Interventional Neuroradiology最新文献

ObjectiveThe distal transradial approach (dTRA) may reduce puncture-site complication rates compared with the conventional transradial approach (cTRA). However, the treatment outcomes of dTRA performed with large-bore catheters and the factors associated with procedural success remain unclear. We report the treatment outcomes of neurointerventional therapy performed via dTRA with a sheathless 8-Fr balloon guide catheter (BGC) and identify factors associated with procedural failure.MethodsWe retrospectively reviewed 51 consecutive patients who underwent neurointerventional therapy via dTRA with a sheathless 8-Fr BGC at our institution between April 2023 and March 2025. The primary endpoint was the procedural success rate. The secondary endpoint was the rate of puncture-site-related complications. We also analyzed factors associated with crossover from dTRA to cTRA or to a transfemoral approach (TFA).ResultsProcedural success was achieved in 42 of the 51 patients (82.4%). Crossover to cTRA was required in 5 cases (9.8%), and to TFA in 4 cases (7.8%). Patients requiring crossover to cTRA were significantly older than those who completed the procedure via dTRA (p = 0.02). Acute ischemic stroke (p < 0.01) and use of local anesthesia with light sedation (p < 0.01) were independently associated with crossover to TFA. No major complications occurred. Minor puncture-site hematoma was developed in two patients (3.9%), severe radial-artery spasm in three (5.9%), and asymptomatic distal radial artery occlusion in three (5.9%).ConclusionThe dTRA for neurointerventional procedures with a sheathless 8-Fr BGC demonstrates an acceptable success rate and safety profile. However, challenges remain with these procedures in older patients and cases with mechanical thrombectomy or local anesthesia with light sedation.

ObjectiveRecurrent or growing non-acute subdural hematoma (SDH) following standalone or adjunctive middle meningeal artery embolization (MMAe) present a complex clinical challenge. This study aims to investigate the multifactorial causes of recurrence and growing SDH, including vascular and systemic contributors, and explores management strategies to improve outcomes.MethodsWe conducted a retrospective analysis of 22 patients with non-acute SDH requiring rescue treatment after adjunctive or stand-alone MMAe. Patients with documented trauma deemed responsible for the SDH expansion were excluded. Data were collected on patient demographics, clinical presentations, imaging findings, treatment approaches, and outcomes. A systematic review was also conducted across PubMed, Web of Science, Scopus, and Embase databases, adhering to PRISMA guidelines.ResultsNon-traumatic recurrent or growing SDHs were associated with MMA recanalization (27%), contralateral supply from the contralateral MMA (27%), CSF-venous fistulas (5%), and recruitments of vascular collaterals such as deep temporal artery (5%). Management strategies included, respectively, repeat MMAe using polyvinyl alcohol particles, coils, and liquid agents; contralateral MMAe, transvenous embolization for CSF-venous fistulas; and targeted embolization for other vascular contributors. Follow-up assessments were available for 14 patients (64%). Of these, 10 patients (45%) achieved complete resolution of symptoms, three patients (14%) experienced symptomatic improvement, and one patient (5%) had worsening symptoms. In terms of hematoma resolution, nine patients (41%) had complete or near-complete resolution, three patients (14%) exhibited stable hematoma size, and two patients (9%) demonstrated a reduction in hematoma size. Notably, no recurrences were observed after the final treatment. Two patients (9%) died within 10 days of the final embolization treatment due to malignancies.ConclusionRecurrent or growing SDHs following MMAe are linked to subdural membrane vascularity and intracranial hypotension which must be investigated and addressed. Treatment of these issues results in high cure rates.

