Interventional Neuroradiology最新文献

Background: Early identification and quantification of core infarct is of importance in stroke management for treatment selection, prognostication, and complication prediction. Non-contrast computed tomography (CT) (NCCT) remains the primary tool, but it suffers from limited sensitivity and inter-rater variability; CT perfusion is inconsistently available and commonly blighted by movement artefact. We assessed the performance of a standardised form of CT angiographic source imaging (CTASI) obtained through addition of a delayed phase at 40 seconds post-contrast injection (DP40) following fast-acquisition CT angiography.

Methods: Contrast resolution between ischaemic and normal grey matter (GM) was compared qualitatively and quantitatively to NCCT. Using Alberta Stroke Program Early CT Score (ASPECTS), DP40 low density was compared to NCCT and venous phase CT perfusion source images (CTPSI) and to 24-hour NCCT ASPECTS in patients with timely endovascular recanalisation (Thrombolysis In Cerebral Infarction 2C/3).

Results: Seventy-four patients with a proximal middle cerebral artery or terminal internal carotid artery occlusion were included. The mean attenuation difference between ischaemic and normal GM increased from 4.86+/-3.12 HU (NCCT) to 9.30+/-3.14 HU (DP40) (p < 0.0001). Subjective assessment by two raters revealed that DP40 improved ischaemic tissue conspicuity in 39 to 41 (78-82%) of cases (kappa 0.805, standard error 0.108, 95% confidence interval: 0.593-1.000). The correlation between ASPECTS on baseline imaging and eventual 24-hour ASPECTS improved from R = 0.7197 for NCCT to R = 0.9875 for DP40 (z = 7.89, p < 0.0001). The correlation between DP40 and venous phase CTPSI ASPECTS was 0.9681, p < 0.0001.

Conclusion: DP40 CTASI represent a simple technique for improving detection and estimation of extent of ischaemia over NCCT and show close correlation with surrogate measures of infarct core.

Background: WEB shape modification has been analyzed in relation to the aneurysm occlusion outcome and techniques have been presented with one-dimensional measurements of the device to quantify the change after implantation. In this work, we present an analysis of pre-treatment vascular morphology and hemodynamics of cases treated with WEB devices, which were three-dimensionally quantified in morphology and position to detect modifications.

Methods: Seventeen WEB-treated aneurysms with pre-treatment, post-treatment and follow-up 3D flat-panel CT were included. Three-dimensional measurements of the WEB morphology and position were made at post-treatment and at follow-up. Differences between acquisitions of all measured variables were statistically evaluated (Wilcoxon signed-rank paired test, P-value = 0.05). Pre-treatment aneurysm angles were three-dimensionally measured and CFD simulations were performed to evaluate the influence of flow on WEB changes.

Results: WEB height and diameter presented statistically significant changes. Modification of the angle between the WEB axis and parent artery was significantly higher in the group with WEB shape modification (Mann-Whitney U test, P < 0.05). In this group, the median pre-treatment aneurysm angle was smaller than in the group without shape modification (8.16° vs. 13.14°, P = 0.06). Inflow ratio was higher in the WEB shape modification group.

Conclusions: An association between the magnitude of morphological changes of the WEB with the direction of its axis within the aneurysm was found. The analysis of pre-treatment morphological and hemodynamic conditions would allow the detection of aneurysm cases in which the WEB will undergo a more pronounced modification.

Introduction: We aimed to explore if anatomical and technical features could interact and favor the chances of reperfusion according to the treatment strategy: combined technique (CoT) of mechanical thrombectomy (MT) with contact aspiration and stent-retriever (SR) versus SR alone.

Methods: Retrospective analysis of a prospective MT database for carotid terminus or MCA-M1 occlusion, first-line SR alone or CoT, and angiographic run with SR deployed on the first pass. The primary analysis involved the interaction between clinical and angiographic characteristics and first-line MT modality on first-pass effect (FPE; first pass eTICI2c-3).

