Interventional Neuroradiology最新文献

Background: Delays in reperfusion treatment, both intravenous thrombolysis (IVT) and endovascular treatment (EVT), adversely affect outcomes in patients with acute ischemic stroke (AIS). To alleviate these delays, it is essential to comprehend how patients' baseline and stroke characteristics impact in-hospital reperfusion delays. While demographic and socioeconomic factors affect stroke outcomes, their impact on in-hospital delays remains unclear.

Method: This is retrospective analysis at a tertiary stroke center, encompassing AIS patients receiving IVT and / or EVT between 2019 and 2022 (re-canalization cohort). Outcomes of interest were time intervals of admission to CT and admission to recanalization. Univariable analyses explored age, gender, baseline functional status, socioeconomic status (SES), ethnicity, vascular risk factors, and stroke characteristics. Subsequently, multivariable logistic regression analyses were performed.

Results: Altogether, 313 patients treated with IVT and 293 with EVT were included in the re-canalization cohort. No demographic variables were found to be associated with stroke treatment time intervals. Following multivariable analysis, stroke severity (low NIHSS, p < 0.01), arrival to the hospital by other means than ambulance (p < 0.01), and atypical stroke symptoms (p < 0.01), were associated with in-hospital delays, both in the EVT and the IVT groups.

Conclusion: Our findings indicate that patients with a more severe ischemic stroke, typical stroke symptoms, and arrival by ambulance have shorter stroke treatment time intervals. These results emphasize that, in atypical cases, even a lower suspicion of stroke should promote urgent workup for stroke diagnosis. Our findings do not indicate any influence of demographic or SES on in-hospital reperfusion delays.

Objective: The Pipeline Vantage Embolization Device (PVED) is a novel coated flow diverter with reduced wire diameters to improve neoendothelialization and stent porosity. This systematic review evaluates the safety and efficacy of the PVED based on the current literature.

Methods: Following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, a thorough literature search was conducted using PubMed, EMBASE, and Cochrane. The random effects model was used to calculate estimates with major neurological complications within 30 days of treatment as the primary safety endpoint and ≤1-year complete occlusion rate as the primary efficacy endpoint.

Results: Six single-arm studies (5 retrospective, 1 prospective) with 392 patients and 439 aneurysms (6.8% ruptured) were included. Antiplatelet regimens varied, but dual antiplatelet therapy was administered in the majority. The pooled technical success rate was 99.0% (95%CI, 98.0%-100%) with an average of 1.2 devices implanted per procedure. Balloon angioplasty was performed in 17.0% (95%CI, 6.4-27.6%) and adjunctive coiling in 28.0% (95%CI, 17.8-38.2%), with significant heterogeneity for both variables. Pooled estimates for major neurological complications were 3.5% (95%CI, 1.7%-5.2%) with total ischemic events in 4.1% (95% CI, 1.6%-6.6%) and hemorrhagic events in 1.0% (95% CI, 0.0%-1.9%). The rate of complete angiographic occlusion was 75.7% (95%CI, 70.7%-80.6%) at a mean follow-up of 7 months, with in-stent stenoses in 8.1% (95%CI, 4.5%-11.8%).

Conclusions: The safety and efficacy profile of the PVED appears comparable to competing devices, with potentially fewer complications than first-generation flow diverters. Long-term and comparative studies are needed to further confirm these results.

Introduction: This study is the first multicentric report on the safety, efficacy, and technical performance of utilizing a large bore (0.081″ inner diameter) access catheter in neurovascular interventions.

Methods: Data were retrospectively collected from seven sites in the United States for neurovascular procedures via large bore 0.081″ inner diameter access catheter (Benchmark BMX81, Penumbra, Inc.). The primary outcome was technical success, defined as the access catheter reaching its target vessel. Safety outcomes included periprocedural device-related and access site complications.

Results: There were 90 consecutive patients included. The median age of the patients was 63 years (IQR: 53, 68); 53% were female. The most common interventions were aneurysm embolization (33.3%), carotid stenting (12.2%), and arteriovenous malformation embolization (11.1%). The transradial approach was most used (56.7%), followed by transfemoral (41.1%). Challenging anatomic variations included severe vessel tortuosity (8/90, 8.9%), type 2 aortic arch (7/90, 7.8%), type 3 aortic arch (2/90, 2.2%), bovine arch (2/90, 2.2%), and severe angle (<30°) between the subclavian artery and target vessel (1/90, 1.1%). Technical success was achieved in 98.9% of the cases (89/90), with six cases requiring a switch from radial to femoral (6.7%) and one case from femoral to radial (1.1%). There were no access site complications or complications related to the 0.081″ catheter. Two postprocedural complications occurred (2.2%), unrelated to the access catheter.

Conclusion: The BMX™ 81 large-bore access catheters was safe and effective in both radial and femoral access across a wide range of neurovascular procedures, achieving high technical success without any access site or device-related complications.

Background: Bioresorbable polymer-based flow-diverting stents have potential benefits over existing metal devices. This study aimed to evaluate the safety and efficacy of the novel ReSolv device, which is a primarily polymer-based flow-diverting stent, using the in vivo rabbit sidewall saccular aneurysm model.

