Interventional Neuroradiology最新文献

Background and purposeThe transradial (TR) approach is an alternative to the traditional transfemoral (TF) approach for extracranial carotid artery stenting (eCAS). A successful eCAS may be contingent on the geometry of the great vessels. We aimed to analyze the vessel geometry to identify predictors for successful stent placement, enabling tailored approaches.Materials and methodsMulticenter retrospective data was collected from the electronic health record of patients who underwent eCAS from January 2018 to December 2022. Geometric parameters for great vessels were measured using computed tomography angiography (CTA) or magnetic resonance angiography (MRA). A successful approach was defined as completing eCAS without conversion. We performed a geometric analysis of features correlated with complications and successful completion of eCAS.Results1346 patients underwent TF (1081) and TR (265) eCAS. Conversion from TR to TF occurred in 44 cases (17%). Three TF cases required conversion. Complication rates did not differ between approaches (P = .773), but converting to TF had significantly higher Category 1 complications (P < .001). A smaller angle of origin of the left common carotid artery (A3) correlated with increased complications (P = .039), particularly with angles <90°, peaking at 50°. No other geometric features predicted the success.ConclusionBoth TR and TF stenting can be safely performed for carotid disease, but the angle of the left carotid artery origin predicted an increased risk of complications. No other aortic arch types or great vessel geometry predicted complications. Conversion from TR to TF predicted increased stroke, ICH, and MI.

Background and objectivesMiddle meningeal artery embolization (MMAE) has become a pivotal intervention in managing chronic subdural hematomas (cSDHs). This systematic review synthesizes past, recent, and ongoing clinical trials to assess MMAE's role in cSDH treatment.MethodsA systematic review was conducted using PRISMA guidelines, incorporating PubMed, ClinicalTrials.gov, and reverse bibliography searches to identify clinical trials evaluating MMAE for cSDH. Inclusion criteria included randomized and nonrandomized trials reporting outcomes, such as recurrence rates and procedural safety. Case reports, retrospective reviews, and opinion pieces were excluded.ResultsSeven published and 15 ongoing trials were identified. Landmark randomized controlled trials (RCTs), including EMBOLISE, STEM, and MAGIC-MT, demonstrated reductions in hematoma recurrence and surgical rescues with MMAE, establishing its role as both an adjunctive and standalone therapy. Ongoing trials, such as EMPROTECT and CHESS, investigate diverse embolic agents, procedural strategies, and patient populations to optimize MMAE outcomes. However, challenges remain, including variability in patient selection criteria, embolic materials, and endpoints.ConclusionMMAE is an innovative and minimally invasive approach that has reshaped cSDH management. Evidence supports its efficacy and safety as an adjunct to surgery and a potential standalone therapy for select patients. Future research should focus on long-term outcomes, subgroup analyses, and standardization of protocols to further refine its application and integration into clinical practice.

ObjectiveIntra-arterial chemotherapy (IAC) is a well-established treatment for retinoblastoma (RB). However, there are no standardized recommendations regarding the choice of drugs. This study compares the outcomes of single- versus multi-drug therapy.MethodsClinical data was reviewed for RB children treated with IAC at our institution between 2018 and 2023. Patients were divided into single- and multi-drug treatment groups. Clinical parameters included total number of IAC treatments, treatment-related adverse events, duration of additional post-IAC treatments, residual disease, recurrence, and the need for enucleation.ObservationsA total of 101 IAC treatments were included. Multi-drug therapy showed improved outcomes as compared to single-drug therapy, particularly in RB group B and C patients. After multi-drug IAC, less secondary treatment time was required compared to single-drug treatment (2.1 months versus 4.6 months; p = 0.019). Group B and C patients required a median of 8.5 fewer months of secondary treatment after multi- vs. single-drug IAC. Patients treated with multi-drug IAC had an overall lower rate of residual disease or recurrence compared to single-drug IAC patients (26.3% vs. 35.7% recurrence; 52.6% vs. 71.4% residual). In group B and C patients, the difference was more pronounced (12.5% vs. 40% recurrence; 37.5% vs. 60% residual). The overall success rate in preventing enucleation was 90.9%.ConclusionsIAC treatment for RB is safe and effective. IAC prevented enucleation in >90% of our patients. Multi-drug IAC patients required less secondary treatment post-IAC, particularly group B and C patients.

