Interventional Neuroradiology最新文献

Lesions of the subclavian artery often involve pathologic stenosis due to high degrees of calcification within the vessel wall. While endovascular angioplasty and stenting is generally the preferred method for obtaining flow reconstitution, calcification of the vessel wall has proven to significantly impair the efficacy of successful stent deployment. Shockwave intravascular lithotripsy (IVL) is a technology that has been very successful in addressing this challenge in other vascular territories, however its use has yet to be approved for supra-aortic vessels such as the subclavian artery. In this report, the use of IVL for a case of subclavian steal syndrome due to a highly stenosed left subclavian artery is described along with a review of the literature. Although several cases utilizing this technology in subclavian arteries have been reported, none have described the use of a left transradial approach. Therefore the purpose of this report is to demonstrate the efficacy of IVL for supra-aortic vessels so that its benefits can be expanded to a broader patient population.

Medium vessel occlusions (MeVOs), defined as occlusion of the M2/M3 and A2/A3 segments of the middle cerebral artery (MCA) and anterior cerebral artery, can be challenging to visualize on CT angiography (CTA) and MR angiography (MRA), given the anatomic complexity of the mid- and distal intracranial vasculature and smaller vessel caliber (Leary MC, Kidwell CS, Villablanca JP, et al. Validation of computed tomographic MCA "dot" sign: an angiographic correlation study. Stroke 2003; 34: 2636-2640; Luijten SPR, Wolff L, Duvekot MHC, et al. Diagnostic performance of an algorithm for automated large vessel occlusion (LVO) detection on CTA. J Neurointerv Surg 2022; 14: 794-798). In turn, the appearance of a sudden vessel cutoff in these vascular distributions on CTA or MRA is not always straightforward and may represent true occlusion, variant anatomy, and/or artifact (Leary MC, Kidwell CS, Villablanca JP, et al. Validation of computed tomographic MCA "dot" sign: an angiographic correlation study. Stroke 2003; 34: 2636-2640; Luijten SPR, Wolff L, Duvekot MHC, et al. Diagnostic performance of an algorithm for automated LVO detection on CTA. J Neurointerv Surg 2022; 14: 794-798). Given the importance of rapidly establishing an accurate diagnosis in the setting of stroke, combined with recent clinical trials and movements promoting the efficacy of endovascular therapeutic approaches to treat MeVOs, it remains imperative to detect such occlusions accurately and quickly on imaging. In turn, we present five imaging patterns of the Sylvian Triangle on sagittal reformatted images from CTA Head examinations, which our practice has utilized to assess patency of the M2 and M3 divisions. This approach is rapidly deployable and can be utilized by radiology and non-radiology healthcare providers alike, thus facilitating rapid and accurate diagnosis of MeVO, timely evaluation of candidacy for endovascular therapy, and ultimately supporting favorable door-to-intervention time and successful patient outcomes.

Introduction: Distal medium vessel occlusion (DVO) thrombectomy has been shown to be efficacious with safety profiles comparable to large vessel occlusion (LVO) thrombectomy. A novel, highly-trackable, bevel-tipped Zoom 35 catheter can be used as an aspiration catheter for DVO thrombectomy.

Methods: This is a retrospective, single-arm, multi-institutional observational study evaluating the efficacy and safety of aspiration thrombectomy for DVO using the Zoom 35 catheter. Patient demographics, presenting and discharge NIHSS, primary and rescue thrombectomy, site of occlusion, TICI score, and intracranial hemorrhage were chart abstracted. Descriptive statistics were used to evaluate the efficacy and safety of thrombectomy.

Results: Fourteen patients (mean age 66.64 ± 13.75 years) were included. The mean NIHSS at presentation was 10.79 ± 5.48, and the mean ASPECTS was 9.00 ± 0.89. Nine patients (64.3%) received tPA. Primary occlusion location was M3 in nine cases (64.3%), M2/M3 junction in two cases (14.3%), A2 in one case (7.1%), A3 in one case (7.1%), and P1 in one case (7.1%). TICI scores were 3 in seven cases (50.0%), 2C in three cases (21.4%), and 2B in four cases (28.6%). There was one postoperative SAH (7.1%) and one asymptomatic ICH (7.1%). Mean discharge NIHSS was 3.38 ± 4.44, with a mean decrease of 7.31 from presentation (p < 0.0001, t-test).

Conclusion: Zoom 35 beveled-tip aspiration microcatheters are highly trackable and associated with improved radiographic and clinical outcomes for the treatment of DVO with a good safety profile.

The artery of Bernasconi and Cassinari is a small infraclinoid branch of the internal carotid artery that originates from its cavernous segment and then runs along the tentorium. Because of its gracile appearance, it is often visible only when related to neoplasms and vascular lesions in the tentorial regions.¹ Dural arteriovenous fistulas (dAVFs) are arteriovenous shunts contained within the dural leaflets, supplied largely by the regional meningeal arteries and classified based on the type of venous drainage. Tentorial dAVFs are mostly supplied by branches of the meningohypophyseal trunk, including the artery of Bernasconi and Cassinari.² Unlike fistulas of other locations, tentorial fistulas are linked with a higher risk for venous hypertension and hemorrhage and thus demand immediate and appropriate treatment.³ Digital subtraction angiography is necessary to understand its arterial and venous components. Treatment aims to achieve complete embolization of the fistulous connection and venous portions by either a transarterial or transvenous approach, without causing serious changes in the flow dynamics.^{4, 5}.

Background: Acute ischemic stroke poses a significant health threat, and thrombectomy has become a routine treatment. Tirofiban has emerged as a promising adjunct therapy to minimize reocclusion after thrombectomy. We aimed to investigate whether renal function influences the safety and efficacy of tirofiban in patients undergoing endovascular therapy.

