Interventional Neuroradiology最新文献

BackgroundIn recent years, newer flow diverters have been developed with surface modification and varying wire densities. Our study evaluated outcomes among three newer generation flow diverter devices, FRED-X, PED Shield and Surpass Evolve.MethodsThis was a retrospective study of patients from five participating institutions across the United States. Patients who underwent flow diversion of intracranial aneurysms using the FRED-X, PED Shield or Surpass Evolve between February 2022 and September 2024 were included. Outcomes of interest were technical success, angiographic occlusion and in-stent stenosis (ISS).ResultsAmong 447 patients with 452 aneurysms, adjunct device use was highest with Surpass Evolve (36.4%) versus PED Shield (15.7%) and FRED-X (6.4%) (p < .001). Good wall apposition after angioplasty/stenting was most frequent with Surpass Evolve (32.3%) versus PED Shield (13.7%) and FRED-X (4.5%) (p < .001). At six months, complete occlusion was achieved in 69.3% (PED Shield), 63.6% (FRED-X), and 58% (Surpass Evolve) (p = .254). ISS rates were comparable at six months (p = .826). At 12 months, complete occlusion was observed in 78.9% of PED Shield, 68.4% of FRED-X, and 64.5% of Surpass Evolve aneurysms. Most ISS cases at 12 months were mild. Kaplan-Meier analysis showed no significant difference in occlusion rates (p = .914).ConclusionsFlow diversion using FRED-X, PED Shield and Surpass Evolve resulted in comparable rates of angiographic occlusion and ISS. However, adjunctive devices were more commonly needed with Surpass Evolve.

IntroductionMechanical thrombectomy (MT) techniques affect procedure lengths and radiation exposure, with both reduced with contact aspiration (CA) compared to combination stentriever-assisted aspiration (SA). Monopoint MT has higher first pass effect (FPE) rates, less technical crossover, and recanalization with fewer passes. Monopoint MT may thus be associated with shorter procedural times and less radiation.Materials/MethodsAnterior circulation large vessel MT cases across four centers were identified, assigning cases to Monopoint, CA, or SA groups based on the first-line technique employed, excluding cases that could not be assigned to one of these three groups. Clinical variables, technical details, times to first and final pass, fluoroscopy time, dose-area product (DAP), and radiation dose were recorded. Univariable and multivariable analyses were performed to compare procedural times and radiation data among treatment groups.ResultsSeventy-seven Monopoint, 32 CA, 42 SA cases were analyzed. Time to first pass was shortest with Monopoint (p < 0.001), as was time to final pass (p < 0.001). There was no significant difference in fluoroscopy time between Monopoint (17.7 min) and CA (17.6, p = 0.835); both were lower than SA (26.4, p < 0.001). DAP was lowest for Monopoint (18,854 µGy*m²) compared to CA (31,325) and SA (29,483, p < 0.001). Radiation dose was lowest with Monopoint (884 mGy) compared to CA (1095) and SA (1994, p < 0.001).ConclusionMT for anterior circulation large vessel occlusions had shorter procedural times and involved less radiation with Monopoint compared to CA and SA. Further investigation is warranted to assess other clinical and technical factors that affect procedure duration, DAP, and radiation dose.

BackgroundFlow diversion has proven feasible for treating posterior circulation aneurysms. These studies, however, are limited to the utilization of low-mesh density devices. The high-mesh density and mesh geometry of the Surpass Evolve and Streamline flow diverters theoretically allow increased flow diversion while preserving perforators, a critical consideration in posterior circulation flow diversion. We investigate this phenomenon in the largest known series utilizing solely high-mesh density devices for basilar aneurysms.MethodsA prospectively maintained, IRB-approved database of the senior authors was retrospectively reviewed for flow diversion cases involving the upper basilar artery and utilizing Surpass Evolve or Streamline. Technical success was defined as the successful implantation of the device without intraprocedural device removal.ResultsOver a 52-month study period, 23 cases were identified utilizing Surpass Evolve (21 devices) and Surpass Streamline (2 devices) treating aneurysms located along the basilar apex (12 cases, 52%) and superior cerebellar artery (11 cases, 48%). Technical success was achieved in all cases (23 cases, 100%). Patients were placed on antiplatelet therapy consisting of aspirin (22 cases, 95.7%) and ticagrelor (20 cases, 87%) or prasugrel (4 cases, 17.4%). There was one mortality within the 30-day postoperative window due to complications of the presenting high-grade SAH.ConclusionThe treatment of upper basilar and basilar apex aneurysms with high mesh density devices can be performed with acceptable safety standards. Further studies are needed to confirm the safety profile, occlusion rates, and applicability of these findings to lower mesh-density 48-wire flow-diverter implants at the basilar apex.