Results: A total of 300 consecutive patients were included (SR alone, n = 210 vs CoT, n = 90). Baseline characteristics as well as baseline ASPECTS, CTA collateral score, clot burden score, FPE were similar amongst groups. Anatomical and technical variables (presence of reperfusion channel, frequency of SR position in dominant MCA division, angle of device-clot interaction, and clot length) were comparable between groups, with exception of SR opening (diameter across the occlusion) and length of SR purchase beyond the clot being more pronounced in the SR group. None of the clinical, anatomical, and technical factors were found to have an interaction with the MT strategy on the chances of FPE (P-interaction ≥ 0.001). Multivariable logistic regression showed that clot burden score ≥8 (aOR 3.02, P = 0.003), angle of interaction (aOR 1.01, P = 0.015) but not the MT modality were associated with FPE.

Conclusion: No specific anatomical or technical features were observed to predispose to benefit when combining contact aspiration and SR thrombectomy. Clot burden score ≥ 8 and angle of interaction were independent factors associated with FPE. Additional studies are warranted.

Background: The impact of certain comorbidities on mechanical thrombectomy (MT) outcomes remains largely unexplored. Diabetes mellitus (DM) and admission hyperglycemia have been associated with poor clinical outcomes for patients treated with MT. In this study, we sought to investigate the effects of DM and admission hyperglycemia on MT outcomes.

Methods: Following PRISMA guidelines, a systematic literature search was conducted in Medline, Embase, Scopus, and Web of Science databases. Data regarding successful recanalization (modified Thrombolysis in Cerebral Infarction [mTICI] ≥2b), functional independence (modified Rankin Scale [mRS] 0-2), excellent outcomes (mRS 0-1), symptomatic intracranial hemorrhage (sICH), and mortality were extracted from the included studies. The pooled odds ratios (ORs) and their corresponding 95% confidence intervals (CIs) were calculated using random effects model.

Results: Twenty-one studies comprising 9708 patients were included. A total of 2311 patients (24%) had a history of DM, and 2026 patients (21%) had admission hyperglycemia. Admission hyperglycemia was associated with significantly lower odds of mTICI ≥2b (OR = 0.7, 95% CI = 0.55-0.89), mRS 0-2 (OR = 0.47, 95% CI = 0.41-0.53), and mRS 0-1 (OR = 0.43, 95% CI = 0.34-0.55) as compared to normoglycemic state. Patients with hyperglycemia had significantly higher rates of sICH (OR = 2.05, 95% CI = 1.66-2.54) and mortality (OR = 1.99, 95% CI = 1.58-2.52) than normoglycemic patients. Diabetes mellitus was associated with significantly high rates of mortality (OR = 1.74, 95% CI = 1.31-2.3) and lower rates of mRS 0-2 (OR = 0.60, 95% CI = 0.48-0.76) in sensitivity analyses.

Conclusion: Our results indicate that admission blood glucose levels and DM can negatively affect MT outcomes. Further research should focus on optimizing MT outcomes for these patients.

Background: Intrasaccular flow diversion using the woven endobridge device (WEB; MicroVention, Aliso Viejo, CA, USA) for the treatment of intracranial aneurysms has demonstrated large scale safety and efficacy. However, limitations arise from its structural configuration, restricting its application to specific aneurysm sizes and shapes.

Technique overview: We introduce the CUPCAKE technique, a combination of conventional coiling followed by WEB intrasaccular flow disruption in select cases of atypical aneurysms with technically challenging morphology not typically treatable by WEB alone.

Materials and methods: A retrospective analysis of a prospectively-maintained dataset from three Australian neurovascular tertiary referral centers, identifying patients treated with the CUPCAKE technique between April 2018 and September 2023. Evaluation of patient and aneurysm characteristics, procedure parameters, complications, radiological and clinical outcomes at follow-up was performed.

Results: The CUPCAKE technique was used for the treatment of 22 intracranial aneurysms of total 169 treated with WEB. Overall successful immediate flow stagnation was observed in 95.5% (n = 21) of aneurysms with no cases of perforation or intraoperative hemorrhage. Imaging confirmed thromboembolic complications occurred in two patients, one patient had persistent flow requiring re-treatment during initial admission. Follow-up imaging demonstrated 88.2% complete aneurysm conclusion with no delayed aneurysm expansion or rupture.

