Interventional Neurology最新文献

Background/objective: Compliant dual-lumen balloon microcatheters have been used to perform balloon-assisted embolization (BAE) of brain arteriovenous malformations (AVMs) with ethylene vinyl alcohol copolymer (Onyx). However, vessel rupture and microcatheter retention have been reported from BAE using these microcatheters. Using an extra-compliant balloon microcatheter (Scepter XC; Microvention, Tustin, CA, USA) could help avoid pial vessel rupture during BAE. We herein report our experience using this balloon microcatheter for BAE.

Methods: This retrospective study included patients who underwent BAE of brain AVMs at our institution between June 2012 and March 2017.

Results: The extra-compliant Scepter XC balloon microcatheter was used for BAE of brain AVMs in 23 patients aged 44.3 ± 16.7 years (range 0-65 years). A total of 40 intracranial vessels (39 pial arteries and 1 pial vein) were catheterized and embolized during 30 separate sessions. In all instances, the balloon microcatheter could be successfully advanced to the AVM nidus. A mean volume of 2.4 ± 1.7 mL (range 0.65-4.6 mL) of Onyx was injected per session. There were no instances of vessel rupture, microcatheter retention, or stroke.

Conclusion: Utilization of the extra-compliant balloon microcatheter results in safe and effective BAE, which adds to the growing experience with BAE for AVM treatment.

Background: Timely treatment of acute ischemic stroke is crucial to optimize outcomes. Mobile stroke units (MSU) have demonstrated ultrafast treatment compared to standard emergency care. Geospatial analysis of the distribution of MSU cases to optimize service delivery has not been reported.

Methods: We aggregated all first-year MSU dispatch occurrences and all cases classified by clinical teams as true stroke by zip code and calculated dispatch and true stroke incidence rates. We mapped dispatch and stroke cases and symbolized incidence rates by standard deviation. We confirmed visual impressions of clusters from map inspection by local Moran's I, boxplot inspection, and t test. We calculated service areas using drive times to meet dispatch and true stroke need.

Results: A significant cluster of high dispatch incident rate was confirmed around our MSU base in urban Memphis within a 5-min driving area supporting the initial placement of the MSU based on 911 activation. A significant cluster of high true stroke rate was confirmed to the east of our MSU base in suburban Memphis within a 10-min driving area. Mean incident longitude of cases of true stroke versus disregarded status was significantly eastward (p = 0.001785).

Conclusion: Our findings will facilitate determination of socio-spatial antecedents of neighborhood overutilization of 911 and MSU services in our urban neighborhoods and service delivery optimization to reach neighborhoods with true stroke burden.

Introduction: Symptomatic intracranial hemorrhage represents one of the most feared complications of endovascular reperfusion. We aim to describe a series of patients that experienced immediate reperfusion injury with active intraprocedural extravasation within the territory of the deep penetrating arteries and provide real-time correlation with CT "spot sign."

Methods: This was a retrospective analysis of patients that suffered reperfusion injury with active arterial extravasation during endovascular stroke treatment in two tertiary care centers.

Results: Five patients were identified. Median age was 63 (58-71) years, 66% were male. Median NIHSS was 13.5 (9.5-23.0), platelet level 212,000 (142,000-235,000), baseline systolic blood pressure 152 (133-201) mm Hg, and non-contrast CT ASPECTS 7.0 (6.5-9.0). Two patients were taking aspirin and one had received intravenous thrombolysis. There were three middle cerebral artery M1, one internal carotid artery terminus, and one vertebrobasilar junction occlusion. Three patients had anterior circulation tandem occlusions. Stroke etiology was extracranial atherosclerosis (n = 2), intracranial atherosclerosis (n = 2), and cervical dissection (n = 1). The median time from onset to puncture was 5.5 (3.9-8.6) h. Intravenous heparin was administered in all patients (median dose of 4,750 [3,250-6,000] units) and intravenous abciximab in four. All tandem cases had the cervical lesion addressed first. Four lenticulostriates and one paramedian pontine artery were involved. Intraprocedural flat-panel CT was performed in four (80%) cases and provided real-time correlation between the active contrast extravasation and the "spot sign." The bailout included use of protamine, blood pressure control, and balloon guide catheter or intracranial compliant balloon inflation plus coiling of targeted vessel. All patients had angiographic cessation of bleeding at the end of the procedure with parenchymal hemorrhage type 1 in one case and type 2 in four. Three patients had modified Rankin score of 4 and two were dead at 90 days.

Conclusions: Active reperfusion hemorrhage involving perforator arteries was observed to correlate with the CT "spot sign" and to be associated with poor outcomes.

Background: To assess the safety and clinical efficacy of carotid artery stenting with and without an embolic protection device (EPD) in both symptomatic and asymptomatic carotid disease cases.

Methods: Retrospective data of 55 symptomatic (≥50% occlusion by digital subtraction angiography [DSA], ≥70% by ultrasound, computed tomography angiography [CTA], and magnetic resonance angiography [MRA]) and asymptomatic (≥60% by DSA, ≥70% by ultrasound, ≥80% by CTA and MRA) carotid disease cases undergoing carotid stenting/angioplasty revascularization from February 2014 to October 2017 was reviewed. All symptomatic patients either experienced recurrent transient ischemic attacks or one or more stroke attacks. An EPD protocol was designed for its selective use based on plaque morphologies and working diameters. The primary end points at 30 days of follow-up were a periprocedural incidence of any stroke, myocardial infarction or death, and ipsilateral stroke during the follow-up period.

