Interventional Neuroradiology最新文献

Middle meningeal artery embolization (MMAe) is rapidly emerging as a valuable intervention to decrease the risk of recurrent subdural hematoma (SDH) after surgical evacuation. The role of upfront bilateral MMAe for unilateral SDH and the value of contralateral MMAe after SDH recurrence post evacuation and ipsilateral MMAe are still unknown. Here, we report the case of an elderly patient that presented with a large acute on chronic SDH and underwent surgical drainage and ipsilateral MMAe (with Contour PVA particles, 150-250 µm). At one month follow-up, he was found to have a significant radiographic recurrence of the SDH with interval acute hemorrhage. Angiography revealed complete occlusion of the trunk of the previously embolized ipsilateral MMA, and the presence of robust anastomotic branches from the contralateral MMA crossing the midline to collateralize patent distal branches of the previously embolized MMA. Decision was made to proceed with contralateral MMAe, which resulted in near complete SDH resolution at 6 months follow-up.

Introduction: Recent literature continues to demonstrate the successful role of large-bore aspiration catheters in thrombus ingestion during mechanical thrombectomy. However catheter-to-microwire step-off and distal navigation are ongoing challenges in thrombectomy. A new to market 0.035' macrowire (Aristotle 35 Colossus Guidewire, Scientia Vascular, West Vale City, UT) may address such challenges. We report here our early experience in 30 mechanical thrombectomy cases.

Materials and methods: We analyzed a prospectively maintained database of the senior authors to identify cases utilizing a 0.035' macrowire with 0.035' aspiration catheters for mechanical thrombectomy.

Results: Thirty consecutive cases were identified. Seventeen (57%) patients were female with an average age of 75.3 ± 2.2 years (range 55-97). Average presenting NIHSS was 13.0 ± 1.7. Thrombus locations included 7% (n = 2) in the cervical ICA, 47% (n = 14) in the M1, 43% (n = 13) in the M2, and 3% (n = 1) in the P1. An 088' ID aspiration catheter was navigated to at least the M1 segment in all anterior circulation cases and the basilar in the posterior circulation case. The 0.035' macrowire was placed proximal to the occlusion in all cases allowing coaxial 035' and 071' catheter aspiration passes. TICI 2C/3 was achieved in 87% of cases (n = 26) and TICI 2B in the remaining cases. There were no wire-related perforations or vessel dissections.

Conclusion: The Colossus 0.035' macrowire may offer advantages over its smaller counterparts by reducing ledge effect and the need to cross the thrombus. Further comparative studies against currently available microwires in various anatomies are warranted.

Background: The optimal treatment for carotid free-floating thrombus (CFFT) remains uncertain due to limited evidence, with no randomized clinical trials and scarce guidelines, such as ESVS 2023, favoring conservative management. Anticoagulation (ACT) and antiplatelet (APT) therapies are emerging as promising alternatives to high-risk surgical interventions. This systematic review aimed to evaluate the safety and efficacy of ACT and APT therapies for CFFT.

Methods: A systematic search was performed across PubMed, Embase, Web of Science, and Cochrane databases. Safety and efficacy endpoints were assessed. A two-sample t-test compared baseline characteristics between groups, and a Chi-square test evaluated differences in categorical variables. Statistical significance was set at p < 0.05. Data were analyzed using R 4.3.0 with the meta package v.7.0-0.

Results: Four studies met the inclusion criteria, involving 170 patients diagnosed with CFFT. The APT group included 96 patients (mean age 55.35 ± 13.52 years; 56.25% male), and the ACT group included 74 patients (mean age 58.57 ± 14.28 years; 51.35% male). Thrombus regression was slightly lower in APT (42%) compared to ACT (48%). Both groups showed similar rates of residual stenosis. Antiplatelet had fewer ischemic events within 30 days (none vs. 4% in ACT) and lower intracranial hemorrhage rates (3.3% vs. 5.4% in ACT) but higher mortality (6.3% vs. none in ACT).

Conclusion: Both ACT and APT are effective for managing CFFT, each with distinct efficacy and safety profiles. However, randomized trials are necessary to better assess these therapies in CFFT management.

Background and purpose: As flow diversion (FD) is becoming increasingly important in the endovascular treatment of intracranial aneurysms, the rate of technical complications is also increasing. Inadequate FD implantation may lead to both ischemic complications and decreased treatment efficacy. The aim of this study was to evaluate the efficacy of off-label stent retriever (SR) use in managing technical complications associated with FD implantation.

Materials and methods: A retrospective analysis of data from patients who underwent FD treatment at two neuroradiology centers was performed. The objective was to identify cases in which the FD was inadequately deployed and SR expansion was performed as a corrective maneuver. The analysis included anatomic characteristics, technical information, angiographic and clinical outcomes, and complications.

Results: A total of 35 corrective maneuvers with SR were performed in 25 FD treatments. The corrective maneuvers in all treatments were successful, and no additional devices or therapies were required. No procedural complications or technical difficulties were documented.

