Authors:
Diestro; J. D. B. Pages: 833 - 834 Abstract: The treatment of emergent large vessel occlusion (ELVO) was revolutionized by endovascular thrombectomy (EVT). The identification of eligible patients for EVT has sparked significant interest in determining the neuroimaging modality that offers optimal results. The American Stroke Association recommend the use of both non-contrast CT and CT angiogram for patients coming in the early window (0–6 hours).1 In the late window (6–24 hours) the randomized trials, DAWN and DEFUSE 3, showed clinical benefit utilized some form of quantitative estimation of the core infarct.2 3 Consequently the society recommends automated perfusion CT neuroimaging in addition to non-contrast CT and CT angiogram when dealing with patients presenting in the late window (6–24 hours). Having quantitative estimates would help neurointerventionalists identify patients who already have a large core and small penumbra—factors that may be associated with procedural futility and/or symptomatic hemorrhagic transformation. Perfusion imaging is not the only way... PubDate: 2023-08-17T06:10:21-07:00 DOI: 10.1136/jnis-2023-020860 Issue No:Vol. 15, No. 9 (2023)
Authors:
Fraser, J. F; Heit, J. J, Mascitelli, J. R, Tsai, J. P. Pages: 835 - 837 Abstract: Guideline summary The 2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage was recently released with endorsements from multiple societies, including the Society of NeuroInterventional Surgery.1 All who worked on this document should be congratulated for their work, as it provides many updates, and addresses new components of aneurysmal subarachnoid hemorrhage (aSAH) care. We encourage providers to thoroughly read the statement. While this Guideline statement is thorough, it is important to highlight opportunities for future research, and gaps in the literature, where rigorous adherence to evidentiary levels leaves providers without clear guidance. There are several new topics and recommendations included in the Guideline. These include new updates supporting the treatment of aSAH patients with advanced age, while recommending against treatment of those with irreversible neurological injury. The Guideline clarifies the use of lumbar puncture in assisting in diagnosis, while supporting the use of diagnostic... PubDate: 2023-08-17T06:10:22-07:00 DOI: 10.1136/jnis-2023-020675 Issue No:Vol. 15, No. 9 (2023)
Authors:
Biondi, A; Primikiris, P, Vitale, G, Charbonnier, G. Pages: 838 - 843 Abstract: BackgroundThe Contour Neurovascular System is a novel device designed to treat intracranial aneurysms by intrasaccular flow disruption. We report our experience and mid-term follow-up in a series of patients treated with the Contour.MethodsThe patients were divided into an intention to treat and a per protocol population, the latter defined by the successful implantation of the Contour device. The intention to treat population included 53 patients (30 women, mean age 56 years) with 60 unruptured intracranial aneurysms (53 in the anterior circulation and seven in the posterior circulation). There was clinical and angiographic follow-up immediate postoperatively and at 24 hours, 3 months and 1 year using the Raymond–Roy classification and the O’Kelly–Marotta grading scale.ResultsThe Contour was successfully implanted in 54/60 (90%) aneurysms. With regard to the angiographic follow-up, there was adequate occlusion (defined as complete occlusion or presence of a neck remnant) in 31.5% of 54 aneurysms immediately postoperatively, 62.3% (in 53/54 aneurysms) at 24 hours, 81.4% (in 43/54 aneurysms) at 3 months, and 89.3% (in 28/54 aneurysms) at 1 year. Technical complications in 60 aneurysms of the intention to treat population included two (3.3%) inadvertent detachments of the device. Thromboembolic events were observed in four of the 60 aneurysms (6.7%), with no clinical symptoms in three patients and transient morbidity in one (1.7%). No aneurysm bleeding was observed and no patient was retreated during the 1-year follow-up period. There was no permanent morbidity or mortality.ConclusionsThe Contour device is effective and safe in the treatment of intracranial aneurysms. However, more experience and long-term follow-up are needed. Keywords:
Editor''s choice, New devices
PubDate: 2023-08-17T06:10:22-07:00 DOI: 10.1136/jnis-2022-019271 Issue No:Vol. 15, No. 9 (2023)
Authors:
