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OBJECTIVES: Despite successful recanalization after Mechanical Thrombectomy (MT), approximately 25% of patients with Acute Ischemic Stroke (AIS) due to Large Vessel Occlusion (LVO) show unfavorable clinical outcomes, namely Futile Recanalization (FR). We aimed to use a Machine Learning (ML) Non-Contrast brain CT (NCCT) imaging predictive model to identify FR in patients undergoing MT. MATERIALS & METHODS: Between July 2022 and December 2022, 70 consecutive patients with LVO undergoing a complete recanalization (eTICI 3) with MT within 8 hours from onset at our Centre were analyzed. Two NCCT images per patient of middle cerebral artery vascular territory and patients' clinical characteristics were classified by the presence of ischemic features on 24h NCCT after MT. Each slice was segmented with "Mazda" software ver.4.6 by placing a Region Of Interest (ROI) on the whole brain by two radiologists in consensus. A total of 381 features were extracted for each slice. The dataset was split into train and test set with a 70:30 ratio. RESULTS: Eleven classification models were trained. An Ensemble Machine Learning (EML) model was obtained by averaging the predictions of models with accuracy on a test set >70%, with and without patients' clinical characteristics. The EML model combined with clinical data showed an accuracy of 0.76, a sensitivity of 0.88, a specificity of 0.69 with a NPV of 0.90, a PPV of 0.64, with AUC of 0.84. CONCLUSION: NCCT and ML analysis shows promise in predicting FR after complete recanalization following MT in AIS patients. Larger studies are required to confirm these preliminary results.
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PURPOSE: The aim of this registry was to assess technical success, procedural safety and mid- to long-term follow-up results of the Silk Vista "Mama" (SVM) flow diverter (BALT, Montmorency, France) for the treatment of proximal intracranial aneurysms. METHODS: Between August 2020 and March 2022, data from nine Italian neurovascular centres were collected. Data included patients' clinical presentation, aneurysms' size, location and status, technical details, overall complications and mid- to long-term angiographic follow-up. RESULTS: Forty-eight aneurysms in 48 patients were treated using the SVM. Most aneurysms were small (≤ 10 mm: no. 29, 60%) and unruptured (no. 31, 65%); 13 aneurysms were recurrent after coiling or clipping. 37/48 aneurysms involved the internal carotid artery (77%). Optimal opening and complete wall apposition of the device were achieved in 46 out of 48 cases (96%). Four intra- or periprocedural complications occurred (two thrombotic complications successfully resolved, one cerebellar ischemia, one perirenal hematoma), without new neurological deficit. No significant intra-stent stenosis or stent displacement was observed during follow-up. No FD-related morbidity nor mortality was reported. At midterm (6-12 months) to long-term (> 12 months) follow-up, complete aneurysm occlusion (OKM D) was achieved in 76% of cases. Eighty-eight percent of patients had complete aneurysm occlusion or entry remnant (OKM D + C). CONCLUSIONS: Our experience suggests that the new generation of low-profile SVM flow diverter for the treatment of proximal intracranial aneurysms is safe and effective, with low rates of intraprocedural complications and acceptable mid- to long-term occlusion rate.
