Interventional Neurology最新文献

Background: A carotid web (CaW) is a shelf-like lesion in the posterior aspect of the internal carotid bulb and represents an intimal variant of fibromuscular dysplasia. CaW has been associated with recurrent strokes and conventionally treated with surgical excision. We report a multicenter experience of stenting in patients with symptomatic CaWs.

Methods: Retrospective review of consecutive patients admitted to 5 comprehensive stroke centers who were identified to have a symptomatic CaW and treated with carotid stenting. A symptomatic CaW was defined by the presence of a shelf-like/linear, smooth filling defect in the posterior aspect of the carotid bulb diagnosed by neck CT angiography (CTA) and confirmed with conventional angiography in patients with negative stroke workup.

Results: Twenty-four patients with stented symptomatic CaW were identified (stroke in 83% and transient ischemic attack in 17%). Their median age was 47 years (IQR 41-61), 14 (58%) were female, and were 17 (71%) black. The degree of stenosis by NASCET was 0% (range 0-11). All patients were placed on dual antiplatelets and stented at a median of 9 days (IQR 4-35) after the last event. Closed-cell stents were used in 18 (75%) of the cases. No periprocedural events occurred with the exception of 2 cases of asymptomatic hypotension/bradycardia. Clinical follow-up after stent placement occurred for a median of 12 months (IQR 3-19) with no new cerebrovascular events noted. Functional independence at 90 days was achieved in 22 (91%) patients. Follow-up vascular imaging (ultrasound n = 18/CTA n = 5) was performed at a median of 10 months (IQR 3-18) and revealed no stenosis.

Conclusions: Stenting for symptomatic CaW appears to be a safe and effective alternative to surgical resection. Further studies are warranted.

Introduction: Distal access catheters are an infrequent focus of technical notes in neurointervention. The 5-French SOFIA's unique design allows for compatibility with 6-French guide catheters, while its supple construction allows for remarkably distal access for a catheter with a 0.055-inch inner diameter.

Methods: The authors reviewed a prospectively maintained endovascular database for cases utilizing the 5-French SOFIA from February 2017 through November 2017. Case type, SOFIA location, microcatheter used, and catheter-related complications were noted.

Results: Over the evaluated period, the 5-French SOFIA was utilized in 33 cases, including 13 aneurysm treatments, 10 arteriovenous shunt embolizations, 5 stroke thrombectomies, and 5 other cases. Of 5 flow diversion cases, 1 was for a symptomatic cavernous internal carotid artery aneurysm necessitating transradial access, another for a ruptured A3 aneurysm, and another for a middle cerebral artery (M2) aneurysm; 2 were more proximal aneurysms. Thrombectomies were for M2 (n = 3) or A2 (n = 2) occlusions. In all cases, the 5-French SOFIA reached its anticipated distal target without complication or the need to utilize a smaller/alternative catheter. Of these 33 cases, there were 10 cases of distal SOFIA target locations: 6 M2/M3, 3 anterior cerebral arteries (ACA), and 1 posterior cerebral artery (PCA). M2/M3 and PCA catheterization was achieved over 2.1-Fr microcatheters; ACA catheterization employed a 2.9-Fr microcatheter for pipeline embolization and a deployed stentriever in the setting of two thrombectomies.

Conclusion: The 5-French SOFIA can be safely utilized for distal, superselective catheterization in the context of complex neurointervention, including aneurysm and arteriovenous shunt embolization and distal thrombectomy.

Background: Treatment of large vessel occlusion acute ischemic stroke with mechanical thrombectomy has become the standard of care after recent clinical trials. However, the degree of recanalization with stent retrievers remains very important in overall outcomes. We sought to review the utility of a new balloon guide catheter (BGC) in improving the degree of recanalization in conjunction with mechanical thrombectomy.

Methods: The medical records of a prospectively collected endovascular ischemic stroke database were reviewed. All consecutive strokes when a FlowGate BGC was used with a thrombectomy stent retriever were identified. Use of a FlowGate BGC, number of passes, final Thrombolysis in Cerebral Infarction (TICI) score, trackability, and use of adjunct devices were all collected and analyzed.

Results: Use of a FlowGate BGC resulted in 64% (33/52) first-pass effect (FPE) of TICI 2b/3, and specifically 46% (24/52) TICI 3 FPE (true FPE). A total of 52/62 (84%) of thrombectomy cases were treated with BGCs. In the remaining 10, the BGC was not inflated or used due to the clot not being visualized or the lesions being distal and BGC use thus not deemed appropriate. Adjunct use of an aspiration catheter was seen in 12% (6/52) of cases. The overall success with FlowGate BGCs with one or more passes of TICI 2b/3 was 94% (49/52). Trackability was achieved in 92% (57/62) of cases.

Conclusions: Use of the FlowGate BGC as an adjunct to mechanical thrombectomy was associated with good FPE and an overall recanalization of TICI 2b/3 of 94%.

