Prediction of delayed cerebral ischemia followed aneurysmal subarachnoid hemorrhage. A machine-learning based study.

INTRODUCTION: Delayed Cerebral Ischemia (DCI) is a significant complication following aneurysmal subarachnoid hemorrhage (aSAH) that can lead to poor outcomes. Machine learning techniques have shown promise in predicting DCI and improving risk stratification. METHODS: In this study, we aimed to develop machine learning models to predict the occurrence of DCI in patients with aSAH. Patient data, including various clinical variables and co-factors, were collected. Six different machine learning models, including logistic regression, multilayer perceptron, decision tree, random forest, gradient boosting machine, and extreme gradient boosting (XGB), were trained and evaluated using performance metrics such as accuracy, area under the curve (AUC), precision, recall, and F1 score. RESULTS: After data augmentation, the random forest model demonstrated the best performance, with an AUC of 0.85. The multilayer perceptron neural network model achieved an accuracy of 0.93 and an F1 score of 0.85, making it the best performing model. The presence of positive clinical vasospasm was identified as the most important feature for predicting DCI. CONCLUSIONS: Our study highlights the potential of machine learning models in predicting the occurrence of DCI in patients with aSAH. The multilayer perceptron model showed excellent performance, indicating its utility in risk stratification and clinical decision-making. However, further validation and refinement of the models are necessary to ensure their generalizability and applicability in real-world settings. Machine learning techniques have the potential to enhance patient care and improve outcomes in aSAH, but their implementation should be accompanied by careful evaluation and validation.

Metal allergy and neurovascular stenting: A systematic review.

BACKGROUND: Intracranial stents and flow diverters contain significant amounts of metals, notably nickel, which can cause allergic reactions in a considerable portion of the population. These allergic responses may lead to complications like in-stent stenosis (ISS) and TIA/Stroke in patients receiving stents or flow diverters for intracranial aneurysms. METHODS: We conducted a systematic review of studies from inception until July 2023, which reported outcomes of patients with metal allergy undergoing neurovascular stenting. The skin patch test was used to group patients into those with positive, negative, or absent patch test results but with a known history of metal allergy. RESULTS: Our review included seven studies with a total of 39 patients. Among them, 87% had a history of metal allergy before treatment. Most aneurysms (89%) were in the anterior circulation and the rest (11%) were in the posterior circulation. Skin patch tests were performed in 59% of patients, with 24% showing positive results and 33% negative. Incidental ISS was observed in 18% of patients, and the rate of TIA/Stroke was reported in 21%. The pooled rates of ISS and TIA/Stroke were higher in the first group (43% and 38%) compared to the second (18% and 9%) and third groups (15% and 15%), but these differences were not statistically significant. CONCLUSIONS: The current neurosurgical literature does not provide a conclusive association between metal allergy and increased complications among patients undergoing neurovascular stenting. Further studies are necessary to gain a more comprehensive understanding of this topic.

Antiplatelets and antithrombotics in neurointerventional procedures: guideline update

Antiplatelet and antithrombotic medication management before, during, and after neurointerventional procedures has significant practice variation. This document updates and builds upon the 2014 Society of NeuroInterventional Surgery (SNIS) Guideline 'Platelet function inhibitor and platelet function testing in neurointerventional procedures', providing updates based on the treatment of specific pathologies and for patients with specific comorbidities

Antiplatelets and antithrombotics in neurointerventional procedures: Guideline update.