BackgroundDuring mechanical thrombectomy for large-vessel occlusions, a ledge effect makes navigating the aspiration catheters (ACs) to the occlusion difficult. New large-bore macrowires minimize this while ensuring flexibility and navigational control. We evaluated the technical feasibility of delivering large-bore ACs to posterior circulation occlusions.MethodsThis retrospective multicenter study evaluated patients treated for posterior circulation strokes with adjunct-free macrowire-only direct aspiration first-pass technique (MO-ADAPT) using 0.024- and 0.035-in macrowires between October 2022 and December 2024. Primary outcomes included successful catheter delivery, successful MO-ADAPT (i.e. adjunct-free catheter delivery and successful clot aspiration), and first-pass reperfusion (i.e. modified thrombolysis in cerebral infarction (mTICI) score ≥ 2b after one MO-ADAPT pass).ResultsAmong 42 included patients (mean age 68.3 ± 15.4 years), adjunct-free delivery of ACs to the occlusion using macrowires only was successful in 95.2%. An MO-ADAPT primary approach achieved successful reperfusion in 81.0%, with first-pass reperfusion in 54.8%. Among patients with successful AC delivery, the aspiration success rate was 85.0%. Final mTICI scores of 3, 2c, and 2b after all procedures were seen in 78.6%, 14.3%, and 4.8%, respectively, regardless of thrombectomy method. No vascular complications were observed, and postprocedural intracranial hemorrhage and distal emboli occurred in 2.4% each. A favorable clinical outcome at 90 days was observed in 33.3% of cases. Multivariable analysis showed that underlying intracranial atherosclerotic disease was a negative predictor of both MO-ADAPT success and first-pass reperfusion; no factors predicted AC delivery success.ConclusionIn this retrospective series, MO-ADAPT appeared to be technically feasible for treating posterior circulation strokes, with promising procedural results and a low complication rate. Observed failures were mainly associated with underlying intracranial atherosclerotic disease requiring stent retriever-assisted mechanical thrombectomy. Given the limited sample size and study design, further studies, ideally with larger cohorts and comparative designs, are necessary to clarify the relative safety, efficacy, and cost effectiveness of MO-ADAPT.

Background and PurposeSarcopenia is an age-related syndrome that is associated with poor outcomes in many disease states. In this study, we aimed to evaluate the utility of muscle biomarkers of sarcopenia in predicting clinical outcomes for patients with large vessel occlusion (LVO) acute ischemic stroke (AIS).MethodsThis was a single-center observational cohort study of consecutive patients that underwent endovascular thrombectomy (EVT) for LVO AIS. A deep-learning model was employed to segment and measure the volume, surface area, and maximum thickness of temporalis and sternocleidomastoid (SCM) muscles. The primary outcome was functional independence (FI), defined by a modified Rankin Scale of 0-2 at 3 months post-stroke. Univariable and multivariable logistic regression models were performed to evaluate associations between muscle biomarkers and outcome measures after adjusting for clinical variables of age, sex, and National Institute of Health Stroke Scale (NIHSS), and successful recanalization status which was defined as a thrombolysis in cerebral infarction scale of 2B, 2C, or 3.ResultsIn total, 122 (41.1%) of 297 included patients achieved FI. For each 10 cm³ decrease in SCM volume and temporalis volume, the odds of FI decreased by 34% (odds ratios (OR) 0.66, 95% confidence interval (CI) 0.52-0.84, p < 0.001) and 18% (OR 0.82, 95% CI 0.73-0.91, p < 0.001) respectively. After adjusting for age, sex, NIHSS, and successful recanalization status, our baseline outcome model yielded an area under the receiving operating characteristics curve of 0.749.ConclusionsOur study identified that temporalis and SCM muscle volumes were independently associated with functional outcomes after EVT for LVO AIS and may help to identify high-risk patients who would benefit from early post-stroke multidisciplinary management to prevent longer-term complications.