Conclusion: Synergistic use of conventional coiling with WEB intrasaccular flow disruption presents a viable solution for technically difficult aneurysm treatment. In our series, 13% of all patients treated with WEB received CUPCAKE treatment, resulting in high technical success and no increase in thromboembolic complications with the union of two methods.

Introduction: Mechanical thrombectomy (MT) for medium vessel occlusions (MeVO) is emerging as a promising treatment in acute stroke. We aim to evaluate the utility of additional imaging (CTP) in patients with MeVOs who received thrombolysis at a spoke hospital and were transferred to the hub.

Methods: This was a retrospective review of prospectively collected data from April 2018 to June 2023. Patients were transferred to one of the following destinations: CT scanner for a perfusion scan, directly to the angiography suite, or admitted to the neurological intensive care unit (NICU). We compared baseline characteristics, MT times, radiographic and clinical outcomes between the group that was initially transferred to CTP vs. the group that was not initially transferred to CTP.

Results: Seventy-eight MeVO patients who received IV thrombolysis and were transferred to our comprehensive stroke center were included in the analysis. Forty patients went directly to CTP, thirty went directly to the angiography suite (DTA), and eight were transferred to the NICU. 67.5% of patients presenting to CTP did not subsequently go to the angiography suite. The CTP and non-CTP groups did not differ significantly in terms of demographics, rates of successful recanalization, complications, and clinical outcomes at 90 days. The CTP group had significantly longer median door-to-groin times and median door-to-recanalization times.

Conclusion: Mechanical thrombectomy should be considered in stroke patients with confirmed medium vessel occlusions who receive thrombolysis. CTP utilization may lead to lower angiography utilization and longer door-to-procedure times but does not significantly affect long-term outcomes.

Background: Middle meningeal artery embolization (MMAE) emerges as an alternative to conventional surgical drainage (CSD) for chronic subdural hematomas (cSDH). Several studies have suggested that MMAE improves the cost efficacy of cSDH treatment. However, further comprehensive analyses of the outcomes and healthcare costs of MMAE are necessary.

Methods: Merative MarketScan Research Database from 2017-2022 was used to compare demographics, reoperation rates, complications, healthcare utilization, and payments of patients being treated with CSD, CSD and adjunctive MMAE, or standalone MMAE for cSDH or nontraumatic subdural hemorrhage.

Results: From 2017-2022, there were 2108 patients who underwent CSD (n = 2015), or CSD+MMAE (n = 23) or MMAE only (n = 70). The median age of the surgical group was 61 years (IQR 53-73 years), the surgery plus MMAE was 67 years (56-77 years) and the MMAE group was 65 years (55-77 years). Median hospital days were significantly longer for the CSD (6 (IQR 5-7) days) and CSD + MMAE (7 (IQR 6-7) days) groups compared to MMAE only (0 days(IQR 0-1)(p < 0.0001). Median index hospitalization payments were significantly higher for the CSD+MMAE group ($74,568) compared to both CSD ($39,658) (p = 0.003) and MMAE groups ($22,286) (p < 0.0001). The total median payments at six-month follow-up for the CSD group were higher compared to CSD+MMAE ($11494 vs $7300, p = 0.0017) but not compared to MMAE only ($10,680, p = 0.08).

Conclusions: The reduced complications, infection rate, hospital utilization, and costs observed in this study support MMAE as a promising treatment option in the arsenal for cSDH management.

Background: Previous studies suggest a positive relationship between higher hospital endovascular thrombectomy (EVT) volume and improved outcomes. We investigated this association using the National Inpatient Sample (NIS) database from 2016 to 2020.

Methods: A cross-sectional analysis of the NIS examined the relationship between hospital EVT volume and outcomes. Data on clinical and demographic variables were collected. Outcomes included favorable functional outcome (discharge home without assistance), inpatient mortality, and intracerebral hemorrhage (ICH). Hospitals in the top quintile of annual EVT volume were classified as high-volume centers. We conducted univariate, multivariate, nearest neighbor matched analysis, and an exploratory analysis to identify annual EVT volume cutoffs.