BACKGROUND: Antiplatelet and antithrombotic medication management before, during, and after neurointerventional procedures has significant practice variation. This document updates and builds upon the 2014 Society of NeuroInterventional Surgery (SNIS) Guideline 'Platelet function inhibitor and platelet function testing in neurointerventional procedures', providing updates based on the treatment of specific pathologies and for patients with specific comorbidities. METHODS: We performed a structured literature review of studies that have become available since the 2014 SNIS Guideline. We graded the quality of the evidence. Recommendations were arrived at through a consensus conference of the authors, then with additional input from the full SNIS Standards and Guidelines Committee and the SNIS Board of Directors. RESULTS: The management of antiplatelet and antithrombotic agents before, during, and after endovascular neurointerventional procedures continues to evolve. The following recommendations were agreed on. (1) It is reasonable to resume anticoagulation after a neurointerventional procedure or major bleeding episode as soon as the thrombotic risk exceeds the bleeding risk in an individual patient (Class I, Level C-EO). (2) Platelet testing can be useful to guide local practice, and specific approaches to using the numbers demonstrate marked local variability (Class IIa, Level B-NR). (3) For patients without comorbidities undergoing brain aneurysm treatment, there are no additional considerations for medication choice beyond the thrombotic risks of the catheterization procedure and aneurysm treatment devices (Class IIa, Level B-NR). (4) For patients undergoing neurointerventional brain aneurysm treatment who have had cardiac stents placed within the last 6-12 months, dual antiplatelet therapy (DAPT) is recommended (Class I, Level B-NR). (5) For patients being evaluated for neurointeventional brain aneurysm treatment who had venous thrombosis more than 3 months prior, discontinuation of oral anticoagulation (OAC) or vitamin K antagonists should be considered as weighed against the risk of delaying aneurysm treatment. For venous thrombosis less than 3 months in the past, delay of the neurointerventional procedure should be considered. If this is not possible, see atrial fibrillation recommendations (Class IIb, Level C-LD). (6) For patients with atrial fibrillation receiving OAC and in need of a neurointerventional procedure, the duration of TAT (triple antiplatelet/anticoagulation therapy=OAC plus DAPT) should be kept as short as possible or avoided in favor of OAC plus single antiplatelet therapy (SAPT) based on the individual's ischemic and bleeding risk profile (Class IIa, Level B-NR). (7) For patients with unruptured brain arteriovenous malformations there is no indication to change antiplatelet or anticoagulant management instituted for management of another disease (Class IIb, Level C-LD). (8) Patients with symptomatic intracranial atherosclerotic disease (ICAD) should continue DAPT following neurointerventional treatment for secondary stroke prevention (Class IIa, Level B-NR). (9) Following neurointerventional treatment for ICAD, DAPT should be continued for at least 3 months. In the absence of new stroke or transient ischemic attack symptoms, reversion to SAPT can be considered based on an individual patient's risk of hemorrhage versus ischemia (Class IIb, Level C-LD). (10) Patients undergoing carotid artery stenting (CAS) should receive DAPT before and for at least 3 months following their procedure (Class IIa, Level B-R). (11) In patients undergoing CAS during emergent large vessel occlusion ischemic stroke treatment, it may be reasonable to administer a loading dose of intravenous or oral glycoprotein IIb/IIIa or P2Y12 inhibitor followed by maintenance intravenous infusion or oral dosing to prevent stent thrombosis whether or not the patient has received thrombolytic therapy (Class IIb, C-LD). (12) For patients with cerebral venous sinus thrombosis, anticoagulation with heparin is front-line therapy; endovascular therapy may be considered particularly in cases of clinical deterioration despite medical therapy (Class IIa, Level B-R). CONCLUSIONS: Although the quality of evidence is lower than for coronary interventions due to a lower number of patients and procedures, neurointerventional antiplatelet and antithrombotic management shares several themes. Prospective and randomized studies are needed to strengthen the data supporting these recommendations.

The role of venous anatomy in guiding treatment approach for dural arteriovenous fistulas of the craniocervical junction; case series & systematic review.

BACKGROUND: Dural arteriovenous fistulas (DAVF) of the craniocervical junction (CCF) are an uncommon entity with the following venous drainage pattern: inferior, superior and mixed. Patients may present with subarachnoid hemorrhage, myelopathy or brainstem dysfunction. CCJ DAVF can be treated with microsurgery or with transarterial and transvenous embolization, depending on the venous drainage pattern. We present our institutional experience of treating CCJ DAVFs along with a systematic review of the literature. METHODS: Six patients with CCJ DAVF were treated at our institution over five years. Data was collected using electronic medical record review. Systematic review was performed on CCJ DAVF using the PubMed database from 1990 to 2021. We characterized venous drainage patterns, treatment choices, and outcomes to create a classification system. RESULTS: 50 case reports, consisting of 115 patients, were included in our review. 61 (53.0 %) patients had inferior drainage while 32 (27.8 %) patients had superior drainage and 22 (19.2 %) patients had mixed venous drainage. Patients with inferior drainage had the fistulous connection at the foramen magnum while patients with superior drainage had a fistulous connection at C1-C2 (p value = 0.026). Patients with inferior drainage were more likely to present with myelopathy while patients with superior drainage presented with hemorrhage (p value = 0.000). CONCLUSIONS: Classifying the venous drainage pattern is essential in making treatment decision. Transvenous embolization works best with large superior venous drainage. If endovascular treatment is not an option, then surgical clipping can achieve successful cure. Transarterial embolization is a reasonable option in cases with a large arterial feeder.