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Embolización Terapéutica , Aneurisma Intracraneal , Sistema de Registros , Stents , Humanos , Aneurisma Intracraneal/terapia , Aneurisma Intracraneal/diagnóstico por imagen , Aneurisma Intracraneal/cirugía , Masculino , Femenino , Embolización Terapéutica/métodos , Embolización Terapéutica/instrumentación , Persona de Mediana Edad , Anciano , Estudios de Seguimiento , Círculo Arterial Cerebral/diagnóstico por imagen , Adulto , Angiografía Cerebral , Italia , Resultado del TratamientoRESUMEN
Background: Enteropathic spondyloarthritides (eSpAs) are chronic inflammatory joint diseases associated with inflammatory bowel disease (IBD). Limited data are available on the prevalence since arthritis in IBD patients may be underestimated because medications may hide disease activity with a possible diagnostic delay. Objectives: We aimed to evaluate diagnostic delay in eSpA and explore associated demographic, clinical, and radiographic characteristics. Design: Single-centre cross-sectional study conducted on consecutive out-patients referred to the combined Gi-Rhe clinic (November 2018-October 2019). Methods: We analysed eSpA patients for diagnostic delay, disease activity, inflammatory markers, conventional radiography (CR) and magnetic resonance images (MRI) of sacroiliac joints/spine. Results: A total of 190 eSpA patients [118 peripheral SpA, 72 axial (Ax) SpA including 44 non-radiographic (nr)-axSpA] were enrolled. axSpA patients had a higher prevalence of men sex, HLA-B27 positivity, uveitis and pancolitis compared with peripheral eSpA. Median diagnostic delay in eSpA was 48 months (IQR 6-77) with no difference between axial and peripheral patients. Radiographic-axial SpA (r-axSpA) patients displayed a higher diagnostic delay compared with nr-axSpA (median/IQR 36/17-129 versus 31/10-57 months, p = 0.03) and were older, with longer disease duration, low education status and high rate of employment than patients with nr-axSpA. r-axSpA patients with sclerosis, syndesmophytes and bridge at CR had higher diagnostic delay than those without lesions. Men showed higher prevalence of spine damage lesions than women as sclerosis, squaring, syndesmophytes and bridges. Longer disease duration was detected in patients with radiographic damage as bridge and sacroiliitis grade 3. On MRI, sacroiliac bone oedema was associated with reduced diagnostic delay, whereas bone erosions were associated with higher diagnostic delay compared with that in patients without these lesions. Patients with psoriasis displayed a higher diagnostic delay compared to those without skin involvement. Conclusion: Diagnostic delay was higher in r-axSpA compared with nr-axSpA despite the same treatment. Demographic, clinical features and radiological lesions were associated with diagnostic delay.
Diagnostic delay in patients affected by enteropathic spondyloarthritis Enteropathic Spondyloarthritides (eSpA) are chronic inflammatory joint diseases associated with inflammatory bowel disease (IBD). Limited data are available on the prevalence since arthritis in IBD patients may be underestimated because medications may hide disease activity with a possible diagnostic delay. We aimed to evaluate diagnostic delay in eSpA and explore associated demographic, clinical and radiographic characteristics. We analysed eSpA patients for diagnostic delay, disease activity, inflammatory markers, conventional radiography and magnetic resonance images of sacroiliac joints/spine. 190 eSpA patients (118 peripheral SpA, 72 axial (Ax) SpA including 44 non-radiographic (nr)-axSpA)) were enrolled. Median diagnostic delay in eSpA was 48 months with no difference between axial and peripheral patients. Radiographic-axial SpA (r-axSpA) patients displayed a higher diagnostic delay compared with nr-axSpA and were older, with longer disease duration, low education status and high rate of employment than patients with nr-axSpA. Patients with psoriasis displayed a higher diagnostic delay compared to those without skin involvement. Diagnostic delay was higher in r-axSpA compared with nr-axSpA despite the same treatment. Demographic, clinical features and radiological lesions were associated with diagnostic delay.
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BACKGROUND: Treatment of brain arteriovenous malformations (b-AVM) carries a risk of iatrogenic injury to eloquent brain regions. Intraoperative neuro-monitoring (IONM) has increasingly been used to monitor spontaneous or evoked neural activity during neurosurgery, but its use is not as well characterized in the endovascular treatment (EVT) of b-AVMs. We aimed to provide a systematic review and meta-analysis of studies reporting any neurological deficit after b-AVM embolization with IONM, with or without provocative test (PT), and no-IONM. METHODS: This systematic review followed the PRISMA guidelines. Medline, EMBASE, and Scopus were searched from conception until March 1, 2022 for studies evaluating EVT with IONM and PT. Primary outcome was the rate of postoperative neurological deficits in EVT with IONM versus no-IONM, while secondary outcome was the subanalysis of IONM with or without PT. Meta-analysis was performed using the Mantel-Haenszel method and random effects modeling. RESULTS: Six studies reached synthesis. Out of a total of 192 EVT, 14 events occurred. Results demonstrated a nonsignificant trend favoring IONM compared to no-IONM to prevent neurological deficits (OR 0.09, 95% CI 0-4.68). Among the EVT with IONM, PT was done in 411 branches with 10 events (0.2%) despite a negative PT. There was a nonsignificant trend favoring IONM plus PT compared to IONM without PT (OR 0.16, 95% CI 0.02-1.07). CONCLUSIONS: Our study suggests that b-AVM EVT with IONM plus PT might reduce rates of postprocedural neurological deficits compared with EVT without IONM. Further studies are needed to confirm these results.