Diestro, J. D. B; Dibas, M, Adeeb, N, Regenhardt, R. W, Vranic, J. E, Guenego, A, Lay, S. V, Renieri, L, Al Balushi, A, Shotar, E, Premat, K, El Naamani, K, Saliou, G, Möhlenbruch, M. A, Lylyk, I, Foreman, P. M, Vachhani, J. A, Zupancic, V, Hafeez, M. U, Rutledge, C, Rai, H, Tutino, V. M, Mirshani, S, Ghozy, S, Harker, P, Alotaibi, N. M, Rabinov, J. D, Ren, Y, Schirmer, C. M, Goren, O, Piano, M, Kuhn, A. L, Michelozzi, C, Elens, S, Starke, R. M, Hassan, A, Salehani, A, Nguyen, A, Jones, J, Psychogios, M, Spears, J, Parra-Farinas, C, Bres Bullrich, M, Mayich, M, Salem, M. M, Burkhardt, J.-K, Jankowitz, B. T, Domingo, R. A, Huynh, T, Tawk, R, Ulfert, C, Lubicz, B, Panni, P, Puri, A. S, Pero, G, Griessenauer, C. J, Asadi, H, Siddiqui, A, Ducruet, A. F, Albuquerque, F. C, Du, R, Kan, P, Kalousek, V, Lylyk, P, Boddu, S. R, Stapleton, C. J, Knopman, J, Jabbour, P, Tjoumakaris, S, Clarencon, F, Limbucci, N, Aziz-Sultan, M. A, Cuellar-Saenz, H. H, Cognard, C, Patel, A. B, Dmytriw, A. A. Pages: 844 - 850 Abstract: BackgroundThe Woven EndoBridge (WEB) device is a novel intrasaccular flow disruptor tailored for bifurcation aneurysms. We aim to describe the degree of aneurysm occlusion at the latest follow-up, and the rate of complications of aneurysms treated with the WEB device stratified according to rupture status.MethodsOur data were taken from the WorldWideWeb Consortium, an international multicenter cohort including patients treated with the WEB device. Aneurysms were classified into two groups: ruptured and unruptured. We compared clinical and radiologic outcomes of both groups. Propensity score matching (PSM) was done to match according to age, gender, bifurcation, location, prior treatment, neck, height, dome width, daughter sac, incorporated branch, pretreatment antiplatelets, and last imaging follow-up.ResultsThe study included 676 patients with 691 intracranial aneurysms (529 unruptured and 162 ruptured) treated with the WEB device. The PSM analysis had 55 pairs. In both the unmatched (85.8% vs 84.3%, p=0.692) and matched (94.4% vs 83.3%, p=0.066) cohorts there was no significant difference in the adequate occlusion rate at the last follow-up. Likewise, there were no significant differences in both ischemic and hemorrhagic complications between the two groups. There was no documented aneurysm rebleeding after WEB device implantation.ConclusionThere was no significant difference in both the radiologic outcomes and complications between unruptured and ruptured aneurysms. Our findings support the feasibility of treatment of ruptured aneurysms with the WEB device. Keywords:
New devices
PubDate: 2023-08-17T06:10:22-07:00 DOI: 10.1136/jnis-2022-019153 Issue No:Vol. 15, No. 9 (2023)
Authors:
Radu, R. A; Cagnazzo, F, Derraz, I, Dargazanli, C, Rapido, F, Lefevre, P.-H, Gascou, G, Costalat, V. Pages: 851 - 857 Abstract: BackgroundThe optimal management of chronic total carotid artery occlusion (CTO) is still debated. Endovascular treatment is being increasingly used with heterogeneous technical and clinical results.MethodsPatients with CTO treated with modern endovascular approaches during the past several years (January 2018–December 2021) were retrospectively reviewed.ResultsTwenty patients, with a mean age of 63.7 years, were treated during the study period. Indications for treatment were recurrent stroke in 12 (60%), hemodynamic impairment in 4 (20%), and progressive stroke in 4 (20%) patients. In 6 (30%) patients, the occlusion was limited to the cervical portion, in 5 (25%) to the petrous segment, and in 9 (45%) to the cavernous segment. Technical treatment success was achieved in 80% of cases. In patients with successful recanalization, median pretreatment hypoperfusion volumes dropped from 126 mL (25–75 IQR, 33–224 mL) to 0 mL (25–75 IQR, 0–31.5 mL). Symptomatic procedure-related complications were 30% and permanent procedure-related morbidity-mortality was 5%. Early stent occlusion occurred in 5 (25%) cases. Two cases were asymptomatic and were not retreated, 3 cases presented transient symptoms of which two were successfully recanalized. Stent occlusion was not associated with permanent symptoms. In successfully recanalized patients no intraprocedural emboli were observed.ConclusionsIn the modern endovascular era, revascularization of CTO is a feasible procedure in most cases, and it may be offered in selected patients. However, the high re-occlusion rate is still a limitation of the technique, underlining the need for more research on the technical procedural and periprocedural management. Keywords:
New devices
