Thrombectomy versus Medical Management for Isolated Anterior Cerebral Artery Stroke: An International Multicenter Registry Study.

Background Evidence supporting a potential benefit of thrombectomy for distal medium vessel occlusions (DMVOs) of the anterior cerebral artery (ACA) is, to the knowledge of the authors, unknown. Purpose To compare the clinical and safety outcomes between mechanical thrombectomy (MT) and best medical treatment (BMT) with or without intravenous thrombolysis for primary isolated ACA DMVOs. Materials and Methods Treatment for Primary Medium Vessel Occlusion Stroke, or TOPMOST, is an international, retrospective, multicenter, observational registry of patients treated for DMVO in daily practice. Patients treated with thrombectomy or BMT alone for primary ACA DMVO distal to the A1 segment between January 2013 and October 2021 were analyzed and compared by one-to-one propensity score matching (PSM). Early outcome was measured by the median improvement of National Institutes of Health Stroke Scale (NIHSS) scores at 24 hours. Favorable functional outcome was defined as modified Rankin scale scores of 0-2 at 90 days. Safety was assessed by the occurrence of symptomatic intracerebral hemorrhage and mortality. Results Of 154 patients (median age, 77 years; quartile 1 [Q1] to quartile 3 [Q3], 66-84 years; 80 men; 94 patients with MT; 60 patients with BMT) who met the inclusion criteria, 110 patients (median age, 76 years; Q1-Q3, 67-83 years; 50 men; 55 patients with MT; 55 patients with BMT) were matched. DMVOs were in A2 (82 patients; 53%), A3 (69 patients; 45%), and A3 (three patients; 2%). After PSM, the median 24-hour NIHSS point decrease was -2 (Q1-Q3, -4 to 0) in the thrombectomy and -1 (Q1-Q3, -4 to 1.25) in the BMT cohort (P = .52). Favorable functional outcome (MT vs BMT, 18 of 37 [49%] vs 19 of 39 [49%], respectively; P = .99) and mortality (MT vs BMT, eight of 37 [22%] vs 12 of 39 [31%], respectively; P = .36) were similar in both groups. Symptomatic intracranial hemorrhage occurred in three (2%) of 154 patients. Conclusion Thrombectomy appears to be a safe and technically feasible treatment option for primary isolated anterior cerebral artery occlusions in the A2 and A3 segment with clinical outcomes similar to best medical treatment with and without intravenous thrombolysis. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Zhu and Wang in this issue.

Aspiration Versus Stent Retriever Thrombectomy for Distal, Medium Vessel Occlusion Stroke in the Posterior Circulation: A Subanalysis of the TOPMOST Study.

BACKGROUND: The optimal endovascular strategy for reperfusing distal medium-vessel occlusions (DMVO) remains unknown. This study evaluates angiographic and clinical outcomes of thrombectomy strategies in DMVO stroke of the posterior circulation. METHODS: TOPMOST (Treatment for Primary Medium Vessel Occlusion Stroke) is an international, retrospective, multicenter, observational registry of patients treated for DMVO between January 2014 and June 2020. This study analyzed endovascularly treated isolated primary DMVO of the posterior cerebral artery in the P2 and P3 segment. Technical feasibility was evaluated with the first-pass effect defined as a modified Thrombolysis in Cerebral Infarction Scale score of 3. Rates of early neurological improvement and functional modified Rankin Scale scores at 90 days were compared. Safety was assessed by the occurrence of symptomatic intracranial hemorrhage and intervention-related serious adverse events. RESULTS: A total of 141 patients met the inclusion criteria and were treated endovascularly for primary isolated DMVO in the P2 (84.4%, 119) or P3 segment (15.6%, 22) of the posterior cerebral artery. The median age was 75 (IQR, 62-81), and 45.4% (64) were female. The initial reperfusion strategy was aspiration only in 29% (41) and stent retriever in 71% (100), both achieving similar first-pass effect rates of 53.7% (22) and 44% (44; P=0.297), respectively. There were no significant differences in early neurological improvement (aspiration: 64.7% versus stent retriever: 52.2%; P=0.933) and modified Rankin Scale rates (modified Rankin Scale score 0-1, aspiration: 60.5% versus stent retriever 68.6%; P=0.4). In multivariable logistic regression analysis, the time from groin puncture to recanalization was associated with the first-pass effect (adjusted odds ratio, 0.97 [95% CI, 0.95-0.99]; P<0.001) that in turn was associated with early neurological improvement (aOR, 3.27 [95% CI, 1.16-9.21]; P<0.025). Symptomatic intracranial hemorrhage occurred in 2.8% (4) of all cases. CONCLUSIONS: Both first-pass aspiration and stent retriever thrombectomy for primary isolated posterior circulation DMVO seem to be safe and technically feasible leading to similar favorable rates of angiographic and clinical outcome.

