Covered Stent Graft for Treatment of Carotid Blowout Syndrome in Patients With Head and Neck Cancer.

Importance: Carotid blowout syndrome (CBS) is a rare life-threatening complication of head and neck cancer that requires either surgical or endovascular treatment such as a carotid occlusion procedure or stent-graft placement. CBS outcomes and complications of its management using endovascular stent-graft placement remain unclear due to limited published data. Given that this treatment approach is increasingly used, understanding its efficacy and associated risks is paramount. Objective: To evaluate the periprocedural and postprocedural complications and outcomes associated with stent-graft treatment for CBS in patients with head and neck cancer. Design, Setting, and Participants: This case series study conducted at the Institut Gustave Roussy (Villejuif, France) between January 2006 and December 2021 included all eligible patients with head and neck cancer who experienced CBS and were referred for endovascular treatment. Risk factors and periprocedural and postprocedural data were collected retrospectively from medical records. Data analyses were performed from July 2022 to July 2024. Exposure: Endovascular stent-graft placement for the treatment of CBS in patients with head and neck cancer. Main Outcomes and Measures: Periprocedural and postprocedural complications of stent-graft placement. Secondary outcomes were technical success, defined as immediate control of hemorrhage; 30-day and overall survival rates; and risk factors for mortality and rebleeding. Risk factors considered were body mass index (BMI), CBS presentation, hemodynamic status, tumor stage, and radiation dose. Results: In all, 67 CBS-related stent-graft procedures were performed in 62 patients (mean [SD] age, 55.4 [10.1] years; 10 [16.1%] females and 52 [83.9%] males), most with advanced-stage head and neck cancer, over 15 years. The most frequently observed clinical complications were rebleeding (16 patients [38.8%]) and stroke (9 patients [13.4%]). Immediate hemostasis was achieved in 100% of cases. The survival rate was 77.3% (51 participants) at 30 days postprocedure, with a median (IQR) overall survival time of 59 (32-141.5) days. Acute CBS presentation (risk ratio, 4.30; 95% CI, 1.11-28.23) and BMI (risk ratio, 0.88; 95% CI, 0.77-0.99) showed a statistically significant association with 30-day mortality in univariate analysis. Conclusions and Relevance: The findings of the case-series study indicate that CBS can be safely managed with endovascular stent-graft placement that preserves carotid patency; however, it carries significant risks of ischemia and rebleeding. These findings suggest that stent grafts should be used only in specific clinical scenarios. Despite achieving a high rate of technical success in controlling hemorrhage, the overall and 30-day survival outcomes underscore the critical implications of CBS in patients with cancer and its associated therapeutic challenges.

Comparative analysis of single plane and biplane angiography systems for mechanical thrombectomy for acute ischemic stroke: a systematic review and meta-analysis.

BACKGROUND: The choice of angiography system could influence the outcomes of mechanical thrombectomy (MT) in the treatment of acute ischemic stroke (AIS), but its impact is not yet well understood. This study aims to compare the clinical and technical outcomes of MT performed with single plane versus biplane angiography systems. METHOD: We conducted a systematic review and meta-analysis, following PRISMA guidelines, by searching PubMed, Embase, Web of Science, and Scopus to include studies on patients with AIS who underwent MT with either single plane or biplane angiography up to May 4, 2024. The primary outcome was a favorable outcome defined as a modified Rankin Scale (mRS) score of 0-2 at 90 days after the procedure. Data were analyzed using a random-effects model and heterogeneity was assessed using the I2 test and Q statistics. RESULTS: Five studies with a total of 1562 patients were analyzed. Of these, 68.4% were treated with biplane systems and 31.6% with single plane systems. Single plane angiography was associated with a significantly higher rate of favorable outcomes (OR 1.43; 95% CI 1.13 to 1.80; P<0.01). There were no significant differences in successful recanalization, periprocedural complications, procedure time, total fluoroscopy time, or contrast volume between the two systems. CONCLUSION: While single plane angiography systems may offer slightly better outcomes in MT for AIS, both systems appear equally effective in most clinical and technical perspectives, suggesting that system selection may be more dependent on availability and procedural requirements rather than inherent superiority. Our findings may encourage clinicians to use single-plane angiography in settings where the biplane angiography suite availability is limited, but it should be noted that this observation may have been influenced by selection bias, particularly since the larger studies included in our meta-analysis did not observe this effect in adjusted analyses for potential confounder factors.

