Interventional Neuroradiology最新文献

BackgroundIntracranial high-flow vascular malformations greatly alter neonatal cerebral hemodynamics and can cause significant morbidity and mortality. X-ray digital subtraction angiography (DSA) is the standard of care to assess angioarchitecture and plan for intervention, but exposes patients to radiation and procedural risks, and only allows for subjective interpretation. Objective noninvasive assessment of hemodynamics could improve prognostication. Data on normal or abnormal cerebral hemodynamics in neonates is limited due to the lack of readily available and validated methods. 4D flow MRI may offer noninvasive quantitative assessment of hemodynamic metrics to gain a better understanding of pathophysiology and may one day help to guide endovascular intervention. Here, we explore the feasibility of 4D flow MRI for the assessment of high-flow vascular malformations and present our initial experience.MethodsRetrospective analysis of 4D flow MRI studies was performed for five children with high-flow vascular malformations before and/or after embolization of their lesions. Two raters independently performed the 4D flow measurements: flow rate and peak speed. We compared quantitative measurements with qualitative angiographic findings.ResultsInterrater reliability of flow measurements was high (intraclass correlation coefficient 0.959). Quantitative changes in arterial and venous 4D flow measurements after embolization corresponded with qualitative changes on DSA.Conclusions4D flow MRI is a feasible and precise tool for studying high-flow intracranial vascular malformations in children with safety advantages over DSA. Standardized acquisition protocols and postprocessing methods could facilitate adoption across multiple centers.

BackgroundCriticism of clinical trials of endovascular therapy of acute ischemic stroke due to large vessel occlusion includes their lack of generalizability. We aimed to evaluate the impact of vessel tortuosity on the outcomes of large-bore and super-bore aspiration catheters in the Imperative Trial and to compare trial's selection of patients to a real-world setting.MethodsUsing baseline craniocervical angiography, we performed semi-automated analysis of various tortuosity characteristics. Comparison of tortuosity characteristics was made to a previously published cohort of 100 consecutive patients treated with thrombectomy (real-world cohort).ResultsOf the 249 Imperative Trial patients with anterior circulation strokes, 187 (89%) had complete tortuosity assessments from the aortic arch to the occlusion site. Tortuosity indexes for the common carotid, extracranial and intracranial internal carotid artery segments were similar for both cohorts (right side 0.18 ± 0.10, 0.17 ± 0.09, 0.45 ± 0.09 vs. 0.20 ± 0.09, 0.17 ± 0.09, 0.45 ± 0.09; left side: 0.12 ± 0.08, 0.19 ± 0.09, 0.44 ± 0.07 vs. 0.15 ± 0.08, 0.18 ± 0.08, 0.47 ± 0.07 in the Imperative Trial and in the real-world cohort, respectively). The proportion of patients with type 3 aortic arches was higher in the Imperative Trial than the real-word cohort (26% vs. 15%, p = .038).ConclusionsImperative trial patients treated with aspiration thrombectomy had similar vascular tortuosity characteristics compared to patients treated with thrombectomy in a real-world clinical setting. This confirms the generalizability of Imperative Trial findings to real-world clinical practice.

BackgroundDelivery assist catheters are a new class of devices designed to better navigate tortuous segments and reach the clot interface in mechanical thrombectomy. The RED 72 aspiration catheter with SENDit technology is one such example. SENDit is a novel tapered obturator used instead of a microcatheter to bring up the RED 72. It was designed to speed materials setup and overcome "ledge" effect. This case series aims to assess the safety, efficacy, and associated materials costs of SENDit in a postmarket study.MethodsThis was a single-institution retrospective case series of endovascular thrombectomy for anterior circulation large vessel occlusions affecting the internal carotid artery, M1, or M2 treated with SENDit between August 2023 and May 2024. Demographic, clinical, and cost variables were collected.ResultsMedian time from groin puncture to first pass was 14.0 min, and median time from groin puncture to recanalization was 25.0 min. Modified first-pass effect (mTICI ≥2b) was achieved in 51.4% of cases. The final recanalization mTICI ≥2b rate was 91.9%. A stentriever was required for 10.8% of cases. The rate of functional independence (mRS 0-2) at 3 months follow-up was 43.8%. The average materials cost per case was $7517.40 ± $2795.25; 10.8% of patients experienced access site complications. There was no artery dissection, and the rate of symptomatic intracerebral hemorrhage was 5.4%.ConclusionIn this case series, SENDit achieved a high rate of first pass effect, rapid recanalization, and low stentriever use and materials cost. It is safe given the low rate of procedural complications and favorable clinical outcomes. Delivery assist catheters are a promising alternative to stentrievers.