Methods: ReSolv stents were deployed in 14 New Zealand White rabbits that had undergone aneurysm creation procedures. Animals were allocated to follow-up time points of 1, 3, 6, 9, 12, 16, or 18 months. Angiographic images were evaluated by an independent neurointerventionalist blinded to follow-up time points for (1) in-stent stenosis, (2) parent vessel and jailed side branch patency, (3) wall apposition, and (4) aneurysm occlusion using the Raymond-Roy Occlusion Classification (RROC), O'Kelly Marotta grading scale, and the 4F flow diversion predictive score. Primary efficacy outcome was defined as RROC Class I or II.

Results: At a median follow-up time of 7.5 months, parent vessel (14/14) and jailed side (33/33) branches were patent in all cases. There was no development of thrombus on the stent or cases of significant in-stent stenosis, and all stents had good wall apposition. Adequate occlusion was found in 85.7% (n = 12) of animals, including an RROC Class I in 64.3% (n = 9) and RROC Class II in 21.4% (n = 3).

Conclusions: The ReSolv stent shows encouraging angiographic safety and efficacy outcomes after placement in a rabbit sidewall saccular aneurysm model. Longer term studies are ongoing to determine eventual fate of the aneurysm, parent vessel, and jailed side branches after absorption of the polymer component of the stent.

Background: Carotid-cavernous fistulas (CCFs) are complex arteriovenous shunting lesions of the cavernous sinus with diverse clinical presentations. This study aimed to analyze clinical outcomes and differentiate patients treated with conservative observation versus those needing endovascular intervention.

Methods: A retrospective analysis of 84 patients with angiographically confirmed CCF was conducted from 2000 to 2022. Endovascular treatment decisions were made at the discretion of neurointerventionalists. Clinical and angiographic data were collected, including Barrow CCF classification and treatment outcomes.

Results: Patients managed conservatively (n = 17) had longer symptom duration (165 vs 42 days) and more indirect CCF (100% vs 68%) compared to those treated with endovascular embolization (n = 67). High-risk clinical symptoms, including proptosis, diplopia, decreased visual acuity, and chemosis, were more common in the embolization group. Cortical venous reflux and ophthalmic venous reflux were more prevalent in the embolization group (39% and 91%, respectively). Overall, 31% of embolized CCFs required retreatment, mainly Barrow type D lesions (65%). Transvenous coil embolization was the primary technique used (78%), followed by feeder artery embolization (16%), and internal carotid artery flow diversion (8%).

Conclusion: In selected CCF patients without high-risk symptoms or angiographic features, conservative observation is a safe and effective alternative to endovascular embolization. High-risk symptoms and angiographic features favor endovascular intervention. Complications were rare, and most were transient, emphasizing the safety of endovascular management. Longitudinal angiographic and ophthalmologic surveillance is essential for monitoring fistula persistence or recurrence.

Although rare, cerebral arterial fenestration may present challenges in diagnosis and treatment. Here we present a case of a supraclinoid internal carotid artery (ICA) fenestration adjacent to an ICA aneurysm, successfully treated with balloon-assisted coil embolization. A female in her 50's presented with an acute subarachnoid hemorrhage from a ruptured left ICA-ophthalmic artery (OA) aneurysm. Digital subtraction angiography revealed a focal ICA fenestration distal to the posterior communicating artery (Pcom). The patient underwent successful coil embolization of the aneurysm using the balloon-assisted technique. No immediate hemorrhagic, thromboembolic, or neurological complications were observed. The patient was discharged in good condition after 2 weeks of hospitalization. A comprehensive literature review of 33 cases was subsequently performed to understand the characteristics of this condition. Cases involving the cranial division of the ICA forming the fenestration exhibited caliber differences significantly more frequently (p = 0.02). Embryological insights revealed distinctions between the cranial divisions of the ICA, influencing fenestration morphology and associated aneurysm formation. Endovascular treatment poses the risk of vascular injury, necessitating the identification of this variation and procedural planning.

Background: In intracranial stenting, good stent apposition is crucial, and high-resolution C-arm computer tomography (CT) is utilized to assess whether stent apposition is complete. This study was aimed at finding optimal hypertonic or isotonic contrast media injection concentration for high-resolution C-arm CT to assess apposition of flow diversion (FD) after carotid artery stenting in swine.

Methods: Twelve FD stents were implanted into the left carotid artery of Bama swine through the endovascular method. During high-resolution C-arm CT scanning, 6%, 8%, 10%, 12%, and 14% dilution percentages of hypertonic contrast media (iopromide 370 mg/ml) and 10%, 12%, 14%, 16%, and 18% dilution percentages of isotonic contrast media (iodixanol 320 mg/ml) were separately injected. A radiologist and a neuro-interventional specialist evaluated and qualitatively scored the post-processed images, and intravascular ultrasound (IVUS) was used to verify the accuracy of these images.

Results: Overall, 12 FD stents were implanted into the left common carotid artery of 12 swine, with a technical success rate of 100%. The best reconstructed images used to observe stent apposition were achieved with iopromide diluted to a concentration of 12% (all P < .05) or iodixanol diluted to a concentration of 16% (all P < .05). Malapposition was noted in one case, and good apposition was noted in 11 cases. These results were consistent with IVUS observations.

Conclusion: Injecting iopromide or iodixanol diluted to 12% or 16% during high-resolution C-arm CT scanning, respectively, can help evaluate FD stent apposition and obtain optimal image quality.

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.