Can the clot meniscus and claw signs predict thrombectomy and clinical outcomes in patients with stroke? A systematic review and meta-analysis.

BACKGROUND: The angiographic shape of an occlusion, like the clot meniscus sign and the claw sign, has been reported to potentially impact the recanalization rate and clinical outcome in patients undergoing mechanical thrombectomy for acute ischemic strokes. METHOD: Following PRISMA guidelines, a systematic literature search was conducted across PubMed, Scopus, Embase and Web of Science databases. Patients were grouped into clot meniscus/claw sign positive and negative groups based on the definitions obtained from each study. Primary outcomes included technical success, with a meta-analysis performed using a random-effects model to calculate proportions and odds ratios (OR) with 95% confidence intervals (Cl). RESULTS: We included seven studies recruiting 1572 patients. The results indicated that the positive and negative groups had comparable first-pass effect (OR 1.95; 95% CI 0.76 to 5.01; P=0.167) and final recanalization (OR 1.36; 95% CI 0.81 to 2.27; P=0.248) rates. However, the rate of having a favorable functional outcome was significantly higher in the positive group than in the negative sign group (OR 1.91; 95% CI 1.25 to 2.92; P<0.003). Within the sign-positive population, the use of contact aspiration was associated with a significantly higher rate of recanalization compared with using a stent retriever (OR 0.18; 95% CI 0.07 to 0.49; P<0.001). This result did not translate into a clinical impact, as both stent retriever and contact aspiration showed comparable rates of functional independence at 3 months (OR 0.22; 95% CI 0.02 to 2.33; P=0.210). CONCLUSION: The presence of the clot meniscus/claw sign is not associated with recanalization outcomes after thrombectomy. However, it might be a good sign to predict which thrombectomy technique might be associated with better recanalization, although current evidence may need further confirmation.

Optimizing the hemodynamics of hand injections in neuroangiography.

PURPOSE: Optimizing the preparation of a 10 ml syringe for manual injection of contrast media can help operators obtain easier and faster injections. This study aims to compare the flow rates of different contrast media injection methods. METHODS: Different contrast media solutions were compared: 100% contrast (10 ml contrast), mixed contrast solution (8:2 contrast/saline), and layered contrast below saline ("Parfait") in different volumes. Contrast media were injected at room temperature (20°C) and after heating (37°C). Four operators injected 10 ml syringes filled with different mediums through 5-French angiographic catheters. The average flow rate was used to compare different contrast injection mediums. The Kruskal-Wallis test with post-hoc pairwise comparisons using Bonferroni correction or Mann-Whitney U-tests were employed depending on the type of comparison. RESULTS: Compared to the 100% contrast solution, every Parfait media and mixed contrast solution demonstrated significantly higher flow rates (p < 0.001). The 5 ml saline Parfait had the highest flow rate among the Parfait solutions. The 5 ml saline Parfait and the mixed solution had comparable flow rates (p = 0.237). Higher flow rates were observed upon heating both 100% contrast (p < 0.001) and mixed contrast solutions (p < 0.001) in comparison to their flow rates at room temperature. CONCLUSION: This study demonstrates the capability of the Parfait and mixed contrast injections to achieve higher flow rates than the 100% contrast solutions. Heating the contrast media to 37°C also proves to be a viable strategy for further enhancing the flow rates for 100% and mixed contrast solutions.

Ultra-early neurological deterioration following a brain arteriovenous malformation rupture.