BackgroundCarotid body tumors (CBTs) are neuroendocrine tumors that arise from the carotid body. The malignant cases can present with a multitude of complications. Thus, surgical resection is the preferred treatment of choice. However, preoperative embolization is an established adjuvant treatment, especially with larger and symptomatic tumors. Current devascularization practice includes numerous techniques and materials, such as using liquid or embolic materials to embolize feeding vessels, coil embolization, direct tumor puncture, and covered stent placement. In this case series, we present our initial experience in pre-treatment of CBTs using a combined approach of established embolization techniques and balloon occlusion of the external carotid artery (ECA) via the EMBOGUARD^™ Balloon Guide Catheter (Johnson & Johnson Neurovascular, Irvine, CA).MethodsWe performed a retrospective review of medical records from March 2023 to February 2024, including patients over 18 years old diagnosed with a carotid body tumor who had pre-operative embolization using the EMBOGUARD^™ Balloon Guide Catheter. The primary outcome measure was the degree of angiographic devascularization achieved. Safety outcomes included procedural complications, such as non-target embolization into previously uninvolved territories and cranial nerve deficits.ResultsWe included three cases in which successful embolization was achieved with varying technical approaches, suggesting this technique's versatility and adaptability to different tumor characteristics.ConclusionThe EMBOGUARD™ Balloon Guide Catheter technique represents a promising addition to the endovascular treatment arsenal for CBTs. Continued evaluation through larger case series and longer follow-up periods is essential to fully establish flow arrest's role in CBT management.

BackgroundVenous sinus stenting (VSS) is a well-established treatment for medically refractory venopathic intracranial hypertension (VIH), with consistent improvements reported in symptoms such as headache, papilledema, and pulsatile tinnitus. Cognitive dysfunction, however, remains underexplored in terms of burden and response to surgical intervention.MethodsA retrospective, single-center study was performed of patients that underwent VSS for VIH. Symptom severity was assessed using the Cerebral Venous Disorder Symptom Severity (CVDSS) scale. Scores were collected pre-operatively and post-operatively at 2 weeks and 6 weeks.ResultsA total of 50 consecutive patients with a mean age of 35.7 years underwent venous sinus stent placement for VIH and were included. VSS resulted in a reduction of the average pressure gradient from 15.0 to 2.8 mmHg. Baseline CVDSS cognitive dysfunction scores were rated as moderate or severe in 84% of patients. Sixty-four percent of patients had improvement in cognitive dysfunction between baseline and 6-week post-operatively (OR 5.1 (95% CI: 2.2, 11.6)), with only 38% reporting ongoing moderate or severe cognitive dysfunction after stenting. Global symptom severity also demonstrated improvement at 6 weeks.ConclusionSelf-reported cognitive dysfunction is highly prevalent and often severe in patients with VIH. VSS is associated with significant improvement in short-term cognitive dysfunction scores in addition to global symptom severity.

BackgroundExternal ventricular drain (EVD) placement is a lifesaving procedure that accesses the ventricular system. It is typically performed freehand using external craniometric landmarks. Herein, we study the utility of digital subtraction angiograms (DSA) in determining the EVD location by comparing it to the deep venous system.MethodsA retrospective review was conducted at a single center from 2021 to 2024 to identify patients with EVD placement for communicating hydrocephalus secondary to a subarachnoid hemorrhage. Two independent reviewers assessed placement using Fargen's grade and a novel grading system. We analyzed inter-reviewer reliability.ResultsWe included 48 patients (mean age 60.3 ± 12.9) in this study. Most patients presented with a modified Fisher score of 4 (76.6%) and a Hunt-Hess grade of 4 (31.9%). Based on the computed tomography (CT) scan, 33 patients had good placement, 13 had contralateral placement, and two had suboptimal EVD placement. Inter-reviewer reliability between the Fargen CT and novel DSA grading systems demonstrated 85.4% overall agreement and Cohen's κ = 0.66 (95% CI, 0.41-0.90). The novel DSA grading system demonstrated moderate discrimination among the three CT-defined categories (one-vs-all AUCs: suboptimal 0.668, contralateral 0.847, good 0.841; multiclass AUC 0.700).ConclusionThis feasibility study suggests that EVD placement can efficiently be determined in the endovascular suite by visualizing the catheter's position in relation to the venous angle on DSA. While this may streamline emergency workflows and reduce reliance on immediate CT scans, subsequent verification with CT or magnetic resonance imaging remains essential. Prospective studies are needed to validate accuracy before wider adoption.