Background and purpose: We have observed that large vessel occlusion acute strokes (LVOS) due to intracranial atherosclerotic disease (ICAD) present with more benign CT perfusion (CTP) profiles, which we presume to potentially represent enhanced collateralization compared to embolic LVOS. We aim to determine if CTP profiles can predict ICAD in LVOS.

Methods: Retrospective review of a prospectively collected interventional stroke database from September 2010 to March 2015. Patients with intracranial ICA/MCA-M1/M2 occlusions and CTP were dichotomized into ICAD versus non-ICAD etiologies. Ischemic core (relative cerebral blood flow < 30%) and hypoperfusion volumes were estimated by automated CTP.

Results: A total of 250 patients met the inclusion criteria, comprised of 21 (8%) ICAD and 229 non-ICAD etiologies. Baseline characteristics were similar between groups, except for higher HbA1c levels (p < 0.01), LDL cholesterol (p < 0.01), systolic blood pressure (p < 0.01), and lower rate of atrial fibrillation (p < 0.01) in ICAD patients. There were no significant differences in volumes of baseline ischemic core (p = 0.54) among groups. ICAD patients had smaller Tmax > 4 s, Tmax > 6 s, and Tmax > 10 s absolute lesions, and a higher ratio of Tmax > 4 s/Tmax > 6 s volumes (median 2 [1.6-2.3] vs. 1.6 [1.4-2.0]; p = 0.02). A Tmax > 4 s/Tmax > 6 s ratio ≥2 showed specificity = 73%/sensitivity = 52% for ICAD and was observed in 47.6% of ICAD versus 26.1% of non-ICAD patients (p = 0.07). Clinical outcomes were comparable amongst groups. Multivariate logistic regression revealed that Tmax > 4 s/Tmax > 6 s ratio ≥2 (OR 3.75, 95% CI 1.05-13.14, p = 0.04), higher LDL cholesterol (OR 1.1, 95% CI 1.01-1.03, p = 0.01), and higher systolic pressure (OR 1.03, 95% CI 1.01-1.04, p = 0.01) were independently associated with ICAD.

Conclusion: An automated CTP Tmax > 4 s/Tmax > 6 s ratio ≥2 profile was found independently associated with underlying ICAD LVOS.

Introduction: This study assessed the safety and effectiveness of the Pipeline embolization device (PED) for persistent and recurrent aneurysms previously treated with either a vascular reconstruction device (VRD) or a flow diverter (FD).

Methods: A prospective, IRB-approved database was analyzed for patients treated with PED for aneurysms previously treated with a stent.

Results: Twenty procedures were performed on 18 patients, 11 with prior FD, 7 with VRD, and 2 previously treated with both. Overall, 15 aneurysms were saccular (75%), and size was 13.5 ± 7.6 mm. Location was internal carotid artery (ICA) in 14 cases (70%) and posterior circulation in 6 cases (30%). Average prior treatments were 1.7. Previously FD cases were re-treated at an average of 18.1 months from most recent treatment. Each case used 1 device, 82% with distal coverage and 82% with proximal coverage of prior stent. Balloon remodeling was performed in 3 cases (27%) and no in-stent thrombosis was observed. Previously VRD stent-coiled cases were re-treated at an average of 87.5 months. These cases used on average 1.9 devices, 89% with distal and 100% proximal coverage. Adjunctive coiling was performed in 1 case (11%), balloon remodeling in 5 cases (56%), and 2 cases (28%) developed thrombosis that resolved with abciximab. Re-VRD cases were longer (59.1 vs. 33.7 min, p = 0.02) than re-FD. Angiographic follow-up was available for 16 cases (80%). In re-FD, occlusion was complete in 56% and partial progressive in 33% at 17.1 months digital subtraction angiography. In re-VRD, occlusion was complete in 57% and partial progressive in 27% at 8.1 months. Two complications occurred (10%), including one asymptomatic cervical ICA occlusion and one stent occlusion with associated mortality (5%). Clinical follow-up was 17.8 months on average (range 0.5-51.9).

Conclusions: Salvage flow diversion for previously stented aneurysms is technically challenging but offers good prospects of aneurysm obliteration with acceptable complication rates.

Background and purpose: The relative contribution of each Alberta Stroke Program Early CT Score (ASPECTS) region to poststroke disability likely varies across regions. Determining the relative weights of each ASPECTS region may improve patient selection for endovascular stroke therapy (EST).