Purpose: This study aims to explore the impact of ultra-early neurological deterioration (U-END) on the outcome (mortality and poor neurological status) following a brain arteriovenous malformation (BAVM) rupture and identify determinants of U-END. Methods: Patients with BAVM ruptures admitted to a single tertiary care center were retrospectively reviewed. U-END was defined as a worsening by two or more points on the Glasgow Coma Scale (GCS). U-END was tested as a potential predictor of in-hospital mortality and poor outcomes. Univariate and multivariate analyses were performed to identify determinants of U-END. Patients with U-END were also matched and compared with BAVM rupture controls presenting with a GCS close or equal to either their initial or their lowest GCS. Results: A total of 248 patients with BAVM ruptures met the inclusion criteria, with 39 (15.7%) patients presenting with U-END. U-END was not associated with and was not an independent predictor of in-hospital mortality (12.8 vs. 10.5% in the rest of the study population; p = 0.67) or poor outcomes (39.5 vs. 36.9%; p = 0.77). The only independent determinants of U-END were hydrocephalus (OR 2.6 [95%CI, 1.1-6.4]; p = 0.03) and intraventricular hemorrhage (IVH; OR 3.5 [95%CI, 1.1-11.7]; p = 0.04). When compared to the initial GCS control group, U-END patients more often presented with IVH (89.5 vs. 64.1%; p = 0.009) and hydrocephalus (73 vs. 38.5%; p = 0.003). When compared to the lowest GCS control group, U-END patients had lower early S100B serum levels (0.35 ± 0.37 vs. 0.83 ± 1; p = 0.009) and a lower rate of poor outcome (39.5 vs. 64.9%; p = 0.03). Conclusion: Ultra-early neurological deterioration in ruptured BAVMs did not result in increased mortality or poor outcomes and was most often related to IVH and hydrocephalus.

Flow diverter braid deformation following treatment of cerebral aneurysms: incidence, clinical relevance, and potential risk factors.

BACKGROUND: Although flow diverters (FDs) have benefited from several technical improvements, recently concerns have arisen regarding the braid stability after implantation. Thus, we investigated frequency, predictive factors, and clinical impact of the phenomenon of FD braid deformation (FDBD). METHODS: Consecutive intracranial aneurysms (IAs) treated with various FDs, between January 2018 and July 2023, were reviewed to identify FDBD (defined as the deformation of a FD without any external force applied to it). Patient, aneurysm, procedural, and FD characteristics were retrieved and analyzed using univariate and multivariable analyses. Morbidity is defined as a score of +1 in the modified Rankin Scale at 3 months. RESULTS: In total, 245 FD procedures (271 FDs implanted; 25 multiple IAs treated with 1 FD) in 228 patients; FDBD was observed in 36/245 cases (14.7%), mainly at follow-up angiography (32/36, 88.9%); fish-mouthing was the most frequent FDBD. Morbidity was related to fish-mouthing and braid collapse and was significantly higher in the FDBD group after retreatment (p=0.04). Drawn filled tubing with platinum (DFT) (adjusted odds ratio (aOR)=7.0, 95% CI 3.0 to 17.5; p<0.001) and FD diameter (aOR=2.2, 95% CI 1.3 to 4.1; p<0.01) were identified as independent predictors of FDBD. The metal alloy composing the FD (p=0.13) and coated surfaces were not significantly associated with FDBD (p=0.54 in multivariable analysis). CONCLUSIONS: FDBD is a frequent phenomenon observed in about 15% of cases, and it was responsible for higher morbidity. Only FD characteristics (DFT and FD diameter) were independent determinants of FDBD. Future research should focus on the impact of novel braid configurations and materials on braid stability.

Neck apposition is a key factor for aneurysm occlusion after Woven EndoBridge device embolization.

BACKGROUND: Sealing of the aneurysm neck with a Woven EndoBridge (WEB) device is recommended for disrupting the blood flow inside the aneurysm. This study investigates the relationship between WEB neck apposition and aneurysm occlusion rates. METHODS: Aneurysms treated with a WEB from March 2017 to May 2022 at a single center were included. WEB neck apposition (poor/good) and WEB protrusion (yes/no) were evaluated on post-detachment high resolution cone beam CT images. Angiographic occlusion was assessed with the Bicêtre Occlusion Scale score (BOSS). Univariate and multivariable analysis tested the association between neck apposition and occlusion rates. RESULTS: The study included 159 aneurysms in 141 patients (mean age 55.8±11.2 years; 64.2% women). Good neck apposition and protrusion were noted in 123 (77.4%) and 30 (18.9%) cases, respectively. Inter-rater agreements were good for neck apposition (κ=0.75) and protrusion (κ=0.78). Complete and adequate occlusion was achieved in 104 (65%) and 130 (82%) cases, respectively (median follow-up 18 months). Good neck apposition was a strong independent predictor for both adequate (adjusted OR (aOR)=5.9, 95% CI 2.4 to 14.9; P<0.001) and complete occlusion (aOR=7.1, 95% CI 3.0 to 18.1; P<0.001). Protrusion was more frequent in the adequate occlusion group versus the aneurysm recurrence group without reaching statistical significance (P=0.06), but was associated with more thromboembolic complications (9/30 (30%) vs 12/129 (9%); P<0.01). WEB shape modification was significantly greater in poor apposition cases (P=0.03). CONCLUSIONS: Achieving good neck apposition of the WEB strongly predicts aneurysm occlusion during follow-up. WEB protrusion should be minimized due to the increase in thromboembolic risk with limited impact on aneurysm occlusion.