Conclusion: With the growing role of FDs in neurointerventional treatment, familiarity with corrective maneuvers after technical complications or inadequate implantation is important. The findings in our selected cohort demonstrated that SR expansion is an effective and safe corrective maneuver for incompletely opened FDs.

Background: The Pipeline^™ Vantage embolization device (Medtronic, Irvine, CA) is the fourth generation of Pipeline flow diverter devices, offering numerous technical improvements. This study aimed to assess the feasibility and safety of The Pipeline^™ Vantage embolization device (Medtronic, Irvine, CA).

Methods: This was a single-center retrospective study describing the use of The Pipeline^™ Vantage embolization device for the treatment of intracranial aneurysms. Technical feasibility and safety were assessed in terms of intra and postprocedural complications, as well as neurological morbidity upon follow-up. Both ruptured and unruptured aneurysms were included.

Results: We included 12 patients in our study (mean age 62; females: n = 9/12, 75%). Aneurysm morphology varied between saccular (41.6%), fusiform (41.6%), blister (8.3%), and pseudoaneurysm (8.3%). Three cases (25%) involved ruptured aneurysms treated in the acute setting. A transradial access was used in 10 cases (83.3%). There was a 100% success in deployment. Seven cases (58.3%) were treated with adjunct embolization device other than a flow diversion. Eight cases (66.6%) were treated with a single flow diversion, three cases (25%) were treated with two flow diversion, and one case (8.3%) was treated with three flow diversion stents. There were no intraoperative complications. There was one postprocedural complication in a dissecting ruptured PICA aneurysm that was ultimately treated with two flow diversion stents and an intrasaccular device.

Discussion: To our knowledge, this is the first US series assessing the periprocedural safety and feasibility of consecutive patients with intracranial aneurysms treated with the Pipeline^™ Vantage device (Medtronic, Irvine, CA).

Introduction: There is a lack of evidence of flow diversion (FD) safety for aneurysms treatment beyond the circle of Willis. Therefore, we provide a single-center real-world experience with the Silk Vista Baby (SVB).

Methods: A single-center database was retrospectively reviewed for aneurysms treated with SVB flow diverters. Demographic information, clinical presentation, radiographic characteristics, procedural complications, and outcomes were assessed.

Results: About 57 patients (66.7% female, mean age 54.3 ± 13.2) encompassing 57 aneurysms were included. Overall, 40.4% were ruptured: 68.4% saccular, 17.5% blister, 8.7% fusiform, and 5.3% dissecting. The majority were in the anterior circulation (68.4%), and in 48.2% of cases, the distal vessel diameter was inferior to 2 mm. The symptomatic ischemic rate was 5.2%, with one case due to in-stent thrombosis (1.8%). There were no hemorrhagic complications. Complication rates did not differ between ruptured and unruptured lesions (p = 0.356). There were no cases of delayed aneurysm rupture, and overall mortality was 1.8%. The median follow-up time was 18 ± 12 months. In-stent stenosis rate was 10.5% (6/57), all of which were asymptomatic. At the last follow-up, 70.2% of cases had an adequate occlusion (OKM C and D), and 96.5% had an mRS of 0-2.

Conclusion: In our series, SVB was shown to be a safe device in the treatment of not only distal anterior circulation aneurysms but also in the management of complex posterior fossa and ruptured blister aneurysms. Multicenter studies are needed to confirm and generalize these results.

Objective: This multicenter study evaluates the safety and efficacy of coated flow diverters (cFDs) for the treatment of cerebral aneurysms under single antiplatelet therapy (SAPT).

Methods: This is a retrospective, observational study of 41 patients (median age: 58 years) with 41 aneurysms (median size: 7 mm, 29 [71%] saccular, 9 [22%] ruptured) treated with cFDs at four neurovascular centers between 2020 and 2023. Scheduled cases received continuous SAPT starting seven days before the procedure. Emergency cases were treated with tirofiban followed by SAPT loading. The safety endpoint was ischemic complications occurring during the procedure and within four months of clinical follow-up.

Results: The Pipeline Vantage or Flex Shield was used in 26 (63%) procedures, the FRED X in 12 (29%), the p48/64 Hydrophilic Polymer Coating in 2 (5%), and the Derivo Embolization Device 2heal in 1 (2%). Single antiplatelet therapy consisted of prasugrel in 27 (66%) patients, ticagrelor in 9 (22%), and ASA in 5 (12%). There were 2 (5%) early ischemic complications (one minor stroke and one transient ischemic attack). There were no late ischemic complications in the four-month follow-up of 35 patients. The six dropouts included four nontreatment-related deaths after subarachnoid hemorrhage and two patients with a poor outcome after subarachnoid hemorrhage. Complete and favorable occlusion rates (median: 7 months) were 75% (27/36) and 89% (32/36), respectively.

Conclusions: Coated flow diverter implantation in the setting of SAPT was safe and effective and warrants confirmation in a prospective comparative trial.

Objectives: The aim of this study is to analyze the effectiveness and safety of medical treatment (MT) versus endovascular treatment (EVT) in acute large vessel occlusion patients with mild nondisabling stroke symptoms.