Impact of aneurysm diameter, angulation, and device sizing on complete occlusion rates using the woven endobridge (WEB) device: Single center United States experience.

BACKGROUND: The Woven EndoBridge device is a novel treatment option for wide-necked bifurcation intracranial aneurysms (WNBA). While this device has had good results, there remains a subset of WNBA that fail this treatment. The main objective of this study is to identify risk factors that are associated with incomplete occlusion of WEB treated aneurysms at short-term follow up. METHODS: This was a retrospective study of 31 patients with intracranial aneurysms who were treated with WEB at a single institution in the USA in 2019-2021. Data was collected via chart review on patient demographics, aneurysm characteristics, procedural details, and occlusion status at six months follow up. Bivariate analyses were performed comparing completely occluded aneurysms with neck remnants and residual aneurysms. RESULTS: 16 (52%) had completely occluded aneurysms while 11 (35%) patients had a neck remnant, and 4 (13%) patients had a residual aneurysm at follow up. Patients with neck remnants and residual aneurysms had aneurysms with a larger diameter. A large aneurysm diameter is an independent risk factor for incomplete occlusion (OR 4.23 95% CI 1.08-16.53 P value = 0.038). Patients with residual aneurysms had an average difference between the aneurysm width and WEB diameter of -0.08mm compared to 1.2 mm in patients with occluded aneurysms. 75% of patients with a residual aneurysm presented with a ruptured aneurysm. Lastly, more patients with a residual aneurysm had an immediate angiographic outcome of incomplete occlusion. CONCLUSION: Larger aneurysms are at risk for incomplete occlusion status post WEB treatment. Larger, ruptured aneurysms with minimal difference in aneurysm and WEB diameter that fail to occlude immediately post-treatment are more likely to present as residual aneurysms at short-term follow up.

Society of NeuroInterventional Surgery: position statement on pregnancy and parental leave for physicians practicing neurointerventional surgery.

BACKGROUND: The aim of this article is to outline a position statement on pregnancy and parental leave for physicians practicing neurointerventional surgery. METHODS: We performed a structured literature review regarding parental leave policies in neurointerventional surgery and related fields. The recommendations resulted from discussion among the authors, and additional input from the Women in NeuroIntervention Committee, the full Society of NeuroInterventional Surgery (SNIS) Standards and Guidelines Committee, and the SNIS Board of Directors. RESULTS: Some aspects of workplace safety during pregnancy are regulated by the US Nuclear Regulatory Commission. Other aspects of the workplace and reasonable job accommodations are legally governed by the Family and Medical Leave Act of 1993, the Affordable Care Act of 2010 and the Fair Labor Standards Act of 1938, Americans with Disabilities Act of 1990, Title IX of the Education Amendments of 1972, Title VII of the Civil Rights Act of 1964 as well as rights and protections put forth by the Occupational Safety and Health Administration as part of the United States Department of Labor. Family friendly policies have been associated not only with improved job satisfaction but also with improved parental and infant outcomes. Secondary effects of such accommodations are to increase the number of women within the specialty. CONCLUSIONS: SNIS supports a physician's ambition to have a family as well as start, develop, and maintain a career in neurointerventional surgery. Legal and regulatory mandates and family friendly workplace policies should be considered when institutions and individual practitioners approach the issue of childbearing in the context of a career in neurointerventional surgery.

Identifying risk factors for perioperative thromboembolic complications in patients treated with the Woven EndoBridge device.