Triple Aspiration versus Conventional Aspiration Techniques: A Randomized In Vitro Evaluation.

BACKGROUND AND PURPOSE: A single-aspiration maneuver using a large-volume syringe is a common and effective technique for aspiration thrombectomy. Multiple aspiration cycles using large aspiration syringes have been proposed as a means to improve the efficacy over single aspiration. In this study, we sought to investigate the efficacy of a "triple aspiration technique" in which a large-volume syringe is cycled 3 times before catheter retraction during aspiration thrombectomy. MATERIALS AND METHODS: A 3D-printed adult vasculature was used as a benchtop thrombectomy platform. Fibrin-rich and red blood cell-rich clots were prepared in centrifuge tubes using human plasma, red blood cells, and calcium chloride. Next, clots were placed in the carotid terminus of the model, and the performances of 3 different aspiration techniques-triple syringe, single syringe, and continuous pump aspiration-were compared in a randomized manner (1:1:1). Outcomes of interest included first-pass efficacy (FPE), complete clot removal (final modified TICI 2c/3), the number of thrombectomy attempts to achieve modified TICI 2c/3, vacuum pressure, and distal embolization. The distal emboli were detected using a 70-µm cell strainer placed at the outflow of the model and quantified using an image-processing algorithm. The vacuum pressures were measured using a pressure transducer. RESULTS: A total of 102 replicates were performed, 34 for each technique. The triple-aspiration technique provided a significantly higher rate of FPE than the syringe and pump aspiration techniques (67.6% versus 41.1%, P = .02). Additionally, the triple-aspiration technique achieved complete clot removal with a significantly lower mean number of thrombectomy attempts compared with single-syringe aspiration (1.2 [SD, 0.5] versus 1.8 [SD, 0.8], P = .005). The triple-aspiration technique generated significantly higher mean vacuum pressure than both the single-syringe and vacuum pump aspiration (28.3 [SD, 0.2] versus 27.2 [SD, 0.3], P = .002 and 26.2 [SD, 0.4], P = .001, respectively). The differences in complete clot removal and distal embolization parameters were not statistically significantly different across the groups. CONCLUSIONS: Our findings suggest that the triple aspiration technique can improve FPE rates and vacuum pressure in aspiration thrombectomy. Further studies are needed to examine the safety and efficacy of triple aspiration in the clinical setting.

CLinical EValuation of WEB 17 device in intracranial aneuRysms (CLEVER): 1-year effectiveness results for ruptured and unruptured aneurysms.

BACKGROUND: The Woven EndoBridge (WEB) device is designed to treat wide-necked bifurcation aneurysms. The WEB 17 is the latest iteration and can be delivered through a 0.017″ microcatheter. The CLEVER study demonstrated that WEB 17 is safe and effective for providing protection against bleeding or rebleeding at 1 month and 1 year. OBJECTIVE: To evaluate angiographic stability at 1 year. METHODS: The CLEVER study was a prospective multicenter study conducted in 17 European centers, involved 163 subjects, comprising 60 ruptured and 103 unruptured aneurysms. Independent assessment of 1-year follow-up imaging was incorporated into the study design. RESULTS: Aneurysm diameters ranged from 2.0 to 9.2 mm, with 95.7% being broad-based (dome-to-neck ratio <2). Follow-up imaging at 1 year was completed for 146 out of 163 subjects (89.6%) and evaluated by an independent core laboratory. The primary efficacy endpoint of adequate occlusion without re-treatment at 1 year was achieved for 120 (82.2%) of all subjects. At 1 year, the adequate occlusion rate was 86.5% for ruptured aneurysms (73.1% complete occlusion) and 82.4% for unruptured aneurysms (57.1% complete occlusion). The overall re-treatment rate at 1 year was 2.6% (4/152), with 3.1% (3/97) for unruptured aneurysms and 1.8% (1/55) for ruptured aneurysms CONCLUSION: Delivery of the WEB 17 via 0.017 inch catheters represents a significant evolution of the WEB design. The results of CLEVER presented here demonstrate that it maintains the same efficacy as previous generations of WEB.