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BACKGROUND: Safety and efficacy of the WEB (Woven EndoBridge) device have been extensively evaluated in several good clinical practice studies. Nonetheless, the WEB had several structural evolutions overtime up to the fifth generation WEB device (WEB17). Here, we tried to understand how this may have modified our practices and enlarged our indications for its use. METHODS: We retrospectively analyzed data from all patients with aneurysms treated (or intended to be treated) with a WEB at our institution between July 2012 and February 2022. The time frame was split in two periods: before and after the arrival of the WEB17 in our center (February 2017). RESULTS: 252 patients with 276 wide-necked aneurysms were included; 78 aneurysms (28.2%) were ruptured. Successful embolization with a WEB device was achieved in 263/276 aneurysms (95.3%). With the availability of WEB17, treated aneurysms were significantly smaller (8.2 mm versus 5.9 mm, p<0.001) and off-label location significantly increased (4.4% versus 17.3%, p = 0.02) with an increase of sidewall aneurysm (4.4% versus 11.6%, p = 0.06). Also, WEB were more significantly oversized (1.05 versus 1.11, p<0.01). Adequate and complete occlusion rates increased constantly during the two periods (54.8% versus 67.5%, p = 0.08 and 74.2% versus 83.7%, p = 0.10, respectively). The proportion of ruptured aneurysms slightly increased between the two periods (24.6% versus 29.5%, p = 0.44). CONCLUSIONS: Over the first decade of its availability, the WEB device usage shifted towards smaller aneurysms and broader indications, including ruptured aneurysms. The oversizing strategy also became the standard of practice for WEB deployment in our institution.
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Aneurisma Roto , Embolización Terapéutica , Procedimientos Endovasculares , Aneurisma Intracraneal , Humanos , Resultado del Tratamiento , Aneurisma Intracraneal/diagnóstico por imagen , Aneurisma Intracraneal/terapia , Estudios Retrospectivos , Aneurisma Roto/diagnóstico por imagen , Aneurisma Roto/terapiaRESUMEN
BACKGROUND: CT perfusion (CTP) is used in patients with anterior circulation acute ischemic stroke (AIS) for predicting the final infarct volume (FIV). Tandem occlusion (TO), involving both intracranial large vessels and the ipsilateral cervical internal carotid artery could generate hemodynamic changes altering perfusion parameters. Our aim is to evaluate the accuracy of CTP in the prediction of the FIV in TOs. METHODS: consecutive patients with AIS due to middle cerebral artery occlusion, referred to a tertiary stroke center between March 2019 and January 2021, with an automated CTP and successful recanalization (mTICI = 2b - 3) after endovascular treatment were retrospectively included in the tandem group (TG) or in the control group (CG). Patients with parenchymal hematoma type 2, according to ECASS II classification of hemorrhagic transformations, were excluded in a secondary analysis. Demographic, clinical, radiological, time intervals, safety, and outcome measures were collected. RESULTS: among 319 patients analyzed, a comparison between the TG (N = 22) and CG (n = 37) revealed similar cerebral blood flow (CBF) > 30% (29.50 ± 32.33 vs. 15.76 ± 20.93 p = 0.18) and FIV (54.67 ± 65.73 vs. 55.14 ± 64.64 p = 0.875). Predicted ischemic core (PIC) and FIV correlated in both TG (tau = 0.761, p < 0.001) and CG (tau = 0.315, p = 0.029). The Bland-Altmann plot showed agreement between PIC and FIV for both groups, mainly in the secondary analysis. CONCLUSION: automated CTP could represent a good predictor of FIV in patients with AIS due to TO.
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BACKGROUND: Woven EndoBridge (WEB) devices are becoming a reliable option for the treatment of wide-neck bifurcation aneurysms, but clear predictive factors are still missing to understand the one in five aneurysm remnant rate. OBJECTIVE: To evaluate occlusion outcomes after WEB treatment to identify potential determinants of aneurysm occlusion. METHODS: A single-center database with consecutive aneurysms treated with WEB between July 2012 and October 2021 was reviewed for potential determinants of aneurysm adequate occlusion (defined as a Bicêtre Occlusion Scale Score (BOSS) of 0, 0', 1 or 2), through univariate and multivariable analysis. Patients without angiographic follow-up were excluded. RESULTS: 215 of 247 individual aneurysms were included in the final analysis, of which 59 (27%) were ruptured. Mean age of patients was 56 years (range 23-90 years) and 65% were female. Mean angiographic follow-up was at 18 months (range 3-97 months). Adequate and complete occlusion were achieved in 171/215 (79.5%) and 135/215 (62.8%) of cases, respectively. Aneurysm irregular shape (aOR=0.42, 95% CI 0.20 to 0.88; p=0.02), aneurysm height (aOR=0.79, 95% CI 0.66 to 0.94; p<0.01), and WEB shape modification (aOR=0.98, 95% CI 0.97 to 1.00; p=0.02) were all independent predictors of aneurysm recurrence, whereas the WEB oversizing ratio (WEB width/aneurysm mean width) (aOR=16.4, 95% CI 1.4 to 266.7; p=0.04) was an independent predictor of adequate occlusion. CONCLUSION: In this study we demonstrated that a width oversizing strategy of the WEB device was an independent predictor of aneurysm angiographic occlusion. Conversely, aneurysm height, irregular aneurysm, and WEB shape modification were all independent determinants of angiographic aneurysm remnant. These results may help to select aneurysms suitable for the WEB device and WEB sizing.