INTRODUCTION: Woven EndoBridge (WEB) is a new endovascular treatment option for wide necked bifurcation aneurysms. Results from the WEB-IT trial showed a 0% risk of thromboembolic complications within 30 days post-op but the rate reported in the literature is as high as 10%. We are exploring potential risk factors associated with immediate thromboembolic complications in patients treated with the WEB device. METHODS: Retrospective study of forty-two patients with intracranial aneurysms who were treated with WEB at a single center from 2019-2021. Data was collected on patient demographics, comorbidities, aneurysm characteristics, procedural details, and hospital course. Bivariate analyses were performed to compare patients who experienced a periprocedural ischemic stroke to those who did not. Multiple logistic regression modeling was performed to identify independent risk factors for thromboembolic complications. RESULTS: Of the 42 patients that were treated with WEB, 6 suffered an ischemic stroke (AIS). These patients were more likely to have an underlying diagnosis of arrythmias (p value = 0.007). Furthermore, they had a median angle of 32.0° in the true neck view on diagnostic angiogram compared to 19.5° (p value = 0.046). Lastly, they had a longer procedure length of 228 min compared to 178 min (p value = 0.002). Patients with thromboembolic complications had a longer length of stay in the hospital and worse outcomes at three months follow up. On logistic regression modeling, these risk factors did not reach statistical significance. CONCLUSION: Risk factors of thromboembolic complications after WEB placement include cardiac arrythmias, acute aneurysmal angle in the true neck view and a longer procedure length.

Ethnic-Associated Phenotype Variations in Moyamoya Cerebrovascular Outcomes.

INTRODUCTION: Moyamoya has been extensively described in East Asian populations, and despite its accepted clinical presentation and course, it is fundamental to describe major cerebrovascular complications in other ethnically diverse samples. Hence, we sought to determine if distinct ethnic groups are at higher risk of developing stroke using the National Inpatient Sample (NIS) database. METHODS: We included all moyamoya patients admitted from January 2013 until December 2018 in the NIS database. Multivariate regression analysis was used to determine the risk of developing stroke and poor outcomes in different races compared to white patients. RESULTS: Out of the 6093 admissions with diagnosis of moyamoya disease that were captured, 2,520 were white (41.6%), 2,078 were African American (AA) (34.1%), 721 were Hispanic (11.8%), and 496 were Asian (8.14%). For arterial ischemic stroke (AIS), we found that AA race had a significantly reduced risk of AIS compared to white patients (odds ratio = 0.8, 95% confidence interval: 0.7-0.9, p = 0.031). While being Hispanic or Asian significantly increased 1.5 and 2-fold the risk of hemorrhagic stroke. CONCLUSION: This study highlights the unique features and phenotypes of moyamoya cases among different ethnicities. While possibly AA are protected from developing AIS due to underlying causes of moyamoya such as sickle cell disease, Asians seems to be more susceptible to hemorrhagic stroke.

Transcarotid access for the treatment of recurrent, previously ruptured wide necked bifurcation aneurysm with the WEB device: A technical video.

The Woven Endobridge (WEB) device is an FDA-approved intrasaccular flow disruptor to treat most intracranial wide-necked bifurcation aneurysms.1 Based on the rising experience with safe and effective results, it has been increasingly utilized for the treatment of residual and recurrent aneurysms.2, 3 Additionally, the device has been reported as an off-label treatment option for Posterior communicating (Pcom) artery aneurysms with optimal morphology.4 A transfemoral or transradial artery access is conventionally utilized for WEB embolization.1- 3 In this technical video, we share our experience with the use of direct carotid puncture to perform WEB embolization for a large recurrent Pcom aneurysm in an elderly female with a history of subarachnoid hemorrhage that was initially treated with surgical clipping. A direct puncture of the left common carotid artery (CCA) under ultrasound guidance was performed after failed attempts to select the left ICA via both transfemoral and transradial access due to type 3 aortic arch and extreme tortuosity of the proximal left CCA. The aneurysm was successfully treated with a 5 mm × 2 mm WEB SL device. There are limited studies of transcarotid access for neurointerventional procedures including mechanical thrombectomy, intracranial stent placement etc.5, 6 To the best of our knowledge, this technical video represents the first documented report of WEB embolization via transcarotid access. We aim to highlight the feasibility of transcarotid arterial access for WEB embolization as an effective bailout strategy. In addition, the nuances of direct carotid puncture along with possible complications, and potential management strategies have been discussed.

Crimping technique to treat iatrogenic vertebral artery injury during spinal fusion.

Iatrogenic arterial injuries may occur during neurosurgical procedures. Particularly, the vertebral artery may be injured in a high-level cervical spinal fusion case, either during the initial exposure or when placing screws.1- 3 If such an injury occurs, obtaining hemostatic control and repairing the laceration are of paramount importance.4, 5 In this technical video, we describe the case of a patient who was undergoing a posterior C1-C2 cervical fusion when the right vertebral artery was injured due to variant anatomy. Using sutures to repair the injury was unsuccessful. Thus, we employed a technique known as crimping, which involves the use of vascular clips to pinch off the site of the tear. This technique is an improvement over existing methods given how quickly and easily it can be performed. In our technical video, we explain how to perform the crimping technique and discuss indications for its use. The patient consented to the procedure.