Creating elastase aneurysms in rabbits: a video primer.

The New Zealand rabbit elastase-induced arterial aneurysm of the right common carotid artery remains a widely used model for assessing the effectiveness and safety of new neuroendovascular devices.1 This model offers a simple and reliable platform for pre-clinical in vivo investigations, crucial for comprehending the biological processes underlying aneurysm healing after endovascular treatment.2 Notably, the induced aneurysm exhibits morphological, hemodynamic, and histological characteristics similar to human intracranial aneurysms. The creation of the aneurysm is performed using open and endovascular techniques. Each step of the procedure requires a meticulous and controlled gesture to ensure reproducibility of the aneurysm and minimize animal misuse. In video 1 we present a step-by-step procedural guide for aneurysm creation and follow-up. We hope this resource will help in promoting this model and provide useful guidance for researchers in the field.neurintsurg;jnis-2024-021912v1/V1F1V1Video 1Surgical procedure of creating elastase-induced aneurysms in rabbits.

Preclinical in vitro and in vivo results of the new silk vista flow diverter with P8RI coating.

BACKGROUND: Flow diverting stents (FDS) have transformed the treatment of intracranial aneurysms; however, their metallic structure associated with their intra-luminal positioning hamper angiographic and clinical outcomes. Therefore, there is a need to develop FDS with optimized surfaces that reduce thrombogenicity while promoting the healing process and endothelialization. METHODS: P8RI, a peptide mimicking the CD31 protein, was previously developed and grafted onto Silk Vista (SV) FDS. P8RI-SV and bare-SV were used in vitro in a blood loop model to test their hemocompatibility using human whole blood and in vivo using the rabbit elastase model for optical coherence tomography (OCT) comparisons of neointimal formation at day 5 and day 28. RESULTS: After blood loop incubation, P8RI-SV showed significant reduction in fibrin binding (p=0.004) and platelet adhesion (p=0.041) compared with bare-SV. Similarly, derivative markers measured in blood, thromboxane B2 (platelet activation) and Thrombin-Antithrombin III complexes (coagulation activation), were also significantly reduced in the P8RI-SV group (both p=0.002). In vivo, complete or near-complete occlusion was reached in all aneurysms (n=6) at day 28. Excellent rate of stent-coverage ratio was obtained at day 5 (89.3% (79.1%-98.7%)) comparable to the observation at day 28 (91.8% (79.1%-100%); p=0.44). These rates were significantly higher compared with bare-SV at day 5 (77.8% (58.3%-86.8%); p<0.001) and at day 28 (67.7% (52.6%-88.9%); p<0.0001). CONCLUSION: In vitro results confirm enhanced hemocompatibility with a significant anti-thrombotic effect of the P8RI-SV. In vivo results provide evidence of rapid neo-intimal growth reaching near-complete tissue healing as early as day 5 in a rabbit model.

Endovascular approach to posterior spinal cord AV shunts via the anterior spinal artery.

Intradural spinal cord arteriovenous shunts are challenging vascular lesions with poor prognosis if left untreated. Therapeutic options include endovascular treatment, microsurgery or a combined approach. Surgical approaches are more complex if the lesions are located anteriorly and supplied by the anterior spinal artery (ASA). ASA can also vascularize shunts located on the posterior surface of the spinal cord either by transmedullary arteries, pial circumferential arteries or, if affecting the lower portions of the cord, by the anastomotic channels of the basket. Each of these vessels can be used for endovascular navigation to reach the shunts with good results if appropriate anatomical rules are followed. We describe here some technical considerations based on the anatomical analysis for the embolization of posterior spinal cord arteriovenous shunts vascularized by the anterior spinal artery.