Methods: Patients' clinical data collected from the stroke unit were analyzed. The modified Rankin scale score and symptomatic intracranial hemorrhage (sICH) were used as outcome measures.

Results: A total of 409 patients (mean age: 66.5 years, 292 males [71.4%]) were included. Tirofiban significantly improved 3-month functional outcomes (adjusted odds ratio [aOR] = 2.408, 95% confidence interval [CI] 1.120-5.175), reduced 3-month mortality (aOR = 0.364, 95% CI 0.155-0.856), and decreased the incidence of sICH (aOR = 0.339, 95% CI 0.149-0.767) in patients with estimated glomerular filtration rate (eGFR) ≥ 90 mL/min/1.73 m². However, no significant improvement in prognosis was observed with tirofiban in patients with eGFR < 90 mL/min/1.73 m². Interaction analysis suggested a potential influence of renal function on tirofiban efficacy.

Conclusion: Renal function may impact the efficacy of tirofiban. Administration of tirofiban in direct thrombectomy patients with normal renal function is safe and improves prognosis. However, the prognostic benefits of tirofiban are limited in patients with impaired renal function.

Objective: To investigate the association between von Willebrand factor (vWF) and neutrophil extracellular traps (NETs) in thrombus with clinical severity and peripheral blood immunocytes' indicators in patients with early-stage acute ischemic stroke (AIS).

Methods: A retrospective study was conducted using the clinical data of 66 patients with AIS who underwent endovascular mechanical thrombectomy and had their thrombus samples collected. The concentrations of vWF and NETs in the thrombus samples were quantitatively assessed. Peripheral blood samples taken in the early stages of the disease were analyzed for total white blood cell counts (WBC), ratios of neutrophils (NEU%), lymphocytes (LYM%), eosinophils (EOS%), and monocytes (MONO%). The severity of clinical symptoms in these patients was evaluated using the modified Rankin Scale (mRS), Essen Stroke Risk Score (ESRS), Barthel Index (BI), and National Institute of Health Stroke Scale (NIHSS).

Results: Higher vWF levels in thrombus were associated with lower NIHSS scores, while higher NETs levels were associated with higher initial NIHSS scores. In the early stages of AIS, WBC count and vWF levels were negatively correlated, as well as NEU%. LYM% was positively correlated with vWF level; however, it was negatively correlated with NETs. EOS% was positively correlated with vWF levels.

Conclusion: In the early stages of AIS, a higher peripheral WBC count and NEU%, combined with decreased EOS% and LYM%, were significantly correlated with a lower vWF level in the thrombus, potentially indicating more severe symptoms. Consequently, the timely administration of vWF-targeted medications is recommended for such patients. Reduced LYM% is indicative of elevated NETs levels and correlated with more severe clinical symptoms. Therefore, the prompt initiation of NETs-targeted medication is warranted for these patients.

Pediatric neurointervention differs from the adult in several important respects. Here we describe a modern approach to readily acquire diagnostic quality images of children. Preparation, access, angiogragraphy and closure have evolved along with new knowledge and technology. This timely "how I do it" series addresses each topic utilizing literature review and our own experience over 35 years.

Background: Reperfusion of medium vessel occlusions is correlated with good outcomes. However, optimal techniques and medical devices are still unclear. In this study, we sought to evaluate the safety and efficacy of mechanical thrombectomy with Embolus Retriever with Interlinked Cages (ERIC™) retrieval device in patients with acute ischemic stroke due to distal medium vessel occlusions.

Methods: A retrospective review of the prospectively collected mechanical thrombectomy database revealed 50 patients who had fulfilled the inclusion criteria. The data collected includes clinical patient characteristics, procedural measures, timestamps at each stage, and patient outcomes. Intravenous thrombolytics application, pre- and post-intervention imaging findings, device-related adverse events and any type of intracranial hemorrhage were recorded.

Results: There were 25 men (50%) and 25 women (50%) with a median of 67 years (interquartile range (IQR) 41-84). Median presenting NIHSS was 14 (IQR, 3-23). First pass rates were: eTICI3 in 16 cases (32%), eTICI-2c in eight cases (16%), eTICI-2B67 in nine cases (10%), eTICI2B50 in three cases (6%) and mTICI 0-2A in 18 cases (36%). Final recanalization rate of mTICI 2b-3 was 90% and 2c-3 was 70%.

Conclusion: In conclusion, the ERIC thrombectomy device offers a high rate of first-pass success along with a favorable safety profile. Larger series and multi-center studies are needed for further investigation.

Background: Reversible cerebral vasoconstriction syndrome (RCVS) is an increasingly recognized condition characterized by thunderclap headache with or without other neurological deficits and diffuse vasoconstriction of cerebral arteries. Altered cerebrovascular tone may produce hemorrhage or stroke.

Methods: A retrospective review of patients with RCVS at our institution (2000-2023) yielded one case of pseudoaneurysm secondary to RCVS.

Results: Diagnostic cerebral angiogram demonstrated diffuse multifocal segmental narrowing consistent with RCVS and a left M4 pseudoaneurysm in proximity to the cortical hemorrhage. The pseudoaneurysm was treated with branch vessel sacrifice using nBCA glue in a 1 : 3 ratio with ethiodized oil. After securing the source of hemorrhage, the patient received an intra-arterial infusion of Verapamil.

Conclusion: This unique presentation of pseudoaneurysm secondary to RCVS in this patient highlights the impact of hemodynamic alteration as a possible source of bleeding and demonstrates a potential management strategy. Endovascular management with nBCA glue embolization successfully treated this lesion.