In neurointervention, fluoroscopic images dominate the educational narrative, highlighting device navigation and deployment but neglecting the manual expertise that enables them. The physician's hands, which execute precise torques, tensions, and micro-movements, remain unseen and underappreciated, leaving a critical gap in procedural education. This editorial argues for systematic recording of operator hand movements during neurointerventional procedures and for aligning these recordings with fluoroscopic feeds to create a dual-visual educational resource. Such integration could enhance procedural understanding, improve trainee skill acquisition through direct visual mimicry, and foster more effective case debriefings. We discuss technological feasibility, cost, privacy concerns, and the potential of this approach to standardize and elevate neurointerventional education worldwide. By widening the lens beyond the screen, we can preserve and transmit the tacit manual knowledge that defines procedural mastery.

IntroductionHemorrhagic transformation is a major complication of large vessel occlusion (LVO) recanalization after mechanical thrombectomy in acute ischemic stroke. The hypoperfusion index ratio (HIR) quantifies the severity of cerebral hypoperfusion in the setting of an acute ischemic stroke using CT perfusion (CTP) to compare the volume of severely hypoperfused tissue (time-to-maximum [Tmax] > 10 s) to total hypoperfused tissue (Tmax >6 s), and has emerged as a potential predictor of ischemic core growth and poor outcomes. We investigated whether computed tomography perfusion (CTP) derived hypoperfusion index ratio correlates with the rate of hemorrhagic transformation.MethodsWe conducted a retrospective cohort analysis of a prospectively maintained patient database. Included patients underwent mechanical thrombectomy for large vessel ischemic stroke from January 2019 to December 2022 at a single comprehensive stroke center. Patients were separated into 2 groups depending on whether hemorrhagic transformation developed. Hemorrhagic transformation included any hemorrhage that could be classified according to the ECASS criteria as hemorrhagic infarction (HI)1, HI2, parenchymal hematoma (PH)1 and PH2. Hypoperfusion index ratio on admission CTP was determined using VizAI software. Data were analyzed using Chi-square and Mann-Whitney U tests.ResultsAmong the 289 patients included (median age, 72.5; 41.5% female), 55 (19%) had hemorrhagic transformation. Patients with hemorrhagic transformation had a significantly higher hypoperfusion index ratio (median, 0 vs 0.2; P = 0.004) compared with those with no hemorrhagic transformation. Multivariable analysis showed that for every 0.1 increase in the hypoperfusion index ratio, there was a significant 4.64-fold increase in hemorrhagic transformation (OR 4.64; 95% CI 1.40 to 15.18; p = 0.011).ConclusionIn patients with LVO who underwent mechanical thrombectomy, a higher hypoperfusion index ratio on admission CTP was associated with an increased rate of hemorrhagic transformation. This suggests that the hypoperfusion index ratio could be used as a predictor for hemorrhagic transformation after mechanical thrombectomy.