Evaluation of flow diverters for cerebral aneurysm therapy: recommendations for imaging analyses in clinical studies, endorsed by ESMINT, ESNR, OCIN, SILAN, SNIS, and WFITN.

BACKGROUND: Multiple studies and meta-analyses have described the technical and clinical outcomes in large cohorts of aneurysm patients treated with flow diverters (FDs). Variations in evaluation methodology complicate making comparisons among studies, hinder understanding of the device behavior, and pose an obstacle in the assessment of further advances in FD therapy. METHODS: A multidisciplinary panel of neurointerventionalists, imaging experts, and neuroradiologists convened with the goal of establishing consensus recommendations for the standardization of image analyses in FD studies. RESULTS: A standardized methodology is proposed for evaluating and reporting radiological outcomes of FD treatment of intracranial aneurysms. The recommendations include general imaging considerations for clinical studies and evaluations of longitudinal changes, such as neointimal lining and stenosis. They cover standards for classification of aneurysm location, morphology, measurements, as well as the assessment of aneurysm occlusion, wall apposition, and neck coverage. These reporting standards further define four specific braid deformation patterns: foreshortening, fish-mouthing, braid bump deformation, and braid collapse, collectively termed 'F2B2'. CONCLUSIONS: When widely applied, standardization of methods of measuring and reporting outcomes will help to harmonize the assessment of treatment outcomes in clinical studies, help facilitate communication of results among specialists, and help enable research and development to focus on specific aspects of FD techniques and technology.

Endovascular Thrombectomy for Carotid Pseudo-Occlusion in the Setting of Acute Ischemic Stroke: A Comparative Systematic Review and Meta-analysis.

BACKGROUND: The effective treatment for patients with acute ischemic stroke (AIS) with cervical internal carotid pseudo-occlusion (cICA-PO) requires comprehensive research on the safety and outcomes of endovascular thrombectomy (EVT). However, there are limited data available, highlighting the need for further research to ensure better treatment strategies and improve the quality of care for these patients. PURPOSE: This study aims to assess the management and outcomes in this population group compared with patients with true carotid occlusion. DATA SOURCES: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, a comprehensive systematic review was conducted by using PubMed, Embase, Web of Science, and Scopus from database inception to November 2023. STUDY SELECTION: The size of the included studies ranged from 16 patients to 146 patients. Through the 4 full-text articles, a total of 259 patients were collected. We compared outcomes between patients with cICA-PO compared with patients with true carotid occlusions undergoing EVT due to AIS. We excluded studies with patients with carotid pseudo-occlusion without stroke, review articles, duplicate studies, overlapped data that included the same patients presented in another included study, case reports, case series with fewer than 5 patients, and meeting abstracts that did not contain the outcomes of interest. We did not pose any limitations regarding sample size or patient characteristics. DATA ANALYSIS: We utilized the R statistical software (V.4.3.1; R package meta) to conduct the analysis of all the data obtained. We calculated the OR for binary variables, and the corresponding 95% CI. To synthesize the data, random-effect models, as well as forest plots were generated to visually represent the synthesis of the data. Additionally, we assessed heterogeneity by using Cochran Q and I 2 tests. A P value < .05 for the Q statistic or I 2 more than 50% suggests notable heterogeneity. Based on a small number of studies (<10), the assessment of publication bias could not be reliably performed. DATA SYNTHESIS: This meta-analysis encompassed data from 4 studies. Patients with cICA-PO and AIS who underwent EVT (n = 135) exhibited lower rates of functional independence (OR = 0.35; 95% CI, 0.20-0.61; P < .001) compared with patients with true occlusions (n = 103), as well as successful recanalization rates (OR = 0.39; 95% CI, 0.20-0.74; P = .004). In addition, the cICA-PO group experienced higher mortality and symptomatic intracranial hemorrhage (sICH) compared with the group with true carotid occlusions (OR = 2.62; 95% CI, 0.21-7.24; and OR = 2.23; 95% CI, 1.00-4.95; P = .049, respectively). LIMITATIONS: Individual patient data were not available. Studies were a retrospective design and some of the studies had small sample sizes. The included studies in our meta-analysis did not exclude patients with tandem occlusions that might influence the results of the comparison. CONCLUSIONS: Compared with patients with true carotid occlusion, the cICA-PO group with AIS undergoing EVT presented poor outcomes with lower functional independence and successful recanalization, as well as higher sICH and mortality rates.