Results: Among 114,640 patients with EVT, 24,415 (21.3%) were treated at high-volume centers. High-volume centers had higher rates of favorable functional outcomes in univariate (odds ratio (OR) 1.20, p < 0.001), multivariate (adjusted OR (aOR) 1.19, p = 0.003), and matched analysis (OR 1.14, p = 0.028). Before matching, inpatient mortality was lower in high-volume centers (OR 0.83, p < 0.001), but this difference was not significant in univariate and matched analyses. No differences in ICH were observed. Functional benefit was noted at ≥ 50 EVTs annually, with centers performing  ≥ 175 EVTs showing significantly higher benefits (aOR 1.42, p = 0.002).

Conclusions: Increased hospital EVT volume is associated with modestly improved functional outcomes in patients with acute ischemic stroke. Functional improvements are evident at ≥ 50 EVTs annually and increase with higher case volumes, without associated increases in inpatient mortality or ICH.

Background and purpose: We report short- and intermediate-term effects on headaches with intra-arterial injection of lidocaine in the middle meningeal artery in patients with severe headaches associated with subarachnoid hemorrhage.

Methods: We treated seven patients with intra-arterial lidocaine in doses up to 50 mg in each middle meningeal artery via a microcatheter bilaterally (except in one patient). We recorded the maximum intensity of headache (graded by 11-point numeric rating scale) prior to procedure and every day for the next 10 days or discharge, whichever came first. We identified changes in the middle meningeal artery pre- and post-intra-arterial lidocaine administration and quantified from Grade 0 (no change) to Grade 5 (severe narrowing or near occlusion of anterior and posterior dural branches or proximal middle meningeal artery that precludes adequate imaging of distal branches).

Results: We observed improvement in severity of headaches of headache in all seven subarachnoid hemorrhage patients. The resolution of headache was immediate and complete in four patients, unilateral immediate resolution in one patient, and delayed complete resolution in patient. Two patients met the definition of severe headache (defined as 2 or more days with maximum pain scores of 8 or greater or need for 3 or more different analgesics for 2 or more days) post-lidocaine treatment. One of these patients had are lapse in headache with the severity matching pretreatment severity and required a second treatment. On analysis of angiographic data, there was consistent narrowing of middle meningeal arteries after administration of intra-arterial lidocaine and was graded as 5 in 2 arteries, 4 in 10 arteries, and 3 in 2 arteries.

Conclusions: We found that intra-arterial injection of lidocaine can result in consistent amelioration of headache in patients with subarachnoid hemorrhage. The therapeutic benefit may be related to vasoconstriction (reversal of vasodilation) in the middle meningeal arteries after administration of lidocaine.

Background: For patients with suspected traumatic vertebral artery injury (TVAI), CT angiography (CTA) is the first-line screening modality. Digital subtraction angiography (DSA) serves as the confirmatory diagnostic imaging, and is the gold standard for cerebrovascular injury assessment, due to its higher sensitivity and specificity. Among patients with TVAI based on CTA who have undergone follow-up DSA, this study aims to investigate how diagnostic information with additional imaging affects clinical management.

Methods: A retrospective review was conducted over 7 years (2016-2023) at a level 1 trauma center for TVAI patients undergoing both CTA and DSA. Pre- and post-DSA approaches to TVAI management were compared and summarized using propensity-score matched analysis.

Results: Among the 69 patients studied, 24.6% were determined to have false-positive TVAI after DSA. The rate of change in management after DSA was significantly different across DSA+ and DSA- cohorts (p = 0.02). The likelihood of a change in management in patients with based on outcome of the DSA was significant (p = 0.03) in the propensity-matched cohort. On average, 3 (NNI = 3.2) patients would need to receive a DSA for one additional patient to undergo a change in management.

Conclusion: This study demonstrates that, despite initial CTA imaging suggestive of TVAI, follow-up DSA imaging negative for TVAI has a significant impact on changing clinical management, including cessation of antithrombotic agents. Thus, for TVAI patients, DSA may be considered in the diagnostic workup for select patients with positive CTA. Larger cohort analyses are needed to refine imaging algorithms and optimize clinical outcomes for TVAI patients.