carotid artery aneurysms, diagnosed through computed tomography angiography performed for headache evaluation. Transfemoral cerebral angiography confirmed the aneurysms and incidentally revealed the anomalous origins of the TCT and LIMA, as well as a left vertebral artery directly arising from the aortic arch. This case emphasizes the importance of recognizing such rare anatomical variations prior to diagnostic or interventional procedures. Thorough preoperative evaluation is critical to avoid complications, particularly in coronary artery bypass grafting and head and neck tumor embolization.

There are few documented cases of bradycardia or asystole occurring during Onyx embolization of intracranial dural arteriovenous fistulas (DAVFs), although these events are more commonly observed in open neurosurgical procedures, particularly those involving the skull base. We present a case treated for a ruptured paramedian occipital DAVF. During the administration of Squid into the middle meningeal artery, while balloons were inflated in the large occipital arteries bilaterally to control the flow during embolization of the DAVF, the patient experienced an abrupt episode of sinus bradycardia, which recurred after a second injection of Squid. After temporarily halting the injections and deflating the balloons, a third injection was successfully administered without complications, allowing total exclusion of the fistula.

The treatment of carotid stenosis complicated by severe vessel tortuosity can present challenges in distal vessel selection and device delivery. This article reports the use of a steerable microcatheter (SM) for carotid artery stenting (CAS) in such cases. A 67-year-old male with transient lower extremity weakness and bilateral cerebral infarctions was found to have bilateral carotid stenosis. CAS was planned for both carotid arteries due to coronary artery disease. The left carotid artery exhibited severe stenosis with a 90-degree angle between the common and internal carotid artery (ICA). Anticipating difficulty in navigating the device, we used a 2.4 Fr SM. By adjusting the catheter tip to align with the ICA, we successfully guided the wire distally. Following the catheter exchange, a distal protection device was deployed, and CAS was completed successfully. SMs provide exceptional vascular selectivity and support, improving success in complex cases.

Purpose: Mechanical thrombectomy (MT) for distal medium vessel occlusions (DMVOs) in the middle cerebral artery (MCA) is less established than for large vessel occlusions. This study evaluates the safety and efficacy of MT in DMVOs, comparing it with M1-segment occlusions.

Materials and methods: This retrospective study analyzed 218 patients who underwent MT for isolated M1 (n=123) or distal M2+M3 (n=35) occlusions between January 2020 and August 2023. Outcomes included procedural complications, hemorrhagic events, reperfusion rates, and clinical severity and disability at admission and discharge. Multivariate logistic regression identified predictors of favorable outcomes (modified Rankin Scale≤2) at discharge.

Results: Median admission National Institutes of Health Stroke Scale (NIHSS) scores were higher in the M1 group (13, interquartile range [IQR]: 8) compared to the distal M2+M3 group (8, IQR: 7; P<0.001), with significant improvements at discharge in both groups (6 [IQR: 8] for M1 and 2.5 [IQR: 5] for M2+M3; P=0.025). Favorable outcomes were more frequent in the M2+M3 group (50.0%) compared to M1 (28.1%; P=0.023). Recanalization rates (modified Thrombolysis in Cerebral Infarction≥2b) were excellent (>90% in both groups; P=0.300). Procedural complications were rare, with vessel perforations occurring infrequently (M1: 1.6%; M2+M3: 2.9%; P=0.531). Symptomatic intracranial hemorrhage rates were similarly low (2.4% vs. 2.9%; P=0.889). Multivariate analysis identified younger age (P=0.045) and lower NIHSS (P=0.061) as predictors of favorable outcomes in distal occlusions.

Conclusion: MT is safe and effective for DMVOs of the MCA, demonstrating significant improvements in clinical outcomes and comparable complication rates to MT for M1-segment occlusions. Given the typically less severe presentations in DMVO and similar risk profiles, careful patient selection and individualized treatment remain critical.