Methods: In the combined Solitaire Flow Restoration with the Intention for Thrombectomy (SWIFT), Solitaire Flow Restoration Thrombectomy for Acute Revascularization (STAR), and Solitaire Flow Restoration with the Intention for Thrombectomy as Primary Endovascular Treatment (SWIFT PRIME) databases, we identified patients treated with the Solitaire stent retriever. Using 24-h CT scan, a multivariate ordinal regression was used to determine the relative contribution of each ASPECTS region to clinical outcome separately in each hemisphere. The coefficients from the regression were used to create a weighted ASPECTS (wASPECTS), which was compared with the original ASPECTS to predict 90-day modified Rankin Scale disability outcomes in an independent validation cohort.

Results: Among 342 patients treated with EST, the average age was 67 years, 57% were female, and the median National Institutes of Health Stroke Scale (NIHSS) score was 17 (IQR 13-20). The median ASPECTS at presentation was 8 (IQR 7-10). The most commonly involved ASPECTS regions on 24-h CT were the lentiform nuclei (70%), insula (55%), and caudate (52%). In multivariate analysis, preservation of M6 (β = 9.7) and M4 (β = 4.4) regions in the right hemisphere was most strongly predictive of good outcome. For the left hemisphere, M6 (β = 5.5), M5 (β = 4.1), and M3 (β = 3.1) generated the greatest parameter estimates, though they did not reach statistical significance. A wASPECTS incorporating all 20 parameter estimates resulted in improved discrimination against the original ASPECTS in the independent cohort (C-statistic 0.78 vs. 0.67, right hemisphere).

Conclusions: For both right and left hemisphere, preservation of the high cortical regions was more strongly associated with improved outcomes compared to the deep regions. Our findings support taking into consideration the location and relative weightings of the involved ASPECTS regions when evaluating a patient for EST.

Background: Variations in aortic arch anatomy have been extensively described from multiple perspectives including gross anatomy, embryology, associated cardiac and other anomalies, early life presentation, and cross-sectional diagnosis. There is however a paucity of literature with an emphasis on safe and timely catheterization, particularly when the variants are found during emergent or other catheter angiographic procedures without benefit of prior cross-sectional vascular imaging. The purpose of this review is to try to fill this gap.

Methods: A review of past 1,000 diagnostic and therapeutic catheterizations was performed to identify arch variants, which are presented in order of frequency encountered at our institutions.

Results: The variants are presented as illustrations and catheter angiographic images, with emphasis on safe and efficient intraprocedural diagnosis and catheterization.

Conclusion: Familiarity with more and less common arch variants, along with low threshold for performance of pigtail aortic arch angiography and comfort in use of general purpose and recurved catheters, will ensure success in the vast majority of encountered variations.

Background: Provision of stroke education to patients is a Centers for Medicare/Medicaid (CMS) requirement. However, little is known about retention of the educational content.

Methods: Two pilot studies were conducted: Pilot A delivered CMS-required stroke education during hospitalization in a standardized manner and tested knowledge retention in patients returning to the Stroke Clinic for 1-month follow-up; Pilot B randomized patients to either a control group with standardized education or a test-enhanced learning group (target), with measurement of stroke knowledge retention at hospital discharge.

Results: A total of 198 patients/caregivers participated in Pilot A, with only 25% scoring 100% correct on required stroke education items. The question most commonly answered incorrectly (n = 117; 59%) was "personal risk factors for stroke," and 74 (37%) could not correctly identify stroke signs and symptoms. Pilot B found that significantly more target group patients could identify their personal stroke risk factors (100 vs. 67%; p = 0.04) and the purpose of their secondary prevention medications (87 vs. 40%; p = 0.02) compared to controls.

Discussion: While stroke education is required during hospitalization, its ability to produce retention may be poor. We propose study of test-enhanced learning methods through the Targeted Education in Stroke Trial (TEST) to examine the effect of novel teaching methods on patient/caregiver knowledge retention.

Background and purpose: Carotid webs are an increasingly recognized cause of acute is-chemic stroke, particularly in younger adults. The optimal medical and surgical strategies for managing these lesions have not been well established. We report a single-center case series of carotid stenting for treatment of symptomatic carotid webs.

Materials and methods: Consecutive patients undergoing stent placement for treatment of symptomatic carotid webs were included. Carotid webs were defined as a thin intraluminal filling defect along the posterior wall of the carotid bulb just beyond the carotid bifurcation on CTA. Data were collected on demographic characteristics, antiplatelet management, clinical presentation, imaging findings, treatment characteristics, complications, and stroke recurrence rates. Descriptive statistics are reported.

Results: A total of 4 patients were treated. Their mean age was 44 years (range 30-50). Three patients were female and 1 was male. All patients were symptomatic presenting with ipsilateral transient ischemic attacks or stroke. Patients were placed on dual antiplatelet therapy with ticagrelor and aspirin prior to the procedure. There were no ischemic or hemorrhagic complications. Three patients had postoperative bradycardia, 1 of whom required atropine immediately following stenting. No patients had recurrent ischemic events.

Conclusions: Stent placement for treatment of carotid webs can be performed safely. Further studies are needed to confirm our findings.