The Woven EndoBridge (WEB) device is an intrasaccular flow disruption device designed for the treatment of wide-necked aneurysms.^{1, 2} Once deployed into the aneurysm it initiates intra-aneurysmal stasis, thrombosis and occlusion, and flow diversion at the interface of the neck of the aneurysm with the parent vessel.³ The device offers the advantage of reduced operating time and reduced radiation exposure to the patient and the operator. We present a case of a patient in their 70s with a subarachnoid haemorrhage secondary to a ruptured aneurysm at the bifurcation of the right middle cerebral artery. Endovascular treatment was initially attempted with a 7 × 2 mm WEB single layer. Its inadvertent displacement following deployment occluded the superior M2 branch. A snare device was used to capture the proximal marker of the WEB and retrieve the device (Video 1).^{4- 5} The aneurysm was subsequently treated during the same session with a balloon and Comaneci-assisted coiling.

IntroductionThree-dimensional rotational venography (3D-RV) expands on three-dimensional rotational angiography to provide high-quality venous anatomy details, complementing traditional two-dimensional digital subtraction angiography and supporting the diagnosis and treatment of venous pathologies. This article presents a series of patients who underwent advanced 3D-RV for the evaluation of idiopathic intracranial hypertension (IIH).MethodsIn this single-center retrospective case series, we analyzed 13 patients with IIH who underwent direct 3D-RV from June 2023 to May 2024. Access was obtained by placing a 6-Fr or larger guide catheter in the rostral internal jugular vein, with a Zoom 35 microcatheter advanced to the middle third of the superior sagittal sinus. A descriptive analysis was performed based on the demographic and radiation metrics.ResultsSixteen direct 3D-RV procedures were performed on 13 patients with IIH (mean age 42.06 ± 13.13 years), including 10 females and three males. General anesthesia was administered for interventions (12 cases) and monitored anesthesia care for manometry (four cases). Venous access was obtained via upper extremity veins in 13 cases (81.25%) and the right common femoral vein in three cases (18.75%). Mean fluoroscopy time was 42.0 ± 29.8 min, contrast dose 92.2 ± 34.2 mL, dose area product (DAP) 18.6 ± 10.5 Gy·cm², and air kerma 1.3 ± 0.56 Gy, with a mean procedure time of 71.3 ± 42.0 min. The 3D-RV procedure contributed an additional 1.86 ± 0.6 Gy to DAP and 0.072 ± 0.021 Gy to air kerma, representing an extra 6.26% and 10.59% of the skin dose, respectively. No procedure-related or in-hospital complications occurred.ConclusionsThe 3D-RV procedure is reliable and safe, offering improved accuracy in assessing venous anatomy and stents without significantly impacting procedure time or radiation dose.

Traditionally, both visual and haptic feedback have been regarded as elementary aspects of endovascular neurosurgical intervention. The literature acknowledges that the lack of haptic feedback and the reliance on visual feedback alone in robotic endovascular neurosurgical intervention (RENI) is a limitation. However, several operators who are at the forefront of applying this technology appear to have become quickly accustomed to visual feedback alone. Some have explained their initial scepticism, but upon using the technology they eventually saw the lack of haptic feedback as less of an obstacle and started to regard visual feedback alone as a feasible and safe means to perform procedures. Therefore, this begs the question as to whether haptic feedback is in effect a necessity or a commodity. In this commentary, several considerations are made, presenting arguments supporting the idea that haptic feedback may not be an absolute necessity, and their potential counterarguments. Such reflection and discussion on the topic of haptic feedback in RENI is timely and presently warranted to guide its research and development.

Background: Endovascular treatment (EVT) of intracranial aneurysms (IAs) has improved significantly with the integration of virtual simulation software (VSS) in surgical planning and device selection. Despite promising outcomes, discrepancies remain between physician and VSS recommendations. This review synthesizes evidence on (1) comparisons between VSS-chosen and physician-chosen dimensions; (2) VSS-chosen and postoperative measured dimensions; and (3) the success rate of VSS-guided device deployment.

Methods: A systematic search adhering to PRISMA guidelines was conducted in Medline, Embase, Web of Science, and Cochrane databases up to January 2024. Eligible studies included case series, cohort studies, and randomized trials assessing VSS for stent selection in IAs treatment. Mean difference (MD) and single-arm meta-analysis with 95% confidence intervals (CIs) under a random-effects model were performed for continuous and binary outcomes. Subanalyses were conducted for Sim&Size and PreSize software.

Results: Ten studies comprising 658 IAs were included. Pipeline Embolization Device was most commonly used. Findings demonstrated (1) high accuracy of VSS when comparing simulated and postoperative lengths (MD -1.7 mm; 95% CI -4.37 to 0.98 mm); (2) physician-chosen lengths overestimated compared to VSS (MD -2.11 mm; -3.43 to -0.79 mm); (3) no significant difference in physician- versus VSS-chosen diameters (MD -0.04 mm; -0.13 to 0.06 mm); and (4) high VSS-guided deployment success (96%; 93-99%) with low complications (4%). Subanalyses showed 95% and 92% deployment success rates for Sim&Size and PreSize, respectively.