Mechanical thrombectomy in basilar artery occlusions: impact of first-line strategy as a function of the occlusion level.

BACKGROUND: Retrospective studies suggest the superiority of first-line contact aspiration (CA) thrombectomy over stent-retriever (SR) in basilar artery occlusions (BAO). We aimed to investigate the impact of first-line mechanical thrombectomy per the occlusion level, considering differences in stroke etiology prevalence between proximal and distal BAO. METHODS: A retrospective, multicentric analysis of the Endovascular Treatment in Ischemic Stroke Registry (ETIS) included consecutive BAO patients treated from January 2016 to May 2022. Patients were categorized into SR (±aspiration) and CA alone groups. Occlusion levels were determined through digital subtraction angiography. Favorable clinical outcome was defined as 90-day modified Rankin Scale (mRS) 0-3. RESULTS: A total of 380 patients were analyzed (251 CA alone, 129 SR±aspiration). Globally, first-line SR showed lower recanalization rates (89.1% vs 94.8%, OR=0.29, 95% CI 0.16 to 0.53; p<0.001) and worse clinical outcomes (mRS 0-3: 46.0% vs 52.2%, OR=0.62, 95% CI 0.44 to 0.87; p=0.006) compared with CA. In proximal occlusions, SR was significantly associated with poorer clinical outcomes (mRS 0-3: 20.9% vs 37.1%; OR=0.40, 95% CI 0.19 to 0.83; p=0.014) despite similar recanalization rates. Conversely, in distal occlusions there was no difference in clinical outcomes although recanalization rates were higher with CA (modified Thrombolysis in Cerebral Infarction score (mTICI 2b/3): 97.7% vs 91.7%; OR=0.17, 95% CI 0.05 to 0.66; p=0.01). CONCLUSIONS: In our BAO population, CA demonstrated better angiographic outcomes in middle and distal occlusions and better clinical outcomes in proximal occlusions. This translated into better angiographic and clinical results in the global study population. Clinical results were particularly influenced by the negative impact of SR on 90-day mRS, independently of recanalization rates in proximal BAO.

Thromboembolic Events With the Woven Endobridge Device: Incidence, Predictive Factors, and Management.

BACKGROUND AND OBJECTIVES: The Woven EndoBridge (WEB) device has been increasingly used to treat wide-neck aneurysms showing a safe and effective profile, but a relatively high number of thromboembolic events (TEEs) have been reported with such treatment. We aimed to evaluate the incidence and management of TEEs and possible predictive factors related to WEB embolization of ruptured and unruptured intracranial aneurysms. METHODS: A single-center database with consecutive aneurysms treated with a WEB device between July 2012 and May 2022 was reviewed for intraoperative and delayed TEEs. Univariate and multivariable analyses were used to determine factors associated with TEEs. RESULTS: A total of 266 independent aneurysms were treated with WEB devices in 245 patients (mean age 55.78 ± 11.64 years, 169 (63.5%) females, 80 (30%) ruptured). The overall rate of TEEs is 13% (35/266), including 8.7% intraoperative. Symptomatic TEEs with clinical sequelae at a 3-month follow-up are reported to be 2.6% (7/266) with no TEE-related mortality. Both the replacement of a WEB device during the procedure (adjusted odds ratio = 2.61, 95% CI 1.24-5.49; P = .01) and ruptured aneurysms (adjusted odds ratio = 2.74, 95% CI 1.31-5.7; P = .007) were independent predictors of TEEs. A case-by-case management of intraprocedural TEE is also presented; tirofiban was successfully used in most cases of this cohort. CONCLUSION: In this study, we demonstrated that ruptured aneurysms and WEB device replacement during the procedure were independent predictive factors for TEEs. As a result, making the correct choice of WEB is crucial for improving treatment outcomes. Moreover, with proper medical management of TEEs, minimal morbidity and no mortality could be achieved, which reinforces the safety of the technique.