PurposeTo evaluate the prognostic utility of visual Alberta stroke program early computed tomography score (ASPECTS) and perfusion parameters obtained from automated RAPID-AI software in patients undergoing mechanical thrombectomy (MT) beyond 6 hours from stroke onset.MethodsWe retrospectively analyzed 86 patients with anterior circulation large vessel occlusion who underwent non-enhanced computed tomography (NECT), multiphase computed tomography angiography, and computed tomography perfusion within 6-24 hours before thrombectomy. Visual ASPECTS (assessed by junior doctor), RAPID-ASPECTS, and RAPID-CTP parameters (ischemic core volume, penumbra, and mismatch ratio) were recorded. The primary outcome was 90-day functional independence (modified Rankin Score 0-2). Multivariable logistic regression and receiver operating characteristic analysis were used to identify independent predictors.ResultsVisual ASPECTS was significantly associated with a favorable outcome (area under the curve = 0.709; optimal cut-off ≥ 6), while no perfusion-derived parameters reached statistical significance. In multivariable analysis, only visual ASPECTS (OR 0.083, 95% CI: 0.033-0.133; p = 0.001), hypertension (OR 0.252, 95% CI: 0.053-0.452; p = 0.014), and symptomatic intracranial hemorrhage (OR 0.634, 95% CI: 0.303-0.964; p < 0.001) remained independent predictors. Agreement between visual and RAPID-ASPECTS was moderate (intraclass correlation coefficient 0.67; 95% CI: 0.49-0.80; p < 0.001), but poor when dichotomized at the ≥ 6 threshold (Cohen's kappa κ = 0.18, p < 0.001).ConclusionVisual ASPECTS outperformed perfusion-derived metrics in predicting clinical outcomes after late-window thrombectomy. These findings support the continued relevance of NECT and expert visual scoring, particularly in settings where perfusion imaging may be limited or inconsistent.

BackgroundIntracranial vessel perforation is a rare but life-threatening complication during endovascular neurointerventions. Despite several described bail-out strategies, there is no consensus on the most effective approach for rapid hemorrhage control. This study aimed to systematically compare common endovascular rescue techniques in a standardized experimental setting.MethodsPatient-specific, 3D-printed vascular models of the anterior circulation were used to simulate standardized vessel perforations at two anatomical sites and three perforation sizes. The impact of the anterior communicating artery (AComA) crossflow was assessed. Proximal balloon guiding catheter inflation, local compliant balloon inflation, temporary coil deployment, and distal intermediate catheter insertion were evaluated against a non-intervention control. The primary outcome was the time it took for 50 ml of fluid extravasation to accumulate.ResultsAs expected, extravasation time inversely correlated with perforation size (ρ = -0.95, p < 0.001). Local balloon inflation at the rupture site most effectively halted leakage. Proximal balloon occlusion was only effective in the absence of an AComA crossflow (p = 0.02). Temporary coil deployment modestly slowed bleeding, especially for small-to-moderate perforations. Distal intermediate catheter placement had no significant effect.ConclusionManaging iatrogenic intracranial vessel perforation is time-critical, as even a brief bleeding time can be fatal. The most effective hemostasis method is compliant balloon inflation at the rupture site. If unavailable, temporary parent artery coiling can reduce bleeding while maintaining perfusion, but it is less effective for larger perforations. Proximal balloon occlusion is only effective in the absence of collateral crossflow.

BackgroundStudies during the COVID-19 pandemic have demonstrated an association between COVID-19 virus infection and the development of acute ischemic stroke, particularly large vessel occlusion (LVO). Studying the characteristics and immunohistochemistry of retrieved stroke emboli during mechanical thrombectomy for LVO may offer insights into the pathogenesis of LVO in COVID-19 patients. We examined retrieved COVID-19 emboli from the STRIP, EXCELLENT, and RESTORE registries and compared their characteristics to a control group.MethodsWe identified COVID-positive LVO patients from the STRIP, RESTORE, and EXCELLENT studies who underwent mechanical thrombectomy. These patients were matched to a control group controlling for stroke etiology based on Trial of Org 10172 in Acute Stroke Treatment criteria. All clots were stained with Martius Scarlet Blue (MSB) along with immunohistochemistry for interleukin-6 (IL-6), C-reactive protein (CRP), von Willebrand factor (vWF), CD66b, fibrinogen, and citrullinated Histone H3. Clot composition was compared between groups.ResultsNineteen COVID-19-positive patients and 38 controls were included. COVID-19-positive patients had a significantly higher percentage of CRP and vWF. There was no difference in IL-6, fibrin, CD66b, or citrullinated Histone H3 between groups. Based on MSB staining, there was no statistically significant difference regarding the percentage of red blood cells, white blood cells, fibrin, and platelets.ConclusionsOur study found higher concentrations of CRP and vWF in retrieved clots of COVID-19-positive stroke patients compared to COVID-19-negative controls. These findings support the potential role of systemic inflammation as indicated by elevated CRP and endothelial injury as indicated by elevated vWF as precipitating factors in thrombus development in these patients.