Dataset on flow diversion procedures performed with the Pipeline Embolization Device, Pipeline Flex, and Surpass Streamline for intracranial aneurysms.

Flow diversion is an evolving endovascular modality for treating intracranial aneurysms. Although rare, serious adverse events following flow diversion may include ischemic stroke, intracranial hemorrhage, or delayed rupture of the treated aneurysm. This dataset describes 141 flow diversion procedures performed with the Pipeline Embolization Device, Pipeline Flex, or Surpass Streamline on 126 subjects with intracranial aneurysms [1]. The retrospective data were collected from electronic medical records at two large tertiary centers. Baseline patient data included age, sex, and medical comorbidities. The dataset also describes aneurysm characteristics including laterality, anatomic location, morphology, dome height, and neck width. In addition, digital subtraction images showing the internal carotid artery tortuosity were included for aneurysms in the anterior cerebral circulation [2]. Procedural data include case duration, radiation exposure, number of flow diverters deployed, and complications encountered during deployment. In addition, data related to the duration of hospitalization and postoperative adverse events are included. Finally, time to follow up and rates of total aneurysm obliteration at first and second postoperative visits are included. This data is propensity score matching are included. This data is presented as a starting point for future prospective comparisons in the safety and efficacy of flow diverters as more devices become approved and commercially available.

Predictors of Radiographic and Symptomatic Hemorrhagic Conversion Following Endovascular Thrombectomy for Acute Ischemic Stroke Due to Large Vessel Occlusion.

Background Endovascular therapy is known to achieve a high rate of recanalization in patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO) and is currently the standard of care. Hemorrhagic conversion is a severe complication that may occur following AIS in patients undergoing endovascular thrombectomy (EVT). There is a scarcity of data on the risk factors related to HV in post-EVT patients, especially those who develop symptomatic hemorrhagic conversion. The main objective of our study is to identify independent predictors of radiographic and symptomatic hemorrhagic conversion in our diverse patient population with multiple baseline comorbidities that presented with AIS and were treated with EVT as per the most updated guidelines and practices. Methodology This is a retrospective chart review in which we enrolled adult patients treated with EVT for AIS at a comprehensive stroke center in the Bronx, NY, over a four-year period. Bivariate analyses followed by multiple logistic regression modeling were performed to determine the independent predictors of all and symptomatic hemorrhagic conversion. Results A total of 326 patients who underwent EVT for AIS were enrolled. Of these, 74 (22.7%) had an HC, while 252 (77.3%) did not. In total, 25 out of the 74 (33.7%) patients were symptomatic. In the logistic regression model, a history of prior ischemic stroke (odds ratio (OR) = 2.197; 95% confidence interval (CI) = 1.062-4.545; p-value = 0.034), Alberta Stroke Program Early CT Score (ASPECTS) of <6 (OR = 2.207; 95% CI = 1.477-7.194; p-value = 0.019), and Thrombolysis in Cerebral Infarction (TICI) 2B-3 recanalization (OR = 2.551; 95% CI = 1.998-6.520; p-value=0.045) were found to be independent predictors of all types of hemorrhagic conversion. The only independent predictor of symptomatic hemorrhagic conversion on multiple logistic regression modeling was an elevated international normalized ratio (INR) (OR = 11.051; 95% CI = 1.866-65.440; p-value = 0.008). Conclusions History of prior ischemic stroke, low ASPECTS score, and TICI 2B-3 recanalization are independent predictors of hemorrhagic conversion while an elevated INR is the only independent predictor of symptomatic hemorrhagic conversion in post-thrombectomy patients.

Arterial Ischemic Stroke in Moyamoya Patients Who Underwent Vaginal Delivery and Cesarean Section.