Results: Of the 55 cases, 39 were males and 16 females; mean age was 64.8 years. Fifty-one patients (92.7%) were symptomatic, with a mean stenosis of 80.1%. EPD was used in only 11 cases (20%). Minor stroke rate during the first 30 postoperative days was 1.8% (1 case) with EPD; no myocardial infarction or mortality. No stroke occurred during the median 1.5 years' follow-up.

Conclusion: Based on our single-center experience and findings of a relatively small sample size, carotid revascularization with stenting and angioplasty without EPD in experienced hands was found to be safe and efficacious. In addition, it proves cost-effective for patients by limiting the use of unnecessary disposables. These results are comparable to those reported in major trials and are well within the complication thresholds suggested in current guidelines. These results also show promise and illustrate the need for a larger, randomized controlled trial in order to thoroughly address this aspect of carotid revascularization.

Introduction: Microcatheter selection is an infrequent focus of stroke thrombectomy technique evaluation. The Headway27 microcatheter strikes an excellent balance of microcatheter dimensions (156 cm length, 2.6 Fr distal OD, ID 0.027 inches) and visibility, making it ideal for stroke thrombectomy.

Methods: We evaluated a prospectively maintained acute stroke thrombectomy database containing 50 consecutive cases using the Headway27 microcatheter. From the database, patient demographics, clinical and angiographic information as well as procedural technical details and complications were extracted.

Results: Manual aspiration thrombectomy (MAT) was performed alone in 72% of cases, stentriever-assisted MAT was performed in 6% of cases, and a combination was used in 22% of cases. Median groin puncture to final recanalization time was 27 min and mTICI 2B/3 recanalization was achieved in 94% of cases. There were 2 intra-procedural complications, neither related to the microcatheter. In all cases, the Headway27 reached the intended target vessel: M1 (n = 4), M2 (n = 26), M3 (n = 13), P2 (n = 3), P3 (n = 1), and basilar artery (n = 3). There were no cases requiring usage of an additional or alternative microcatheter. In 45/47 cases of MAT, the reperfusion catheter tracked over the Headway to the clot/intended target; in two cases, the microcatheter was used to deploy a stentriever that then allowed the reperfusion catheter to track to the clot.

Conclusion: The Headway27 microcatheter reliably facilitated rapid clot access in anterior and posterior circulation acute large vessel occlusions with no microcatheter-associated complications.

Background and aims: Patients with emergent large-vessel occlusion (ELVO) that present earlier than 4 h from onset are usually treated with bridging systemic thrombolysis followed by endovascular thrombectomy (EVT). Whether direct EVT (dEVT) could improve the chances of favorable outcome remains unknown.

Methods: Consecutively, prospectively enrolled patients with ELVO presenting within 4 h of onset were entered into a National Acute Stroke Registry of patients undergoing revascularization. Patients treated with bridging were compared to those treated with dEVT. Excellent outcome was defined as having a modified Rankin Scale score ≤1 at 90 days following stroke.

Results: Out of 392 patients that underwent thrombectomy, 270 (68%) presented within 4 h and were included. Of those, 159 (59%) underwent bridging and 111 (41%) underwent dEVT. Atrial fibrillation and congestive heart failure were more common in the dEVT group (43 vs. 30%, p = 0.04 and 20 vs. 8%, p = 0.009, respectively), but other risk factors, demographics, stroke severity and subtypes as well as baseline vessel patency state and time metrics did not differ. Excellent target vessel recanalization defined as TICI 3 (thrombolysis in cerebral infarction score) was more common in the dEVT group (75 vs. 61%, p = 0.03), but in-hospital mortality, discharge destinations, short- and long-term excellent outcome rates did not differ. On multivariate regression analysis, treatment modality did not significantly modify the chances of excellent outcome at discharge (OR 0.7; 95% CI 0.3-1.5) or at 3 months (OR 0.78 95% CI 0.4-1.4).

Conclusions: The chances of attaining excellent functional outcomes are similar in ELVO patients undergoing dEVT or bridging.

Background: Determining the size of infarct extent is crucial to elect patients for reperfusion therapies. Computed tomography perfusion (CTP) based on cerebral blood volume may overestimate infarct core on admission and consequently include ghost infarct core (GIC) in a definitive lesional area.

Purpose: Our goal was to confirm and better characterize the GIC phenomenon using CTP cerebral blood flow (CBF) as the reference parameter to determine infarct core.

Methods: We performed a retrospective, single-center analysis of consecutive thrombectomies of middle cerebral or intracranial internal carotid artery occlusions considering noncontrast CT Alberta Stroke Program Early CT Score ≥6 in patients with pretreatment CTP. We used the RAPID® software to measure admission infarct core based on initial CBF. The final infarct was extracted from follow-up CT. GIC was defined as initial core minus final infarct > 10 mL.

Results: A total of 123 patients were included. The median National Institutes of Health Stroke Scale score was 18 (13-20), the median time from symptoms to CTP was 188 (67-288) min, and the recanalization rate (Thrombolysis in Cerebral Infarction score 2b, 2c, or 3) was 83%. Twenty patients (16%) presented with GIC. GIC was associated with shorter time to recanalization (150 [105-291] vs. 255 [163-367] min, p = 0.05) and larger initial CBF core volume (38 [26-59] vs. 6 [0-27] mL, p < 0.001). An adjusted logistic regression model identified time to recanalization < 302 min (OR 4.598, 95% CI 1.143-18.495, p = 0.032) and initial infarct volume (OR 1.01, 95% CI 1.001-1.019, p = 0.032) as independent predictors of GIC. At 24 h, clinical improvement was more frequent in patients with GIC (80 vs. 49%, p = 0.01).

Conclusions: CTP CBF < 30% may overestimate infarct core volume, especially in patients imaged in the very early time window and with fast complete reperfusion. Therefore, the CTP CBF technique may exclude patients who would benefit from endovascular treatment.