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Embolización Terapéutica , Procedimientos Endovasculares , Aneurisma Intracraneal , Humanos , Femenino , Adulto Joven , Adulto , Persona de Mediana Edad , Anciano , Anciano de 80 o más Años , Masculino , Aneurisma Intracraneal/diagnóstico por imagen , Aneurisma Intracraneal/terapia , Estudios de Seguimiento , Resultado del Tratamiento , Procedimientos Endovasculares/métodos , Estudios Retrospectivos , Angiografía Cerebral , Embolización Terapéutica/métodosRESUMEN
In 2014, Chapot et al. introduced the pressure cooker technique (PCT), conceived to control undesired reflux of the embolic agent during the treatment of brain arterio-venous malformations (bAVMs). Since then, this technique increased in popularity and it has been extensively used. We present five consecutive cases in which the original PCT was simplified using nylon coils instead of platinum coils and acrylic glue, hence the name of 'Simplified Pressure Cooker Technique' (sPCT). The aim was to obtain a safer, precise and faster creation of the plug to control cohesive embolic agent reflux during the treatment of brain and facial vascular malformations.
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BACKGROUND: Vascular lesions of the spinal cord are rare but potentially devastating conditions whose accurate recognition critically determines the clinical outcome. Several conditions lead to myelopathy due to either arterial ischemia, venous congestion or bleeding within the cord. The clinical presentation varies, according with the different aetiology and mechanism of damage. PURPOSE: The aim is to provide a comprehensive review on the radiological features of the most common vascular myelopathies, passing through the knowledge of the vascular spinal anatomy and the clinical aspects of the different aetiologies, which is crucial to promptly address the diagnosis and the radiological assessment.
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Angioplastia de Balón/instrumentación , Fármacos Cardiovasculares/administración & dosificación , Arteria Carótida Interna , Estenosis Carotídea/terapia , Stents Liberadores de Fármacos , Sirolimus/administración & dosificación , Anciano , Arteria Carótida Interna/diagnóstico por imagen , Estenosis Carotídea/diagnóstico por imagen , Humanos , Masculino , Placa Aterosclerótica , Diseño de Prótesis , Índice de Severidad de la Enfermedad , Resultado del TratamientoRESUMEN
BACKGROUND: The management of ruptured posterior circulation perforator aneurysms (rPCPAs) remains unclear. We present our experience in treating rPCPAs with flow diverter stents (FDs) and evaluate their safety and efficacy at mid- to long-term follow-up. A diagnostic and therapeutic algorithm for rPCPAs is also proposed. METHODS: We retrospectively analyzed data from all consecutive patients with rPCPAs treated with FDs at our institutions between January 2013 and July 2019. Clinical presentations, time of treatments, intra- and perioperative complications, and clinical and angiographic outcomes were recorded, with a mid- to long-term follow-up. A systematic review of the literature on rPCPAs treated with FDs was also performed. RESULTS: Seven patients with seven rPCPAs were treated with FDs. All patients presented with an atypical subarachnoid hemorrhage distribution and a low to medium Hunt-Hess grade. In 29% of cases rPCPAs were identified on the initial angiogram. In 57% of cases, FDs were inserted within 2 days of the diagnosis. Immediate aneurysm occlusion was observed in 14% of the cases and in 71% at the first follow-up (mean 2.4 months). At mean follow-up of 33 months (range 3-72 months) one case of delayed ischemic complication occurred. Six patients had a modified Rankin Scale (mRS) score of 0 and one patient had an mRS score of 4 at the latest follow-up. CONCLUSIONS: The best management for rPCPAs remains unclear, but FDs seem to have lower complication rates than other treatment options. Further studies with larger series are needed to confirm the role of FDs in rPCPA.