BACKGROUND: Moyamoya disease (MMD) is characterized by stenosis, occlusion, and formation of aberrant collaterals of brain vessels. This derangement in the brain vessels in conditions associated with changes in intracranial pressure can lead to arterial ischemic stroke (AIS). A major challenge for stroke physicians is to recommend the safest method of delivery for pregnant patients with MMD. Using a large national database, our objective in this study was to analyze the risk of AIS in patients with MMD who underwent vaginal delivery (VD) and cesarean section (C-section). METHODS: We used the National Inpatient Sample database for the years 2013-2018 to identify patients with a diagnosis of MMD who underwent VD or C-section. Multiple logistic regression was performed to assess the risk of AIS in VD versus C-section. RESULTS: Of 2166 female patients with MMD, 97 underwent VD or C-section: 49 (50.51%) underwent VD, and 48 (49.48%) underwent C-section. The analysis of outcomes between VD and C-section showed a higher prevalence of AIS after VD compared with C-section (8.2% vs 6.3%, P = 0.716). The multivariate analysis for AIS showed that VD is not an independent risk factor compared with C-section (odds ratio = 2.1, 95% CI = 0.3-13.3, P = 0.417). CONCLUSIONS: Our data did not find evidence that VD and C-section are risk factors for AIS in pregnant patients with MMD.

Predicting 90-day Functional Dependency and Death after Endovascular Thrombectomy for Stroke: The BET Score.

OBJECTIVES: Despite being the current standard of care, outcomes after endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) remain highly variable. Though several scoring systems exist to predict outcomes in AIS, they were mainly developed to direct patient selection for treatment. Recognizing the integral role peri-procedural metrics play on outcome, our study aimed to develop a post-EVT prognostic score to predict 90-day functional dependency and death. MATERIALS AND METHODS: We included all eligible adult AIS patients treated with EVT at our institution from June 2016 to January 2020. Data was systematically collected via chart review including pre-, intra- and post-procedural variables. The outcome was modified Rankin score (mRS) at 90 days post-EVT where a poor outcome was defined as mRS 3-6: 3-5 for functional dependency and 6 for death. Model selection methods including stepwise and Lasso were evaluated via cross-validation where the final multivariable logistic regression model was chosen by optimizing the Area Under the Receiver Operating Characteristic Curve (ROC AUC). RESULTS: We included 224 patients (mean age: 65 years old, male: 55%, 90-day poor outcome: 60%). The final model achieved a median AUC of 0.84, IQR: (0.80, 0.87). A 7-point score, called Bronx Endovascular Thrombectomy (BET) score, was developed with more points indicating higher likelihood of 90-day poor outcome (0 point: ≤21% risk; 1-2: 24%; 3: 61%; 4: 86%; 5: 96%; 6-7: ≥99%). One point was awarded for the following variables: current smoker, diabetic, general anesthesia received, puncture to perfusion time ≥45 minutes, and Thrombolysis in Cerebral Infarction (TICI) score <3. Two points were awarded for a post-EVT National Institute of Health Stroke scale (NIHSS) of ≥10. CONCLUSION: Incorporating peri-procedural data we developed the competitive BET score predicting 90-day functional dependency and death, which may help providers, patients and caregivers manage expectations and organize early rehabilitative services.

Cost-effective analysis of mechanical thrombectomy (MT) in patients with poor baseline modified Rankin Score (mRS).

Mechanical thrombectomy (MT) has been established as a standard of care for patients with acute ischemic stroke for the past five years. However, the direct benefits of this treatment in patients with baseline disability remains unclear. This study aims to elucidate the cost impact of performing MT on patients with moderate-to-severe baseline disability to work towards an optimized system of care for acute ischemic stroke. We developed a Markov economic model with a life-time horizon analysis of costs associated with mechanical thrombectomy in patients grouped on baseline disability as defined by modified Rankin Score. Our clinical and economic data is based on an American payer perspective. Our results identified a marginal cost-effective ratio (mCER) of $18,835.00 per quality-adjusted life year (QALY) when mechanical thrombectomy is reserved as a treatment only for patients with no-to-minimal baseline disability as compared to those with any level of baseline disability. Our results provide a framework for these future studies and highlight key sectors that drive cost in the surgical treatment and life-long care of patients with acute ischemic stroke.

Pipeline Embolization Device and Pipeline Flex Versus Surpass Streamline Flow Diversion in Intracranial Aneurysms: A Retrospective Propensity Score-Matched Study.

