Iatrogenic arterial vasospasm during mechanical thrombectomy requiring treatment with intra-arterial nimodipine might be associated with worse outcomes.

BACKGROUND AND PURPOSE: Vasospasm is a common iatrogenic event during mechanical thrombectomy (MT). In such circumstances, intra-arterial nimodipine administration is occasionally considered. However, its use in the treatment of iatrogenic vasospasm during MT has been poorly studied. We investigated the impact of iatrogenic vasospasm treated with intra-arterial nimodipine on outcomes after MT for large vessel occlusion stroke. METHODS: We conducted a retrospective analysis of the multicenter observational registry Endovascular Treatment in Ischemic Stroke (ETIS). Consecutive patients treated with MT between January 2015 and December 2022 were included. Patients treated with medical treatment alone, without MT, were excluded. We also excluded patients who received another in situ vasodilator molecule during the procedure. Outcomes were compared according to the occurrence of cervical and/or intracranial arterial vasospasm requiring intraoperative use of in situ nimodipine based on operator's decision, using a propensity score approach. The primary outcome was a modified Rankin Scale (mRS) score of 0-2 at 90 days. Secondary outcomes included excellent outcome (mRS score 0-1), final recanalization, mortality, intracranial hemorrhage and procedural complications. Secondary analyses were performed according to the vasospasm location (intracranial or cervical). RESULTS: Among 13,678 patients in the registry during the study period, 434 received intra-arterial nimodipine for the treatment of MT-related vasospasm. In the main analysis, comparable odds of favorable outcome were observed, whereas excellent outcome was significantly less frequent in the group with vasospasm requiring nimodipine (adjusted odds ratio [aOR] 0.78, 95% confidence interval [CI] 0.63-0.97). Perfect recanalization, defined as a final modified Thrombolysis In Cerebral Infarction score of 3 (aOR 0.63, 95% CI 0.42-0.93), was also rarer in the vasospasm group. Intracranial vasospasm treated with nimodipine was significantly associated with worse clinical outcome (aOR 0.64, 95% CI 0.45-0.92), in contrast to the cervical location (aOR 1.37, 95% CI 0.54-3.08). CONCLUSION: Arterial vasospasm occurring during the MT procedure and requiring intra-arterial nimodipine administration was associated with worse outcomes, especially in case of intracranial vasospasm. Although this study cannot formally differentiate whether the negative consequences were due to the vasospasm itself, or nimodipine administration or both, there might be an important signal toward a substantial clinical impact of iatrogenic vasospasm during MT.

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.

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.

The Utility of Multimodal Imaging and Artificial Intelligence Algorithms for Overlying Two Volumes in the Decision Chain for the Treatment of Complex Pathologies in Interventional Neuroradiology-A Case Series Study.

3D rotational angiography is now increasingly used in routine neuroendovascular procedures--in particular, for situations where the analysis of two overlayed sets of volume imaging proves useful for planning the treatment strategy or for confirming the optimal apposition of the intravascular devices used. The aim of this study is to identify and describe the decision algorithm for which the overlay function of 3D rotational angiography volumes, high-resolution contrast-enhanced flat panel detector CT adapted for intravascular devices (VasoCT/DynaCT), non-enhanced flat detector C-arm volume acquisition functionality integrated with the angiography equipment (XperCT/DynaCT), and isovolumetric MRI volumes were all used in treatments performed in a series of 29 patients. Two superposed 3DRA volumes were used in the treatment aneurysms located at the junction of two vascular territories and for arteriovenous malformations with compartments fed from different vascular territories. The superposition function of a preoperatively acquired 3DRA volume and a postoperatively acquired VasoCT volume provides accurate information about the apposition of neuroendovascular endoprostheses used in the treatment of aneurysms. The automatic overlay function generated by the 3D workstation is particularly useful, but in about 50% of cases it requires manual operator-dependent correction, requiring a certain level of experience. In our experience, multimodal imaging brings an important benefit, both in the treatment decision algorithm and in the assessment of neuroendovascular treatment efficacy.