BackgroundSpinal dural arteriovenous fistulas (SDAVFs) are the most common type of spinal arteriovenous malformation. Typically, these malformations present with a wide range of nonspecific symptoms indicative of thoracolumbar myelopathy. However, patients with spinal dural arteriovenous fistulas may rarely present with subarachnoid hemorrhage.MethodsA systematic review of MEDLINE and Embase databases was performed querying for cases of spinal dural arteriovenous fistulas with subarachnoid hemorrhage. Patient characteristics and outcomes investigated included spinal level of the fistula, delay of diagnosis, Hunt and Hess grade, interventions, recurrence of the fistula, and postoperative disability. Additionally, we present a unique case in which subarachnoid hemorrhage resulted from a spinal dural arteriovenous fistula that was refractory to multiple endovascular and open surgical interventions.ResultsOf 116 records identified, 45 studies were included comprising 80 patients with spinal dural arteriovenous fistula and subarachnoid hemorrhage. The most common locations of the spinal dural arteriovenous fistula were in the cervical spine (57.5%) and at the craniocervical junction (35%). Patients were treated with open surgical ligation (60.0%), endovascular embolization (22.5%), or an open surgical procedure following persistent symptoms after endovascular treatment (10.0%). Overall, the prognoses among the treated patients were favorable with only two reported (2.5%) mortalities. Rates of neurologic recovery were similar when comparing endovascular and open surgical treatment. Endovascular treatment with coil embolization of a C1-C2 spinal dural arteriovenous fistula presenting as subarachnoid hemorrhage is also described.ConclusionSpinal dural arteriovenous fistulas, particularly in the cervical spine, could be considered as a potential etiology for subarachnoid hemorrhage patients with no obvious intracranial cause. Treatment with either open surgery or embolization appears to offer a positive prognosis for both functional and angiographic outcomes.

BackgroundHypoperfusion intensity ratio (HIR) and cerebral blood volume index (CBVI) have been shown to predict clinical outcome, but further validation is needed in patients initially presenting to non-thrombectomy centers.MethodsWe conducted a retrospective study of patients with an anterior circulation large vessel occlusion (ACLVO) who underwent computed tomography perfusion (CTP) scanning at a non-thrombectomy center and were transferred for consideration of thrombectomy. We evaluated the association of three measures of collateral status (HIR, CBVI, and a collateral score combining both measures) to 90-day modified Rankin scale (mRS).ResultsWe identified 497 eligible patients, of whom 93% underwent thrombectomy. After adjusting for covariates, ascending numerical CBVI was associated with 90-day mRS ≤ 2 in both overall patients and the recanalized subgroup (n = 436). In the recanalized subgroup, 90-day mRS ≤ 2 among patients with CBVI > 0.7 was 56% versus 36% with CBVI ≤ 0.7 [adjusted OR: 1.73 (1.13-2.65), p = 0.012]. Neither HIR thresholds below 0.4, 0.5, and 0.6, nor a good versus poor collateral score, were associated with independent or improved functional outcome,.ConclusionIn this study of ACLVO patients transferred for thrombectomy consideration, ascending numeric CBVI was associated with independent function in both the overall population and the recanalized subgroup, and CBVI > 0.7 was associated with both independent and improved functional outcome in recanalized patients. Among CTP measures of collateral status, CBVI alone may play an important role in stroke prognostication and management for ACLVO patients who initially present to a non-thrombectomy center.

ObjectiveUnderstanding anatomical variations of the middle meningeal artery (MMA), particularly the meningolacrimal anastomosis (MLA), is essential for the safe execution of MMA embolization (MMAe) procedures. Due to the small size of these dural branches, detailed anatomical dissections have been challenging, and conventional clinical angiography often underrepresents their frequency because of competing orbital blood flow. This study aimed to determine the prevalence and anatomical characteristics of the MLA using isolated high-resolution angiography and DynaCT in human cadaveric specimens.MethodsA prospective angiographic study was conducted in eight fresh human cadaveric specimens. Microcatheters were navigated into proximal MMA branches, followed by contrast injection and imaging with angiography and DynaCT. MLA identification, length, diameter, and branching patterns were recorded. Descriptive statistics were used to analyze anatomical characteristics.ResultsThe MLA was visualized in 15 of 16 (93.7%) MMAs. A single MLA was observed in 87.5% of cases; one specimen showed two branches. The mean length of the intradural segment of the MLA (from the origin at the MMA to the entry into the orbit) was 1.77 ± 0.70 cm. The mean diameter of the MLA was 0.93 ± 0.29 mm, and the MMA diameter at the origin of the MLA measured 2.15 ± 0.51 mm. There were no statistically significant differences between genders in any of the parameters.ConclusionsOrbital branches of the MMA, particularly the MLA, are more prevalent than previously appreciated in standard angiography. This has significant implications for the safety of MMAe. Cadaveric angiography may reveal critical anastomoses underrepresented in in vivo imaging, underscoring the need for anatomical vigilance during embolization.