Neurointervention最新文献

A ruptured brain arteriovenous malformation (bAVM) presenting with a hematoma may have unseen parts of the shunts in diagnostic angiography in the acute phase, which may lead to innate incomplete evaluation for the whole angioarchitecture of the bAVM. Even though it is generally accepted that the nidus of a ruptured bAVM may be underestimated in angiography during the acute phase due to hematoma compression, documentation of the underestimated parts has not been described in the literature. The authors report 2 cases of ruptured bAVMs in which the obscured segments were cast with liquid embolic material, which suggests a potential presence of obscured segments in bAVMs.

Purpose: This study aimed to evaluate the effectiveness, safety, and technical considerations of flow diverter (FD) treatment using a Flow Re-direction Endoluminal Device (FRED) for unruptured intracranial vertebral artery dissecting aneurysms (VADAs).

Materials and methods: We conducted a retrospective study of 23 patients with unruptured intracranial VADAs who underwent FD treatment using a FRED between June 2017 and August 2021. Symptoms, imaging findings, treatment strategies, and angiographic and clinical outcomes were evaluated. Dissections were categorized according to the dominance of the VA in which they occurred: dominant VA, co-dominant VA, and non-dominant VA.

Results: All patients successfully underwent FD treatment with either a FRED (n=11) or FRED Jr. (n=12). Complete occlusion rates were 78.3% at 6-month follow-up magnetic resonance angiography and 91.3% at 12-month. There were no instances of complications, recurrence, or retreatment during a median follow-up of 20 months. Dissections occurred in the dominant VA in 3 cases (13.0%), the co-dominant VA in 13 cases (56.5%), and the non-dominant VA in 7 cases (30.4%). Intimal flap and true lumen stenosis were observed in 39.1% and 30.4% of cases, respectively. Four cases required a bilateral VA approach due to technical difficulties, all in the non-dominant VA.

Conclusion: Flow diversion treatment using a FRED for unruptured intracranial VADAs proved feasible and safe, yielding satisfactory occlusion rates. Technical challenges were more likely in lesions involving non-dominant VAs in the acute or subacute stage, mainly due to associated intraluminal lesions compromising the arterial lumen.

The Woven EndoBridge (WEB) (MicroVention/Terumo) device is a treatment option for wideneck bifurcation aneurysms. An uncommon adverse effect is WEB device migration. While certain bailout strategies for WEB recovery have been described, there is still a paucity of information on optimal strategies to maximize both short and long-term post-operative outcomes. We add 2 cases at our institution to the existing literature of WEBectomy in the setting of complicated intracranial aneurysm treatment. We discuss the long-term imaging outcomes with additional fluoroscopy video demonstrating our technique. Our findings reflect a clear benefit for the use of the Amplatz GooseneckTM microsnare (Medtronic) device as a means of WEB recovery, coupled with potential stent-assisted WEB embolization to remove the aneurysm from the parent circulation, while minimizing recurrence and thromboembolic complications.

Stroke in children is a rare but devastating disease. Although endovascular treatment has been reported to be safe and effective in the treatment of stroke with large vessel occlusion in this population, there are still limitations and controversies. In this case report, we describe a 12-month-old girl who was admitted to the hospital with acute onset of left-sided hemiplegia and confusion, which turned out to be due to a large infarct in the right middle cerebral artery territory, possibly caused by dissection of the right cervical internal carotid artery. Aspiration thrombectomy was successfully performed, and the patient was able to walk a few steps and raise her left upper extremity at the 12-month follow-up. The aspiration-only technique in thrombectomy may be safe and technically feasible to treat acute ischemic stroke with large vessel occlusion in children as young as 12 months, although large-volume prospective studies are needed.