Craniofacial venous malformations treated by percutaneous sclerotherapy using polidocanol: a single-center experience.

BACKGROUND: Percutaneous therapy with various sclerosants is an established treatment of venous malformations in general. We investigated the safety and effectiveness of polidocanol in the craniofacial region. PURPOSE: To present and evaluate our subjective and objective mid- and long-term results of patients with craniofacial venous malformations (CFVM) after percutaneous sclerotherapy using polidocanol. MATERIAL AND METHODS: Twenty patients with CFVM treated by percutaneous sclerotherapy were followed up and asked to fill in a questionnaire comparing levels of the following CFVM-related symptoms before and after treatment: pain; functional impairment; cosmetic deformities; and impairment in daily life. Additionally, both size reduction as well as procedural-related complication rates were analyzed. RESULTS: Evaluation of the questionnaire revealed an improvement or complete relief of CFVM-related symptoms with significant reduced impairment in daily life after percutaneous sclerotherapy. Eighteen (90%) patients noticed a post-sclerotherapy improvement of at least one of their corresponding symptoms and expressed satisfaction with regard to their treatment. For 13 patients, a > 50% size reduction of the CFVM could be observed, while seven exhibited a < 50% size reduction. One minor complication was encountered in 56 treatment sessions (1.8%). CONCLUSION: Percutaneous sclerotherapy using polidocanol is a well-tolerated treatment for CFVM with a low complication rate. Size reduction and positive results with improvement of different clinical symptoms can be achieved.

Mechanical thrombectomy of M2 occlusions with distal access catheters using ADAPT.

BACKGROUND AND PURPOSE: The direct aspiration first pass technique (ADAPT) using distal access catheters (DAC) has proven to be an effective and safe endovascular treatment strategy of acute ischemic stroke with large vessel occlusions (LVO). However, data about direct aspiration using DAC in M2 segment occlusions is limited. We assess the safety and efficacy of DACs in acute M2 occlusions using ADAPT with large bore (5 French /6 French) aspiration catheters as the primary method for endovascular recanalization. MATERIALS AND METHODS: From January 2017 to July 2018, 52 patients with an acute ischemic stroke due to M2 occlusions underwent mechanical thrombectomy using ADAPT with DACs (SOFIA 5 French/Catalyst 6) as frontline therapy. Patient demographics, technical parameters and outcome data were recorded. RESULTS: Median National Institutes of Health Strokes Scale (NIHSS) Score was 12 at admission. Successful revascularization to mTICI 2b-3 with ADAPT alone was achieved in 45 of 52 patients (86.5%) with mTICI 3 achieved in 32 patients (61.5%). Additional stent retrievers were used in 6 patients and led to an overall successful revascularisation of 92.3% (48/52). Median NIHSS at discharge was 4. 29 of 52 (55.8%) patients had a modified Rankin Scale (mRS) Score 0-2 at three months. Symptomatic intracranial hemorrhage did not occur. CONCLUSION: DACs can safely be used for mechanical thrombectomy of acute M2 occlusions by the ADAPT approach. Their use alone can be a high efficacious treatment of distal intracranial thromboembolic occlusions.

Mechanical loading increases pro-inflammatory effects of nitrogen-containing bisphosphonate in human periodontal fibroblasts.