ObjectiveTo evaluate a novel peel-away sheath technique for sheathless transradial delivery of an 8 Fr balloon guide catheter (BGC), using a 6 Fr peel-away sheath and a 6 Fr inner catheter, without requiring device exchange or dedicated inner dilators.MethodsIn this technique, a 6 Fr peel-away sheath is first inserted into the radial artery, through which a 6 Fr inner catheter and guidewire are advanced. The sheath is then peeled and removed. The preloaded 8 Fr BGC (Branchor X), coaxially mounted over the inner catheter, is subsequently advanced into the radial artery. We retrospectively analyzed 10 consecutive patients who underwent neuroendovascular procedures using this technique.ResultsThe median patient age was 80 years (interquartile range [IQR], 75-88), with 5 males (50%). The peel-away sheath technique was technically successful in all cases (100%), with the BGC successfully delivered via transradial or transulnar access, navigated to the target vessel, and the intended procedure completed without the need for access conversion or device substitution. The median navigation time was 16 min (IQR, 10-24). Balloon inflation was performed in 5 cases (50%) for proximal flow arrest during thrombectomy, distal embolic protection during carotid artery stenting, or device delivery support during aneurysm treatment. No major access-related complications occurred, and no new permanent neurological deficits were observed.ConclusionsThis peel-away sheath technique provides a safe, efficient, and reproducible method for transradial 8 Fr BGC delivery using commonly available devices, potentially expanding the feasibility of transradial access in neuroendovascular practice.

ObjectiveIntracranial plaque enhancement (IPE) is a potential biomarker of plaque vulnerability but lacks a standardized definition. While subjective assessment may be prone to observer variability, a voxel-based quantification method can detect subtle signal intensity (SI) changes. This study aimed to compare the inter-rater reliability of subjective IPE evaluation with that of a voxel-based quantification method.MethodsPatients with stroke due to intracranial atherosclerosis were prospectively imaged using 7 T vessel wall magnetic resonance imaging. Two adjudicators independently assessed IPE, with discrepancies resolved by a third, experienced neuroradiologist. IPE distribution was quantified using a semiautomated method based on SI measurements from post-contrast T1-weighted images. The mean enhancement ratio was calculated for each plaque to assess gadolinium enhancement. Inter-rater reproducibility and the concordance between subjective and objective assessments were evaluated. Regression analysis was performed to identify plaque morphological features that influenced the reliability of subjective IPE adjudication compared to the objective method.ResultsWe analyzed 75 plaques from 41 patients. Inter-rater agreement for IPE adjudication was poor (κ = 0.34). Following consensus, 43% of plaques (32/75) were classified as enhancing, whereas 57% (43/75) were non-enhancing. The agreement between subjective and objective IPE assessments was moderate (κ = 0.40, p < 0.001). Subjective assessment was more likely to reliably adjudicate IPE for plaques exhibiting >50% stenosis (odds ratio (OR), 1.04; p = 0.02) and a positive remodeling index (OR, 2.20; p = 0.02). In contrast, it was less reliable when evaluating posterior circulation plaques (OR, 0.23; p = 0.01).ConclusionSubjective assessment of IPE demonstrated poor inter-rater agreement and only moderate concordance with voxel-based quantification following consensus.

BackgroundStent-assisted coil embolization (SACE) is widely used for treating cerebral aneurysms, particularly bifurcation aneurysms. Although stents are typically indicated for parent vessels larger than 2 mm, their use in small-diameter vessels (<2 mm) hasn't been extensively studied. This study evaluates the safety of SACE with small-diameter vessels.MethodsThis retrospective study analyzed 324 patients who underwent SACE between 2010 and 2023. Patients were divided into the small-diameter (SD) group (<2 mm, n = 100) and the normal diameter (ND) group (> 2 mm, n = 224). Perioperative ischemic complications and their risk factors were compared between the two groups.ResultsIntraoperative thrombi occurred in 6 patients (6.0%) in the SD group, with 4 (4.0%) asymptomatic and 2 (2.0%) transiently symptomatic. In the ND group, thrombi occurred in 7 patients (3.1%), with 5 (2.2%) asymptomatic and 1 (0.4%) experiencing worsened modified Rankin Scale (mRS). Symptomatic ischemic complications occurred in 5 patients (5.0%) in the SD group and 22 patients (9.8%) in the ND group, with 2 (2.0%) and 7 (3.1%) showing worsened mRS, respectively. A neck diameter > 5.5 mm was identified as a risk factor for perioperative ischemic complications.ConclusionSACE can be safely performed in patients with SD parent vessels without increasing ischemic complications. However, there was only a trend toward higher frequency of intraoperative thrombi in the SD group, highlighting the need for preventive measures and prompt intervention. Having a wide neck diameter > 5.5 mm was identified a risk factor for periprocedural ischemic complications in the SD group.