Endovascular thrombectomy is the standard treatment in selected patients with acute ischemic stroke and large vessel occlusion, but continuous improvement in angiographic and clinical outcome is still needed. Intra-arterial thrombolysis has been tested as a possible rescue tool in unsuccessful thrombectomy, or as an adjuvant therapy after the endovascular procedure, to pursue complete recanalization. Here we present a case series analysis of intra-arterial alteplase administration (5 mg bolus, repeated up to 15 mg if Thrombolysis in Cerebral Infarction (TICI) scale ≥2c is not achieved) in 15 consecutive anterior circulation stroke patients after unsuccessful thrombectomy, defined as TICI score ≤2b after at least 3 passes or if unsuitable for further endovascular attempts, with the aim of improving recanalization. An improvement of final TICI score was achieved in 10 of 15 patients (66.7%). TICI score ≥2c was achieved after 5 mg intra-arterial tissue plasminogen activator (iaTPA) in 4 patients, and after 10 mg iaTPA in 5 cases. Six of 15 patients received 15 mg iaTPA: 1 of 6 showed angiographical improvement. A major effect of intra-arterial alteplase was observed for distally migrated emboli. None of the patients experienced any symptomatic hemorrhagic transformation or other major bleeding. Our report shows, in a very small cohort, a high rate of final TICI score improvement, encouraging the development of randomized controlled trials of rescue intra-arterial thrombolysis in patients with suboptimal angiographic results after mechanical thrombectomy.

Mechanical thrombectomy for acute posterior circulation strokes (PCSs) is recommended based on evidence from anterior circulation strokes (ACSs). Two recent randomized controlled trials showed that endovascular treatment (EVT) leads to better functional outcomes than those of the best medical care. However, many studies have shown that patients undergoing PC-EVT have a higher rate of futile recanalization than those undergoing AC-EVT. The characteristics and outcomes of PC-EVT may differ according to the pathological mechanisms, including cardioembolism, intracranial atherosclerosis, and tandem vertebrobasilar occlusion. We reviewed PC-EVT outcomes reported in recent studies and discussed technical considerations for maximizing treatment efficacy according to the etiology of a PCS.

Among the various perspectives on cerebrovascular diseases, hemodynamic analysis-which has recently garnered interest-is of great help in understanding cerebrovascular diseases. Computational fluid dynamics (CFD) analysis has been the primary hemodynamic analysis method, and studies on cerebral aneurysms have been actively conducted. However, owing to the intrinsic limitations of the analysis method, the role of wall shear stress (WSS), the most representative parameter, remains controversial. High WSS affects the formation of cerebral aneurysms; however, no consensus has been reached on the role of WSS in the growth and rupture of cerebral aneurysms. Therefore, this review aimed to briefly introduce the up-to-date results and limitations made through CFD analysis and to inform the need for a new hemodynamic analysis method.

The management of unruptured brain arteriovenous malformations (ubAVMs) is a complex challenge to neurovascular practitioners. This meta-analysis aimed to identify the optimal management of ubAVMs comparing conservative management, embolization, radiosurgery, microsurgical resection, and multimodality. The search strategy was developed a priori according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched the Ovid Medline, Embase, Web of Science, and Cochrane Library databases to identify relevant papers. Using R version 4.1.1., a frequentist network meta-analysis was conducted to compare different management modalities for the ubAVMs. Overall, the conservative group had the lowest risk of rupture (P-score=0.77), and the lowest rate of complications was found in the conservative group (P-score=1). Among different interventions, the multimodality group had the highest rupture risk (P-score=0.34), the lowest overall complications (P-score=0.75), the best functional improvement (P-score=0.65), and the lowest overall mortality (P-score=0.8). However, multimodality treatment showed a significantly higher risk of rupture (odds ratio [OR]=2.13; 95% confidence interval [95% CI]=1.18-3.86) and overall complication rate (OR=5.56; 95% CI=3.37-9.15) compared to conservative management; nevertheless, there were no significant differences in overall mortality or functional independence when considered independently. Conservative management is associated with the lowest rupture risk and complication rate overall. A multimodal approach is the best option when considering mortality rates and functional improvement in the context of existing morbidity/symptoms. Microsurgery, embolization, and radiosurgery alone are similar to the natural history in terms of functional improvement and mortality, but have higher complication rates.