OBJECTIVES: There is increasing evidence that inflammation and biomechanical loading can influence the effects of bisphosphonates (BP). The aim of this study was to investigate the influence of tensile strain application combined with IL-1ß and clodronate or zoledronate on human periodontal ligament fibroblasts (HPdLF) in vitro. MATERIALS AND METHODS: HPdLF were cultured with 10 nM IL-1ß and 5 µM clodronate or zoledronate for 48 h. Cells were applied to cyclic tensile strain (CTS; 3% elongation) for 12 h in vitro. Cell number was analyzed directly after CTS by MTT assay. Gene expression of receptor activator of cyclooxygenase-2 (COX-2) was investigated using real-time PCR. MMP-8, TIMP-1, and PGE2 were measured by ELISA. Statistics were performed with SPSS (ANOVA, p < 0.05). RESULTS: Zoledronate reduced the cell number of HPdLF (60.3 vs. 100%), which was significant when combined with IL-1ß. Combined with 3% CTS, this effect was voided and cell number increased over the level of the control cells. IL-1ß led to a 10-fold increase of COX-2 gene expression. Combined with CTS and zoledronate, this increase was enhanced to a gene expression 70-fold that of control cells with related PGE2 synthesis. Clodronate neither reduce the cell number nor enhanced the COX-2 gene expression. CTS increased MMP-8 protein synthesis. Combined with BP, this increase was voided. TIMP-1 protein synthesis was increased at all conditions under CTS. CONCLUSIONS: Mechanical loading might activate cell metabolism and abolish BP- and inflammation-induced reduction of viability. Combination of mechanical loading, inflammation, and nitrogen-containing bisphosphonates can cause pro-inflammatory effects. CLINICAL RELEVANCE: Periodontal inflammation should be treated initially before BP intake to prevent decreased cell viability of the periodontium and increased inflammation, which might be enhanced by the addition of mastication forces.

[Influence of trauma mechanisms on thoracic and lumbar spinal fractures]. / Einfluss des Unfallmechanismus auf die Wirbelkörperfraktur.

BACKGROUND: Vertebral body fractures (VBF) can be caused by various trauma mechanisms. The AOSpine classification system differentiates three main types of fractures according to the grade of instability. How the increasing energy of various accident mechanisms changes the complexity of the individual fracture, its localization and the occurrence of further fractures has not yet been finally investigated. OBJECTIVE: What influence do traumatic events with different kinematics have on the localization, complexity and number of VBF in the thoracic and lumbar spine? MATERIAL AND METHODS: In this retrospective study data from patients with a freshly traumatized VBF were analyzed. The patients were divided into six trauma groups (UFG) depending on the trauma mechanism. The VBF were classified on the basis of computed tomography (CT) imaging according to the AOSpine classification system. Testing was performed bilaterally and a significance level of 5% was used. The statistical calculations were carried out using IBM SPSS Statistics. RESULTS: A significant increase in the severity of fractures (AO classification) was found in the high energy trauma groups (UFG III and V). In addition, the incidence of thoracic (TH) VBF was significantly increased for TH7 (p = 0.011) and TH10 (p = 0.001). In comparison to the other low energy trauma groups, the risk of a TH7 fracture was 7­times higher after a high energy trauma (odds ratio OR = 7.0; 95% confidence interval CI = 1.4; 35.2). The UFG III (falls > 3 m) showed the highest number of fractures with a median of 2.5 (SD 1.84) VBF. CONCLUSION: An exact reproduction of the traumatic event enables a distinction between high and low energy trauma groups to be made. In previous studies traffic accidents were recorded as one group, so an influence of the increasing kinematic energy could not be assessed. The accident kinematics can be taken into account by differentiating between high and low-energy trauma groups. In high-energy accidents the TH7 and TH10 vertebrae were found to be at risk vertebrae. In addition to the force direction, the force strength also has a decisive influence on the distribution pattern of VBF.

Hydrocephalus in vein of Galen malformation: etiologies and therapeutic management implications.