Methods: This study is a multicenter observational study in which data from patients at three stroke centers were prospectively obtained and retrospectively analyzed. Patients were included if they arrived for treatment within 6 h of stroke onset or last known well time and had a baseline National Institutes of Health Stroke Scale (NIHSS) score of ≤5. Primary outcome was modified Rankin Scale (mRS) score 0-2 at 90 days. Secondary outcomes included symptomatic intracranial hemorrhage (sICH), discharge NIHSS score, 90-day all-cause mortality and length of stay. Clinical outcomes were compared through a multivariable logistic regression after adjusting for age, treatment type admission and discharge NIHSS score, admission Alberta Stroke Program Early CT (ASPECT) score and length of stay.

Results: Of the 82 patients included in the study, 42 were in the EVT group and 40 were in the MT group. The groups were similar in age (MT:66, EVT:64 age; p = .62), gender (MT:55%, EVT:54.8%; male) admission NIHSS score (MT:2, EVT:3 points; p = .26), ASPECT score (MT:10, EVT:9; p = .15). While discharge NIHSS score was found to be statistically significant between the groups (MT:1, EVT:2; p = .04). There was no difference between the two groups in terms of 90-day mRS scores (MT:1, EVT:1, p = .86) and mortality rates (MT:4, EVT:4; p = .94). In unadjusted analysis, sICH rates were similar between the MT and EVT groups (MT 5%, EVT 7.1%, p = .52). Neurological intensive care unit length of stay (MT:5 days, EVT:2 days p < .001), inpatient clinic length of stay (MT:3, EVT:2 days p = .041), and total length of stay (MT:9 days, EVT:4 days p < .001) were significantly longer in the MT group.

Conclusions: Our multicenter study demonstrated that MT with blood pressure augmentation and anticoagulation at hyperacute stage is an alternative option for emergency large vessel occlusion patients with nondisabling mild stroke symptoms.

Background: Aneurysm treatments are crucial to minimize the rupture risk. The underlying molecular processes mediating cellular remodeling, endothelialization, and aneurysm healing following endovascular treatment are poorly understood. The current study aims to explore circulating miRNA as a treatment and outcome-associated biomarkers in patients undergoing endovascular treatment.

Methods: Patients undergoing endovascular interventions for unruptured intracranial aneurysms, using either flow diverter placement or coil embolization, were enrolled. Blood samples were collected before the intervention and during a follow-up period between 6 and 18 months. Total mRNA/miRNA was isolated from plasma, followed by RNA-seq analysis. Gene Ontology analysis was used to identify pathways linked to altered miRNA expression.

Results: Twenty-three patients participated, with 13 (56.5%) undergoing flow diversion and 10 (43.5%) coil embolization. The median follow-up sample collection time was 10.70 months (SEM ± 1.32). No significant differences in angiographic occlusion were noted between intervention groups. Differentially expressed miRNAs were not identified between groups at baseline. However, at follow-up, 39 miRNAs were upregulated and 41 were downregulated, independent of intervention. Notably, three miRNAs (miR-4746-5p, miR-4685-3p, and miR-490-3p) were downregulated in the flow diversion group compared to the coil embolization group. Bioinformatics analysis revealed associations with upregulated fluid shear stress, p53, adherens junction pathways, along with downregulated apoptosis pathways.

Conclusions: This study suggests that fluid shear stress and apoptosis may influence aneurysm healing or thromboembolic events in flow diverter-treated patients. Further research is warranted to elucidate the functional significance of these findings in treatment outcomes, providing valuable insights for improved patient care in intracranial aneurysm management.

Background: In large vessel occlusion (LVO) stroke patients transferred to a comprehensive stroke center for thrombectomy, spontaneous reperfusion may occur during transport, and anecdotally more frequently in patients transferred via helicopter than by ground. This pattern has been more often observed in conjunction with tenecteplase (TNK) treatment prior to helicopter transport. We aim to explore the "chopperlysis" effect-how helicopter transport, particularly with thrombolytics, may affect reperfusion and clinical outcomes.

Methods: A single thrombectomy capable center (TCC) registry of stroke patients was retrospectively reviewed. Included LVO patients were those who had been transferred to the TCC and received a digital subtraction angiography (DSA) upon arrival. The outcomes were rates of spontaneous reperfusion, distal clot migration, and 90-day good functional outcome. Data were summarized, and endpoints were compared between patients stratified by transport method and/or TNK treatment.

Results: Of 270 patients included, helicopter transport was associated with a higher rate of spontaneous reperfusion, particularly among patients not treated with TNK (p < 0.001). There was no significant difference in prevalence of distal clot migration between any subgroups (p > 0.37). Overall, TNK-treated patients had better functional outcomes, and this difference persisted exclusively in the helicopter-transported patients (p = 0.02).

Conclusion: Helicopter transport was associated with a higher rate of spontaneous reperfusion. There is a potentially synergistic effect between TNK administration and helicopter transport, augmenting thrombolysis and improving long-term outcomes. Further analyses in larger cohorts may expand our understanding of this "chopperlysis" effect.