PubDate: 2023-08-17T06:10:22-07:00 DOI: 10.1136/jnis-2022-019219 Issue No:Vol. 15, No. 9 (2023)
Authors:
Catapano, J. S; Winkler, E. A, Srinivasan, V. M, Dishion, E. L, Rutledge, C, Baranoski, J. F, Cole, T. S, Rudy, R. F, Rumalla, K, Zomaya, M. P, Jadhav, A. P, Ducruet, A. F, Albuquerque, F. C. Pages: 858 - 863 Abstract: BackgroundTransradial artery access (TRA) for neurointerventional procedures is gaining widespread acceptance. However, complications that were previously rare may arise as TRA procedures increase. Here we report a series of retained catheter cases with a literature review.MethodsAll patients who underwent a neurointerventional procedure during a 23-month period at a single institution were retrospectively reviewed for a retained catheter in TRA cases. In cases of retained catheters, imaging was reviewed for anatomical variances in the radial artery, and clinical and demographic case details were analyzed.ResultsA total of 1386 nondiagnostic neurointerventional procedures were performed during the study period, 631 (46%) initially via TRA. The 631 TRA cases were performed for aneurysm embolization (n=221, 35%), mechanical thrombectomy (n=116, 18%), carotid stent/angioplasty (n=40, 6%), arteriovenous malformation embolization (n=38, 6%), and other reasons (n=216, 34%). Thirty-nine (6%) TRA procedures crossed over to femoral access, most commonly because the artery of interest could not be catheterized (26/39, 67%). A retained catheter was identified in five cases (1%), and one (0.2%) patient had an entrapped catheter that was recovered. All six patients with a retained or entrapped catheter had aberrant radial anatomy.ConclusionRetained catheters for neurointerventional procedures performed via TRA are rare. However, this complication may be associated with variant radial anatomy. With the increased use of TRA for neurointerventional procedures, awareness of anatomical abnormalities that may lead to a retained catheter is necessary. We propose a simple protocol to avoid catheter entrapment, including in emergent situations such as TRA for stroke thrombectomy. Keywords:
New devices
PubDate: 2023-08-17T06:10:22-07:00 DOI: 10.1136/jnis-2022-019004 Issue No:Vol. 15, No. 9 (2023)
Authors:
Salem, M. M; Khalife, J, Desai, S, Sharashidze, V, Badger, C, Kuhn, A. L, Monteiro, A, Salahuddin, H, Siddiqui, A. H, Singh, J, Levy, E. I, Lang, M, Grandhi, R, Thomas, A. J, Lin, L.-M, Tanweer, O, Burkhardt, J.-K, Puri, A. S, Gross, B. A, Nossek, E, Hassan, A. E, Shaikh, H. A, Jankowitz, B. T. Pages: 864 - 870 Abstract: BackgroundWe report the largest multicenter experience to date of utilizing the Comaneci device for endovascular treatment of refractory intracranial vasospasm.MethodsConsecutive patients undergoing Comaneci mechanical dilatation for vasospasm were extracted from prospectively maintained registries in 11 North American centers (2020–2022). Intra-arterial vasodilators (IAV) were allowed, with the Comaneci device utilized after absence of vessel dilation post-infusion. Pre- and post-vasospasm treatment scores were recorded for each segment, with primary radiological outcome of score improvement post-treatment. Primary clinical outcome was safety/device-related complications, with secondary endpoints of functional outcomes at last follow-up.ResultsA total of 129 vessels in 40 patients (median age 52 years; 67.5% females) received mechanical dilation, 109 of which (84.5%) exhibited pre-treatment severe-to-critical vasospasm (ie, score 3/4). Aneurysmal subarachnoid hemorrhage was the most common etiology of vasospasm (85%), with 65% of procedures utilizing Comaneci-17 (92.5% of patients received IAV). The most treated segments were anterior cerebral artery (34.9%) and middle cerebral artery (31%). Significant vasospasm drop (pre-treatment score (3–4) to post-treatment (0–2)) was achieved in 89.9% of vessels (96.1% of vessels experienced ≥1-point drop in score post-treatment). There were no major procedural/post-procedural device-related complications. Primary failure (ie, vessel unresponsive) was encountered in one vessel (1 patient) (1/129; 0.8%) while secondary failure (ie, recurrence in previously treated segment requiring retreatment in another procedure) occurred in 16 vessels (7 patients) (16/129; 12.4%), with median time-to-retreatment of 2 days. Favorable clinical outcome (modified Rankin Scale 0–2) was noted in 51.5% of patients (median follow-up 6 months).ConclusionsThe Comaneci device provides a complementary strategy for treatment of refractory vasospasm with reasonable efficacy/favorable safety. Future prospective trials are warranted. Keywords:
New devices
PubDate: 2023-08-17T06:10:22-07:00 DOI: 10.1136/jnis-2022-019272 Issue No:Vol. 15, No. 9 (2023)
Authors:
Pinana, C; Remollo, S, Zamarro, J, Werner, M, Espinosa de Rueda, M, Vega, P, Hernandez, D, Murias, E, Rivera, E, Olier, J, San Roman, L, Paez-Carpio, A, Requena, M, Aixut, S, de Dios Lascuevas, M, Moreu, M, Rosati, S, Gramegna, L. L, Castano, C, Tomasello, A. Pages: 871 - 875 Abstract: BackgroundFlow diverters have emerged in recent years as a safe and effective treatment for intracranial aneurysms, with expanding indications. The Derivo embolization device (DED) is a second-generation flow diverter with a surface finish that may reduce thrombogenicity. We report our multicenter experience evaluating its safety and efficacy.MethodsWe retrospectively analyzed all patients treated with the DED in eight centers in Spain between 2016 and 2020. Demographics, clinical data, procedural complications, morbidity and aneurysm occlusion rates were collected.ResultsA total of 209 patients with 250 aneurysms were treated (77.5% women). The majority of aneurysms were located in the internal carotid artery (86.8%) and most (69.2%) were small ( Keywords:
New devices
PubDate: 2023-08-17T06:10:22-07:00 DOI: 10.1136/jnis-2022-019220 Issue No:Vol. 15, No. 9 (2023)
Authors:
Hang, Y; Wang, C. d, Ni, H, Cao, Y, Zhao, L. B, Liu, S, Shi, H.-B, Jia, Z. Pages: 876 - 880 Abstract: BackgroundThe Alberta Stroke Program Early CT Score (ASPECTS) and collateral score (CS) are two readily available imaging metrics for the evaluation of acute ischemic stroke (AIS) with large vessel occlusion (LVO).ObjectiveTo investigate the predictive value of the ASPECTS combined with CS in detecting patients with CT perfusion (CTP) target mismatch in delayed time windows.MethodsOne hundred and sixty-four patients with LVO-AIS were included. ASPECTS was assessed on non-contrast CT (NCCT). CS was evaluated on single-phase CT angiography (sCTA). Target mismatch was defined as a CTP core volume ≤70 mL, mismatch ratio ≥1.8, and absolute mismatch volume ≥15 mL. Spearman correlation analysis and receiver operating characteristic curve analyses were performed.ResultsThe median NCCT ASPECTS of the 164 patients was 8 (IQR 6–9), median sCTA-CS was 2 (IQR 1–2), and median CTP core volume was 8 mL (IQR 0–29.5). There was a strong correlation between NCCT ASPECTS and CTP core volume (rs=–0.756, p Keywords:
Ischemic stroke
PubDate: 2023-08-17T06:10:22-07:00 DOI: 10.1136/neurintsurg-2022-018960 Issue No:Vol. 15, No. 9 (2023)
Authors:
Bai, X; Fu, Z, Wang, X, Song, C, Xu, X, Li, L, Feng, Y, Dmytriw, A. A, Regenhardt, R. W, Sun, Z, Yang, B, Jiao, L. Pages: 881 - 885 Abstract: Clinical evidence comparing bridging endovascular thrombectomy (bEVT) with intravenous thrombolysis and direct endovascular thrombectomy (dEVT) without thrombolysis for patients with acute ischemic stroke (AIS) presented directly to an EVT-capable center is overwhelming but inconsistent. This study aimed to analyze the progress and controversies in clinical evidence based on current meta-analyses. Three databases, including MEDLINE, EMBASE, and the Cochrane Library, were searched. Relevant data were extracted and reviewed from the pooled studies. The Assessment of Multiple Systematic Review (AMSTAR-2) was used for quality assessment. Twenty-five meta-analyses were finally included. There were 56% (14/25) from Asian countries, 20% (5/25) from North America, and 24% (6/25) from Europe. The majority (72%, 18/25) of evidence arose in a short period from 2020 to 2022 with the serial publication of four randomized controlled trials (RCTs). Among the 25 meta-analyses, 11 pooled at least three RCTs but there is substantial overlap among seven (five recruited the same four RCTs solely and two recruited the same three RCTs solely). Meanwhile, quality rating based on AMSTAR-2 showed 16 ‘high’ rated studies (64%). For functional independence, 40% (10/25) of studies favored bEVT and 60% showed neutral results. For symptomatic intracerebral hemorrhage, most studies (82.6%, 19/23) showed no significant difference. Non-RCT studies contributed to evidence favoring bEVT. Current RCTs provide an update of clinical evidence comparing bEVT and dEVT. However, they simultaneously contribute to an unnecessary overlap among studies. Contemporary observational studies demonstrated different but possibly confounded evidence. Thus, this issue still requires more clinical evidence under standard procedures. Keywords:
Ischemic stroke
PubDate: 2023-08-17T06:10:22-07:00 DOI: 10.1136/jnis-2022-019362 Issue No:Vol. 15, No. 9 (2023)
Authors:
Akiyama, R; Ishii, A, Kikuchi, T, Okawa, M, Yamao, Y, Abekura, Y, Ono, I, Sasaki, N, Tsuji, H, Imamura, H, Hatano, T, Sakai, N, Miyamoto, S. Pages: 886 - 891 Abstract: BackgroundAlthough flow diversion plays a pivotal role in treating internal carotid artery aneurysms presenting with cranial neuropathy, predictors of symptom improvement have not been established.ObjectiveTo investigate improvement of symptoms after flow diversion treatment in patients with internal carotid artery aneurysms causing cranial neuropathy, with sufficient follow-up period. Additionally, to examine factors associated with improvement of symptoms.MethodsThis retrospective multicenter study examined patients with unruptured internal carotid artery aneurysms presenting with cranial neuropathy who were treated using flow diversion and followed up for at least 12 months. Study outcomes were transient worsening of symptoms and symptom status 12 months after treatment. Patient and aneurysm characteristics were statistically analyzed.ResultsSeventy-seven patients were included. Data needed for outcome analysis were available for 66 patients. At the 1-, 3-, 6-, 12-month, and last follow-ups, the proportion of patients with resolved or improved symptoms was 26% (20/77), 51% (39/77), 74% (57/77), 83% (64/77), and 79%(62/77), respectively. Symptom onset-to-treatment time Keywords:
Open access, Hemorrhagic stroke
PubDate: 2023-08-17T06:10:22-07:00 DOI: 10.1136/jnis-2022-019202 Issue No:Vol. 15, No. 9 (2023)
Authors:
Kaiser, D. P. O; Cuberi, A, Linn, J, Gawlitza, M. Pages: 892 - 897 Abstract: BackgroundData on the safety and efficacy of flow diverters (FD) for the treatment of unruptured internal carotid artery (ICA) aneurysms with compressive neuro-ophthalmological symptoms (NOS) are scarce and comprise mainly small case series.MethodsWe performed a search of three databases and included series with ≥10 patients, with unruptured aneurysms of the ICA and NOS, treated with FD. Random-effects analysis of treatment results and safety was performed.ResultsA total of 22 studies reporting on 594 patients were included. Pooled proportions of NOS recovery, improvement, transient and permanent worsening were: 47.4% (95% CI 35.0% to 60.1%); 74.5% (95% CI 67.9% to 80.2%); 7.1% (95% CI 3.3% to 14.7%); and 4.9% (95% CI 3.2% to 7.4%), respectively. Rates of complete recovery and improvement in patients with isolated visual symptoms were 30.6% (95% CI 12.5% to 57.7%) and 56.6% (95% CI 42.3% to 69.9%). Isolated oculomotor symptoms recovered completely in 47.8% (95% CI 29.9% to 66.3%) and improved in 78% (95% CI 69.2% to 84.9%). Morbidity occurred in 5% (95% CI 2.8% to 9%) and mortality in 3.9% (95% CI 2% to 7.5%) of patients. An increased likelihood of symptom improvement was observed when treatment was performed early ( Keywords:
Open access, Hemorrhagic stroke
PubDate: 2023-08-17T06:10:22-07:00 DOI: 10.1136/jnis-2022-019249 Issue No:Vol. 15, No. 9 (2023)
Authors:
Shehata, M. A; Ibrahim, M. K, Ghozy, S, Bilgin, C, Jabal, M. S, Kadirvel, R, Kallmes, D. F. Pages: 898 - 902 Abstract: BackgroundFlow diverters have been widely used in clinical practice for more than a decade. However, most outcome data are limited to 1 year timepoints. This study aims to offer meta-analysis data on long-term (>1 year) safety and effectiveness results for patients with aneurysms treated with flow diverters.MethodsPubMed, Web of Science, Embase, and SCOPUS were searched up to February 24, 2022 using the AutoLit platform. We included primary studies assessing the long-term outcomes for flow diverter devices to manage unruptured internal carotid artery aneurysms with a follow-up period of>1 year. The meta-analysis was carried out using Comprehensive Meta-Analysis software (CMA).ResultsEleven studies were included in the meta-analysis. The pooled occlusion rates after flow diversion treatment for unruptured intracranial brain aneurysms were 77%, 87.4%, 84.5%, 89.4%, 96% for 1 year, 1–2 years, 2 years, 3 years, and 5 years follow-up, respectively. The in-stent stenosis rate was 4.8% and the retreatment rate for the long-term follow-up period was 5%. No delayed rupture of the aneurysm was reported, and there was one case of delayed ischemic stroke. The sensitivity analysis of the prospective studies showed a complete occlusion rate of 83.5% and 85.2% for 1 and 3 years of follow-up, respectively.ConclusionFlow diverters are safe and effective in short- and long-term follow-up and rarely cause serious delayed side effects. Keywords:
Hemorrhagic stroke
PubDate: 2023-08-17T06:10:22-07:00 DOI: 10.1136/jnis-2022-019240 Issue No:Vol. 15, No. 9 (2023)
Authors:
Sanchez, S; Raghuram, A, Wendt, L, Hayakawa, M, Chen, C.-J, Sheehan, J. P, Kim, L. J, Abecassis, I. J, Levitt, M. R, Meyer, R. M, Guniganti, R, Kansagra, A. P, Lanzino, G, Giordan, E, Brinjikji, W, Bulters, D. O, Durnford, A, Fox, W. C, Smith, J, Polifka, A. J, Gross, B, Amin-Hanjani, S, Alaraj, A, Kwasnicki, A, Starke, R. M, Chen, S. H, van Dijk, J. M. C, Potgieser, A. R. E, Satomi, J, Tada, Y, Phelps, R, Abla, A, Winkler, E, Du, R, Lai, P. M. R, Zipfel, G. J, Derdeyn, C, Samaniego, E. A. Pages: 903 - 908 Abstract: BackgroundAnterior cranial fossa dural arteriovenous fistulas (ACF-dAVFs) are aggressive vascular lesions. The pattern of venous drainage is the most important determinant of symptoms. Due to the absence of a venous sinus in the anterior cranial fossa, most ACF-dAVFs have some degree of drainage through small cortical veins. We describe the natural history, angiographic presentation and outcomes of the largest cohort of ACF-dAVFs.MethodsThe CONDOR consortium includes data from 12 international centers. Patients included in the study were diagnosed with an arteriovenous fistula between 1990–2017. ACF-dAVFs were selected from a cohort of 1077 arteriovenous fistulas. The presentation, angioarchitecture and treatment outcomes of ACF-dAVF were extracted and analyzed.Results60 ACF-dAVFs were included in the analysis. Most ACF-dAVFs were symptomatic (38/60, 63%). The most common symptomatic presentation was intracranial hemorrhage (22/38, 57%). Most ACF-dAVFs drained through cortical veins (85%, 51/60), which in most instances drained into the superior sagittal sinus (63%, 32/51). The presence of cortical venous drainage predicted symptomatic presentation (OR 9.4, CI 1.98 to 69.1, p=0.01). Microsurgery was the most effective modality of treatment. 56% (19/34) of symptomatic patients who were treated had complete resolution of symptoms. Improvement of symptoms was not observed in untreated symptomatic ACF-dAVFs.ConclusionMost ACF-dAVFs have a symptomatic presentation. Drainage through cortical veins is a key angiographic feature of ACF-dAVFs that accounts for their malignant course. Microsurgery is the most effective treatment. Due to the high risk of bleeding, closure of ACF-dAVFs is indicated regardless of presentation. Keywords:
Hemorrhagic stroke
PubDate: 2023-08-17T06:10:22-07:00 DOI: 10.1136/jnis-2022-019160 Issue No:Vol. 15, No. 9 (2023)
Authors:
Steiger, K; Singh, R, Fox, W. C, Koester, S, Brown, N, Shahrestani, S, Miller, D. A, Patel, N. P, Catapano, J. S, Srinivasan, V. M, Meschia, J. F, Erben, Y. Pages: 909 - 913 Abstract: BackgroundThis study aims to define the proportion of Medicare neuroendovascular procedures performed by different specialists from 2013 to 2019, map the geographic distribution of these specialists, and trend reimbursement for these procedures.MethodsThe Medicare Provider Utilization Database was queried for recognized neuroendovascular procedures. Data on specialists and their geographic distribution were tabulated. Reimbursement data were gathered using the Physician Fee Schedule Look-Up Tool and adjusted for inflation using the United States Bureau of Labor Statistics’ Consumer Price Index Inflation calculator.ResultsThe neuroendovascular workforce in 2013 and 2019, respectively, was as follows: radiologists (46% vs 44%), neurosurgeons (45% vs 35%), and neurologists (9% vs 21%). Neurologists increased proportionally (p=0.03). Overall procedure numbers increased across each specialty: radiology (360%; p=0.02), neurosurgery (270%; p Keywords:
Vascular neurology
PubDate: 2023-08-17T06:10:22-07:00 DOI: 10.1136/jnis-2022-019297 Issue No:Vol. 15, No. 9 (2023)
Authors:
Maekawa, K; Ohara, N, Takasugi, J, Fujiwara, S, Okada, T, Miyakoshi, C, Imamura, H, Kawamoto, M, Sakai, N. Pages: 914 - 918 Abstract: BackgroundPersistent hypotension (PH) after carotid artery stenting (CAS) is a relatively common complication; however, it is unclear which patients are more likely to experience this phenomenon. Recently, lower left atrial (LA) volume was associated with vasovagal syncope, which has a similar neurological mechanism to hypotension after CAS. This study aimed to investigate whether LA volume can predict PH after CAS.MethodsThis single center retrospective analysis used data from 316 patients who had undergone CAS between March 2013 and February 2021. After the exclusion of urgent CAS, 212 procedures (202 patients) with transthoracic echocardiograms were included. The procedures were divided among two groups according to the presence or absence of PH for more than 1 hour after CAS.ResultsThe mean age of the patients was 73.0±7.5 years. PH was observed during 52 (24.5%) procedures. The PH group exhibited a lower LA volume index (LAVI) than the no-PH group (29.7±9.1 vs 37.7±12.5 mL/m2, respectively; p Keywords:
Clinical neurology
PubDate: 2023-08-17T06:10:22-07:00 DOI: 10.1136/jnis-2022-019094 Issue No:Vol. 15, No. 9 (2023)
Authors:
King, R. M; Peker, A, Anagnostakou, V, Raskett, C. M, Arends, J. M, Dixit, H. G, Ughi, G. J, Puri, A. S, Gounis, M. J, Shazeeb, M. S. Pages: 919 - 923 Abstract: BackgroundHigh-frequency optical coherence tomography (HF-OCT) is an intravascular imaging method that allows for volumetric imaging of flow diverters in vivo.ObjectiveTo examine the hypothesis that a threshold for both volume and area of communicating malapposition can be predictive of early aneurysm occlusion.MethodsFifty-two rabbits underwent elastase aneurysm formation, followed by treatment with a flow diverter. At the time of implant, HF-OCT was acquired to study the rate and degree of communicating malapposition. Treated aneurysms were allowed to heal for either 90 or 180 days and euthanized following catheter angiography. Healing was dichotomized into aneurysm remnant or neck remnant/complete occlusion. Communicating malapposition was measured by HF-OCT using a semi-automatic algorithm able to detect any points where the flow diverter was more than 50 µm from the vessel wall. This was then summed across image slices to either a volume or area. Finally, a subsampled population was used to train a statistical classifier for the larger dataset.ResultsNo difference in occlusion rate was found between device type or follow-up time (p=0.28 and p=0.67, respectively). Both volume and area of malapposition were significantly lower in aneurysms with a good outcome (p Keywords:
Basic science
PubDate: 2023-08-17T06:10:22-07:00 DOI: 10.1136/jnis-2022-019275 Issue No:Vol. 15, No. 9 (2023)
Authors:
Arturo Larco, J. L; Madhani, S. I, Liu, Y, Abbasi, M, Lylyk, P. N, Benike, A, Shahid, A, Tekin, B, Quinton, R, Savastano, L. E. Pages: 924 - 930 Abstract: BackgroundEmbolization of the middle meningeal artery (MMA) is a promising minimally invasive technique that is gaining traction in the treatment of chronic subdural hematoma. Unfortunately, the human meninges and associated arteries are significantly larger than those of conventional laboratory animals, making the development of a clinically relevant animal model for testing of embolization agents elusive.ObjectiveTo introduce the posterior intercostal artery (PIA) model in swine and provide anatomical, angiographic, histological, and procedural data to validate its relevance in modeling the human MMA.MethodsIn human cadaveric specimens, 3D angiograms of the internal maxillary arteries (n=6) were obtained and the dura with MMA were harvested and histologically processed. Angiographic and histologic data of the human MMA were compared with the swine PIA (three animals). Then, embolization of the PIA (n=48 arteries) was conducted with liquid embolization agent (Onyx, Medtronic), and angiographic and histological results were assessed acutely (four animals) and after 30 days (two animals).ResultsThe human MMA has equivalent diameter, length, branching pattern, 3D trajectory, and wall structure to those of swine PIAs. Each swine has 12 to 14 PIAs (6–7 per side) suitable for acute or chronic embolization, which can be performed with high fidelity using the same devices, agents, and techniques currently used to embolize the MMA. The arterial wall structure and the acute and chronic histological findings in PIAs after embolization are comparable to those of humans.ConclusionsThis PIA model in swine could be used for research and development; objective benchmarking of agents, devices, and techniques; and in the training of neurointerventionalists. Keywords:
Basic science
PubDate: 2023-08-17T06:10:22-07:00 DOI: 10.1136/jnis-2022-019105 Issue No:Vol. 15, No. 9 (2023)
Authors:
Caton, M. T; Baker, A, Smith, E. R, Perez, E, Hemphill, K, Cooke, D. L, Dowd, C. F. Pages: 931 - 931 Abstract: Percutaneous sclerotherapy is an effective technique for treating lymphatic malformations of the head and neck, with clinical success rates exceeding 84%.1 Sodium tetradecyl, which damages lipid membranes and stimulates free radical-induced local damage, and doxycycline, which inhibits angiogenesis, have emerged as the safest and most effective of several available sclerosants.2–4 Although severe periprocedural morbidity is rare, temporary local complications are reported in 14% and skin necrosis or scarring in up to 0.8–5.8% of sclerotherapy procedures.5 As these lesions are frequently located in the face and/or neck, even minor complications can be disfiguring and must be avoided. This technical video describes a ‘dual-agent’ approach for percutaneous sclerotherapy of macrocystic lymphatic malformations using sodium tetradecyl as a ‘primer’ followed by doxycycline as a definitive sclerosant (video 1). This technique emphasizes meticulous backtable preparation and effective use of ultrasound and fluoroscopy to minimize complications. Video 1 Keywords:
Technical video
PubDate: 2023-08-17T06:10:22-07:00 DOI: 10.1136/jnis-2022-019255 Issue No:Vol. 15, No. 9 (2023)
Authors:
Su, X; Gao, Z, Ma, Y, Song, Z, Zhang, H, Zhang, P, Ye, M. Pages: 932 - 932 Abstract: We were very interested to read the analysis by Sanchez et al of the largest cohort study of anterior cranial fossa dural arteriovenous fistulas (ACF DAVFs).1 In this study, 60 cases of ACF DAVFs from 12 centers between 1990 and 2017 in the CONDOR database are included. Fifty-three of the 60 cases (88.8%) received treatment. The majority of the patients underwent microsurgery (66%, 35/53) or endovascular surgery (32%, 17/53). All those who received microsurgery as their first line of treatment had their ACF DAVFs completely removed. Only 53% (9/17) of patients who received an endovascular approach as first-line treatment achieved angiographic cure. Complications were lower in patients treated with microsurgery (6%, 2/35) compared with endovascular treatment (12%, 2/17). At an average of 75 days after endovascular treatment, 18% (2/11) of ACF DAVFs had angiographic recurrence. This article also goes into great detail about the clinical presentation and... PubDate: 2023-08-17T06:10:22-07:00 DOI: 10.1136/jnis-2023-020401 Issue No:Vol. 15, No. 9 (2023)
Authors:
Sanchez, S; Samaniego, E. A. Pages: 932 - 933 Abstract: We would like to thank Su X, et al for their interest and their remarks1 on our research. We analyzed the natural history, angiographic characteristics and treatment outcomes of anterior cranial fossa dural arteriovenous fistulas (ACF-dAVFs) during a period of 27 years.2 This analysis determined that microsurgery achieved ACF-dAVF closure in all cases (35/35), while endovascular therapy (EVT) achieved closure in 53% (9/17) of cases. As we acknowledged in the limitations of our study, there has been a robust improvement in endovascular techniques in the last two decades and the inclusion of data acquired within 27 years may not reflect the most up to date EVT. The introduction of new liquid embolics, more navigable microcatheters and improved imaging quality allows the endovascular treatment of complex cerebrovascular lesions.3 4 Two recent studies reported high occlusion rates of 83% (19/23) and 91% (31/34)... PubDate: 2023-08-17T06:10:22-07:00 DOI: 10.1136/jnis-2023-020541 Issue No:Vol. 15, No. 9 (2023)
Authors:
Doddamani, R; Kota, R, Ahemad, N, Chandra, P. S, Tripathi, M. Pages: 933 - 934 Abstract: We read with interest the article by Pearl et al1 on the method of endovascular embolic hemispherotomy (EEH). The authors are to be congratulated for developing this innovative technique of staged embolic hemispherotomy using an endovascular technique as a standalone procedure.1 In the initial period, the authors performed staged embolization for Hemimegalencephaly (HME) with intractable epilepsy in four infants.2 3 In these initial cases, the authors noted a reduction in seizures, and then performed surgical hemispherotomy.2 The authors performed staged embolization beyond the circle of Willis, as a standalone procedure, in three infants in this study.1 This is a challenging technique considering the neonatal/infantile age group, and the small caliber and tortuous vessels. The presence of hemimegalencephaly (HME) distorts the intracranial vasculature, adding to the difficulty. It is too early to comment on the long term seizure... PubDate: 2023-08-17T06:10:22-07:00 DOI: 10.1136/jnis-2023-020076 Issue No:Vol. 15, No. 9 (2023)