Conclusion: VSS effectively estimates device length and achieves high deployment success, with low complication rates, supporting its utility in EVT planning.

Background: This study aimed to evaluate the periprocedural and postprocedural outcomes of endovascular treatments for cerebral vasospasm after subarachnoid hemorrhage using data from the Japan Registry of Neuroendovascular Therapy 4 (JR-NET4) (2015-2019).

Methods: In this retrospective multicenter study, procedures of endovascular treatment for cerebral vasospasms registered in JR-NET4 were analyzed. The procedure outcomes and complications for percutaneous transluminal angioplasty (PTA) and intra-arterial administration of vasodilators (IA-vasodilator) were compared. The factors associated with imaging and symptom improvement were assessed.

Results: Analysis of 1549 procedures revealed that 83.5% of procedures were IA-vasodilator and 16.5% of procedures were PTA. Postprocedural imaging improvement was achieved in 97.0% of patients, and 50.1% of patients experienced symptomatic improvement. The overall complication rate was 1.6%. No significant differences were detected in overall complication rates between patients who underwent PTA and intra-arterial administration of vasodilators; however, hemorrhagic complications were significantly more frequent in patients who underwent PTA. Shorter intervals from symptom onset and the absence of periprocedural complications were associated with improved imaging and neurological outcomes. Local anesthesia and prior treatment with endovascular embolization for ruptured aneurysms were associated with enhanced neurological improvements.

Conclusion: Endovascular treatment for cerebral vasospasm is safe and effective. Factors such as early intervention and treatment under local anesthesia may contribute to neurological improvements. However, caution is warranted for PTA due to the slightly higher incidence of hemorrhagic complications.

Introduction: Pulsatile tinnitus (PT) affects ∼ 10% of the population and can be debilitating. Venous etiologies of PT are increasingly recognized. Identifying the symptomatic vessel, particularly with multiple venous anomalies, remains challenging.

Methods: In this case series, we utilized venous balloon occlusion testing (vBOT) as a real-time diagnostic tool to identify symptomatic vessels in non-sinus stenosis venous PT. vBOT involved using a transform balloon (7 mm × 7 mm) under fluoroscopic guidance to occlude the venous anomaly, with immediate assessment of symptom resolution.

Results: We report four cases involving high-riding jugular bulbs, jugular bulb diverticula, and enlarged emissary veins. vBOT successfully identified the culprit vessels, guiding targeted endovascular coil embolization. These procedures led to significant symptom resolution in all cases, though the varied patient responses underscored the importance of a tailored, iterative approach, particularly in those with bilateral symptoms or multiple venous variants.

Conclusion: This series illustrates the utility of vBOT in accurately identifying symptomatic vessels in non-sinus stenosis venous PT, enabling effective, targeted interventions. While vBOT is a valuable diagnostic tool, its limitations, including potential false negatives due to PT variability or ambient noise, must be considered. Incorporating vBOT into the diagnostic framework for PT can enhance precision in vessel selection and improve patient outcomes, particularly in cases with uncommon venous etiologies.

Background: Rapid reperfusion is an important predictor of neurologic recovery in acute ischemic stroke due to large vessel occlusion (AIS-LVO) treated with mechanical thrombectomy (MT). We present a single-institution retrospective observational study of the ThrOmbectomy withOut Flushes or AnestheSia Teams (TOOFAST) technique, which eliminates continuous heparinized saline flushes and employs conscious sedation (CS) to streamline MT preparation.

Methods: Retrospective review of prospectively collected data for AIS-LVO patients at our comprehensive stroke center from January 1, 2020, to December 31, 2023. Patients were >18 years with premorbid modified Rankin Scale (mRS) <3. Cases were performed under CS without continuous pressurized heparinized saline flushes or anesthesiologist involvement. Cases were categorized as presenting to the emergency department or from inpatient units (in-house), outside hospital transfers, or those undergoing hyperacute MRI.

Results: Among 947 total cases, 638 were analyzed. 374 (58.6%) were in-house activations, 205 (32.1%) were transfers, and 59 (9.2%) underwent hyperacute MRI. Median presenting National Institutes of Health Stroke Scale (NIHSS) was 15 (interquartile range (IQR) 9-20) and 34.7% of patients received intravenous thrombolysis. Median arrival-to-access and NIR-to-access times for in-house activations were 67 (IQR 56-80) and 39 (IQR 29-48) minutes, respectively. Embolization to new territory occurred in 11 (1.7%) patients while vascular perforation occurred in 9 (1.4%). Median NIHSS shift from admission to discharge was -9 (IQR -15 to -5). At 90 days, 46.5% (106/228) remained mRS <3.

Conclusions: The TOOFAST technique may result in rapid access times with a profile of safety, procedural parameters, and neurologic outcomes comparable to published trial standards.