Background and ObjectivesHypothyroidism affects 4.6% of the US population, with incidence increasing in recent years. Systemic effects of hypothyroidism include increased serum cholesterol, endothelial dysfunction, and hypertension, which are widely recognized risk factors for stroke. To better understand the prognostic value of thyroid hormone levels in acute ischemic stroke (AIS), this population-based, cross-sectional study aims to examine the clinical outcomes of patients with AIS with hypothyroidism.MethodsThe National (Nationwide) Inpatient Sample was queried from 2016 to 2020 for patients with AIS with a diagnosis of hypothyroidism using International Classification of Disease Ninth and Tenth Revision diagnostic codes. patients with AIS with and without hypothyroidism were assessed for baseline clinical characteristics, interventions, complications, and clinical outcomes. Propensity score matched analysis (1:1) was conducted to control for possible confounding variables.ResultsOf 2,946,195 patients with AIS identified, 388,235 (13.2%) had a concurrent diagnosis of hypothyroidism. After propensity-score matching, hypothyroidism patients were more likely to experience discharge home (odds ratio (OR) = 0.70; p < 0.01), shorter length of stay (LOS) (4.93 vs. 5.19 days; p < 0.01), and lower rates of inpatient death (OR = 0.80; 95% CI: 0.76-0.84; p < 0.01), compared to patients without hypothyroidism.ConclusionsThis retrospective analysis found that patients with hypothyroidism had shorter inpatient LOS, improved discharge disposition, and lower rates of mortality, suggesting that low thyroid hormone levels may be protective in outcomes of AIS. With the rising prevalence of hypothyroidism in the US population, it is increasingly important to investigate its potential effects on patients with cerebrovascular disease.

BackgroundWhile endovascular thrombectomy (EVT) is firmly established for large vessel occlusion stroke, recent enthusiasm for extending EVT to distal medium vessel occlusions (DMVOs) has been tempered by the neutral results of three major randomized controlled trials: DISTAL, ESCAPE-MeVO, and DISCOUNT.ObjectiveTo critically examine why EVT failed to demonstrate benefit in DMVO trials, assess the associated procedural and clinical challenges, and explore potential future directions for safe and effective treatment in distal cerebrovascular territories.MethodsThis review synthesizes the key findings of recent DMVO thrombectomy trials and contextualizes them within the anatomical, technical, and clinical limitations specific to distal interventions. It further highlights innovations of devices and distal EVT techniques as possible solutions.FindingsThe trials showed no functional benefit of EVT over best medical therapy for unselected DMVO patients and raised safety concerns, including partially increased rates of symptomatic intracranial hemorrhage and mortality in the EVT arms. Contributing factors include the fragility and tortuosity of distal vessels, suboptimal device compatibility, variability in operator experience, and potential limitations in imaging and patient selection. Preliminary data suggest that refined techniques may mitigate risks in very distal occlusions.ConclusionsRoutine EVT for DMVO stroke cannot be recommended based on current evidence. Future research must prioritize patient stratification, dedicated distal devices, and procedural innovation to safely extend thrombectomy into distal territories.