OBJECTIVE: To compare safety and efficacy profiles in aneurysms treated with Pipeline Embolization Device or Pipeline Flex versus Surpass Streamline flow diverters (FDs). METHODS: Patients who underwent flow diversion for aneurysm treatment at 2 centers were included. Covariates comprised patient demographics, comorbidities, and aneurysm characteristics. Metrics included number of devices, adjuvant device use, case duration, and radiation exposure. Outcomes included periprocedural complications and radiographic results at follow-up. Propensity score-matched pairs were generated using demographic and aneurysm characteristics to verify the outcomes in equally sized groups. RESULTS: The majority of 141 flow diversion procedures performed on 126 patients were in the anterior circulation (96%) and unruptured (93%). Operators experienced more complications placing Surpass FDs compared with Pipelines (18.2% vs. 3.1%, P = 0.005) but used fewer Surpass devices per case (1 device in all Surpass cases and range for Pipeline cases 1-7; P < 0.001). Ballooning was more frequent for Surpass (29.5% vs. 2.1%, P < 0.001). There were no differences in mortality (2.1% vs. 0, P = 1.00), intracranial hemorrhage (3.1% vs. 0, P = 0.551), or stroke (4.2% vs. 6.8%, P = 0.680). Rates of aneurysm obliteration at follow-up were similar. Propensity-matched pairs had no differences in FD deployment complications or perioperative events, yet the significant differences remained for adjuvant balloon use and number of FDs deployed. CONCLUSIONS: While the devices demonstrated similar safety and efficacy profiles, deployment of the Surpass Streamline was more technically challenging than Pipeline Embolization Device or Pipeline Flex. Prospective cohort studies are needed to corroborate these findings.

Thrombectomy in special populations: report of the Society of NeuroInterventional Surgery Standards and Guidelines Committee.

BACKGROUND: The purpose of this guideline is to summarize the data available for performing mechanical thrombectomy (MT) for emergent large vessel occlusion (ELVO) stroke in special populations not typically included in large randomized controlled clinical trials, including children, the elderly, pregnant women, patients who have recently undergone surgery, and patients with thrombocytopenia, collagen vascular disorders, and endocarditis. METHODS: We performed a literature review for studies examining the indications, efficacy, and outcomes for patients undergoing MT for ischemic stroke aged <18 years and >80 years, pregnant patients, patients who have recently undergone surgery, and those with thrombocytopenia, collagen vascular diseases, or endocarditis. We graded the quality of the evidence. RESULTS: MT can be effective for the treatment of ELVO in ischemic stroke for patients over age 80 years and under age 18 years, thrombocytopenic patients, pregnant patients, and patients with endocarditis. While outcomes are worse compared to younger patients and those with normal platelet counts (respectively), there is still a benefit in the elderly (in both mRS and mortality). Data are very limited for patients with collagen vascular diseases; although diagnostic cerebral angiography carries increased risks, MT may be appropriate in carefully selected patients in whom untreated ELVO would likely result in disabling or fatal outcome.

Thromboelastography (TEG) results are predictive of ischemic and hemorrhagic complications in patients with unruptured intracranial aneurysms treated with flow diversion.

INTRODUCTION: Flow diversion is an effective treatment modality for intracranial aneurysms but is associated with ischemic and hemorrhagic complications. Patients treated with flow diversion require dual antiplatelet therapy and subsequent platelet function tests. At our institution, Thromboelastography with Platelet Mapping (TEG-PM) is the test of choice. The primary objective of this study was to identify TEG parameters that are predictive of postoperative complications in patients treated with elective flow diversion. METHODS: This was a retrospective study of 118 patients with unruptured intracranial aneurysms treated with flow diversion. Data was collected via chart review. Bivariate analyses were performed to identify significant variables in patients who suffered an ischemic stroke or a groin hematoma. ROC curves were constructed for the TEG parameters with statistical significance. Bivariate analyses were repeated using dichotomized TEG results. RESULTS: Patients who experienced a symptomatic ischemic stroke had a history of stroke (p value = 0.007), larger aneurysm neck width (p value = 0.017), and a higher alpha angle (p value = 0.013). Cut off point for ischemic complication is 63° on ROC curve with a sensitivity of 100% and specificity of 65%. Patients who experienced a groin hematoma were no different from their healthy peers but had a lower alpha angle (p value = 0.033). Cut off point for hemorrhagic complication is 53.3° with a sensitivity of 82% and specificity of 67%. CONCLUSION: The Alpha Angle parameter of TEG-PM has a sizeable predictive ability for both ischemic complications of the central nervous system and hemorrhagic complications of the access site after elective flow diversion.