The Bicêtre occlusion scale is well suited to assess the efficacy of the Contour embolization device.

BACKGROUND: The Contour Embolization Device (CED) is typically assessed using coiling angiographic outcomes. However, these scales do not address device-specific problematics. We evaluated the usability of the Bicêtre occlusion scale (BOS) with the CED. RESULTS: BOS scores can be analyzed as BOSS 0 = no residual flow, BOSS 1 = residual flow inside the CED but with complete neck-sealing, BOSS 2 = neck-remnant, BOSS 3 = aneurysm-remnant, BOSS 1 + 3 = contrast filling inside the device and aneurysmal sac without complete neck-sealing. CONCLUSION: BOS usage should be encouraged as it provides a more comprehensive assessment of the mechanism of CED occlusion, especially considering the potential prognostic value of the neck sealing assessment.

WEB shape modifications: angiography-histopathology correlations in rabbits.

BACKGROUND: WEB Shape Modification (WSM) over time is frequent after aneurysm treatment. In this study, we explored the relationship between histopathological changes and angiographic evolution over time in experimental aneurysms in rabbits treated with the Woven EndoBridge (WEB) procedure. METHODS: Quantitative WSM was assessed using flat-panel computed tomography (FPCT) during follow-up by calculating height and width ratio (HR, WR), defined as the ratio between either measurement at an index time point and the measurement immediately after WEB implantation. The index time point varied from 1 day to 6 months. HR and WR were evaluated with angiographic and histopathological assessments of aneurysm healing. RESULTS: Final HR of devices varied from 0.30 to 1.02 and final WR varied from 0.62 to 1.59. Altogether, at least 5% of HR and WR variations were observed in 37/40 (92.5%) and 28/40 (70%) WEB devices, respectively, at the time of final assessment. There was no significant correlation between complete or incomplete occlusion groups and HR or WR (p=0.15 and p=0.43). Histopathological analysis revealed a significant association between WR and aneurysm healing and fibrosis 1 month following aneurysm treatment (both p<0.05). CONCLUSION: Using longitudinal FPCT assessment, we observed that WSM affects both the height and width of the WEB device. No significant association was found between WSM and aneurysm occlusion status. Although presumably a multifactorial phenomenon, the histopathological analysis highlighted a significant association between width variations, aneurysm healing and fibrosis in the first month following aneurysm treatment.

CLinical EValuation of WEB 17 device in intracranial aneuRysms (CLEVER): procedural, 30-day and 1-year safety results for ruptured and unruptured aneurysms.

BACKGROUND: Intrasaccular flow disruption is an endovascular approach for the treatment of wide-neck aneurysms and, more specifically, wide-neck bifurcation aneurysms, which are challenging to treat with previously developed technologies. The Woven EndoBridge (WEB) device has demonstrated its efficacy and safety, for both unruptured and ruptured aneurysms. METHODS: The CLEVER study was an observational, multicenter, prospective study conducted in 17 European investigational sites using the WEB 17 device, for the treatment of ruptured and unruptured aneurysms. The study objective was to provide safety and efficacy data on the WEB 17 device in the treatment of wide-neck bifurcation aneurysms. Imaging results were assessed independently by a Corelab and adverse events adjudicated by a Clinical Event Adjudicator. This analysis reports procedural results and safety at 30 days and 12 months. RESULTS: A total of 163 patients (mean age 58.1 years; 68.1% women) with 103 unruptured aneurysms and 60 ruptured aneurysms were enrolled. Most aneurysms were located on the anterior communicating artery (ACom) (37.4%) or the middle cerebral artery (MCA) bifurcation (30.1%). Aneurysm widths ranged from 2.0-9.2 mm, and the mean sac width was 5.0 mm. The WEB procedure was successfully completed in 163 patients (100%). At the 12-month follow-up, major stroke events occurred in 3 of 163 patients (1.8%), and no device-related mortality was observed. CONCLUSION: Endovascular treatment of ruptured and unruptured wide-neck bifurcation aneurysms using WEB 17 is safe, with a low complication rate and no device-related mortality. In particular, none of the ruptured aneurysms bled again up to 1 year of follow-up. TRIAL REGISTRATION NUMBER: NCT03844334.