IntroductionChronic subdural hematomas (cSDH) are increasingly recognized as a major cause of morbidity in aging populations. Procedural Innovations such as middle meningeal artery embolization (MMAE) are becoming more widely adopted for cSDH treatment. While embolization reduces hematoma recurrence, the economic cost of different embolic agents remains unclear. This study evaluates inpatient procedural costs associated with particulate versus liquid embolic materials in MMAE for cSDH.MethodsA retrospective cohort study was conducted at a Comprehensive Stroke Center, including patients who underwent MMAE for cSDH between January 2019 and January 2024. Actual hospital expenditure data was used to assess total procedural and material-specific costs. Clinical outcomes, such as modified Rankin Scale (mRS) scores and 90-day retreatment rates, were compared between embolic agent groups. The primary independent variable was the embolic agent, categorized as particulate or liquid embolics (liquid including Onyx and nBCA).Results114 patients were included, with 18 (15.8%) treated with liquid embolics and 96 (84.2%) treated with particulate embolization. Baseline demographics and procedural variables were largely similar across groups. Procedural costs trended higher for liquid embolization than particulates ($27,419.50 ± $15,851.84 vs. $24,731.24 ± $23,195.37, p = 0.639). Material-specific costs were substantially greater for liquid ($3703.17 ± $1797.85) than to particulates ($152.74 ± $75.91, p < 0.0001). Functional outcomes (mRS at discharge, 30 days, and 90 days) and 90-day retreatment rates were not significantly different between groups. Subgroup analyses of hospital costs and access site also showed no significant differences.ConclusionsParticulate embolic agents offer a cost-effective alternative to liquid embolics for MMAE in cSDH, achieving comparable clinical outcomes at a significantly reduced material cost. Cost-conscious embolic selection may help sustain procedural expansion as MMAE adoption grows.

Tandem occlusion in the setting of acute ischemic stroke presents a challenge for endovascular thrombectomy, leading to delayed revascularization with associated poor prognosis and unfavorable outcomes. Simple angioplasty of the carotid stenosis does not always allow the guiding catheter to advance past the stenosis. We present a modified carotid angioplasty technique in which the guiding catheter can successfully be advanced through the carotid stenosis. This allows for faster recanalization and treatment of the intracranial occlusion, knowing that longer procedure times lead to worse outcome. During the modified angioplasty technique, the angioplasty balloon is positioned and inflated partially within the distal guiding catheter and partially within the carotid stenosis. This technique creates momentum for the guiding catheter to advance past the stenosis before it recollapses. Similar techniques have been described before to cross carotid stenosis with an aspiration catheter, and using a diagnostic catheter with a 0.035" wire, using the Dotter technique. However, with this technique it is the guide catheter which can be positioned beyond the proximal carotid stenosis, allowing for access to the intracranial circulation to perform as many thrombectomy passes as required. This allows for faster access to the occluded vessel, without the need for initial stenting, reducing the recanalization times in challenging tandem occlusion cases.

ObjectiveCarotid web can serve as a nidus for clot formation and subsequent thromboembolic stroke. Although treatment historically involved antiplatelet therapy, recent evidence demonstrates notably elevated recurrent stroke rates despite best medical therapy. We examined the safety and efficacy of carotid artery stenting (CAS), which involves placing a coil in the artery, and carotid endarterectomy (CEA), a surgery to remove the clot, for treatment of symptomatic carotid web.MethodsA multi-institutional retrospective registry including adult patients with carotid web with history of ipsilateral acute ischemic stroke or transient ischemic attack (TIA) treated with either carotid artery stenting or endarterectomy was reviewed. Patient demographics, comorbidities, clinical presentation, treatment methodology, and outcomes at follow up were collected.ResultsAmong the 71 included patients (mean age 52.4 years, 44 (62.4%) female), 23 (32.4%) underwent CEA, and 48 (67.6%) underwent CAS. The most common presenting symptoms were hemibody numbness/weakness, aphasia, and gaze deviation. On average, patients had experienced 1.12 ± 0.7 strokes or TIAs before intervention, with a mean delay of 115 ± 224 days between initial stroke/TIA and intervention. The median preintervention modified Rankin Scale (mRS) score was 2. Perioperatively, one patient (1.41%) experienced stroke and none experienced myocardial infarction. During mean 14.8 (±29.2)-month follow up, one patient experienced asymptomatic recurrent stroke (1.41%). Median mRS at follow up was 1, and carotid artery stenting and endarterectomy demonstrated similar rates of postoperative complication and recurrent stroke rates.ConclusionOur results suggest that endarterectomy and stenting are safe and efficacious for minimizing subsequent stroke risk in patients who have experienced stroke or TIA from carotid webbing, warranting further studies to determine the optimal timing and method of treatment.