BACKGROUND: Up to now, only little is known about hydrocephalus (HC) in vein of Galen malformation (VGM). We want to present the different etiologies and our long-term experience (1992-2015) in the management of HC. METHODS: Out of 44 treated children with VGM, we retrospectively reviewed all cases with HC. We analyzed the etiologies, our treatment results and complications. RESULTS: Twenty-one children (48 %) presented either with HC or developed it over time. In 21 % of those cases, high venous pressure was presumably the sole cause. Until 2009, seven of them received ventriculoperitoneal (VP) shunting; six of those resulted in severe postoperative complications. The remaining children have been treated successfully by endovascular embolization. Five out of the 44 children (11 %) developed HC after intraventricular hemorrhage. In four cases, those children were treated with positive results by using transient external ventricular drainages. In one case a VP shunt with highest valve pressure was inserted. Another four children (9 %) presented with aqueductal stenosis-related HC caused by either dilated venous outflow or space-occupying coil masses after embolization. The latter case was successfully treated by ventriculocisternostomy, whereas endovascular treatment decreased the venous outflow in size and thus resolved the HC in the other cases. In the remaining cases (7 %), atrophy due to melting brain syndrome led to HC ex vacuo. CONCLUSIONS: HC in VGM is a common phenomenon with several etiologies requiring different treatments. In most cases, embolization of the VGM as sole treatment is completely sufficient in order to decrease high venous pressure. However, certain other causes of HC should be treated in an interdisciplinary setting by specialized neurosurgeons.

Subcallosal artery stroke: infarction of the fornix and the genu of the corpus callosum. The importance of the anterior communicating artery complex. Case series and review of the literature.

INTRODUCTION: Despite the variable anatomy of the anterior communicating artery (AcoA) complex, three main perforating branches can be typically identified the largest of which being the subcallosal artery (ScA). We present a case series of infarction in the vascular territory of the ScA to highlight the anatomy, the clinical symptomatology, and the presumed pathophysiology as it pertains to endovascular and surgical management of vascular pathology in this region. METHODS: In this retrospective multicenter case series study of patients who were diagnosed with symptomatic ScA stroke, we analyzed all available clinical records, MRI, and angiographic details. Additionally, a review of the literature is provided. RESULTS: We identified five different cases of ScA stroke, leading to a subsequent infarction of the fornix and the genu of the corpus callosum. The presumed pathophysiology in non-iatrogenic cases is microangiopathy, rather than embolic events; iatrogenic SCA occlusion can present after both surgical and endovascular treatment of AcoA aneurysms that may occur with or without occlusion of the AcoA. CONCLUSION: Stroke in the vascular territory of the ScA leads to a characteristic imaging and clinical pattern. Ischemia involves the anterior columns of the fornix and the genu of the corpus callosum, and patients present with a Korsakoff's syndrome including disturbances of short-term memory and cognitive changes. We conclude that despite its small size, the ScA is an important artery to watch out for during surgical or endovascular treatment of AcoA aneurysms.

Cranial Doppler ultrasound in Vein of Galen malformation.

INTRODUCTION: Vein of Galen malformation (VGM) is the severest paediatric neurovascular disease usually requiring multiple staged embolisations. In the high-risk group of children with high-flow arteriovenous shunts, timing of treatment is uncertain. Low Doppler resistance index (RI) is known to be associated with adverse outcome in hypoxic-ischaemic brain injury in children. In this study, we want to present our long-term results of cranial transfontanellar Doppler ultrasound in children with VGM. METHODS: We identified and retrospectively analysed 264 transfontanellar Doppler measurements in 19 endovascular-treated true VGM (five females, 14 males) between 2000 and 2013. The recordings were obtained from the internal carotid arteries (ICA), the anterior cerebral arteries (ACA) and the basilar arteries (BA). Maximal systolic velocity (Vs), end-diastolic velocity (Ved) and the RI were measured before and after embolisation. RESULTS: Untreated, nearly all cases showed pathologic high systolic (up to >1.0 m/s), very high diastolic velocities (up to >0.5 m/s) and low RI (<0.6). There were statistically significant differences (p = 0.012) between the pre-embolisation RI and the post-embolisation RI with pathologic low RI before and nearly normal RI after successful shunt reduction. CONCLUSION: Successful endovascular shunt reduction in VGM leads to significant changes of cranial Doppler RI from pathologic low values to normal values. We propose cranial Doppler ultrasound as an adjunctive technique to other screenings in the management of VGM. Further research is warranted to evaluate the role of the RI in the treatment timing decision.

Induction of IL-6 and MMP-8 in human periodontal fibroblasts by static tensile strain.

OBJECTIVES: Mechanical loading is a potential activator of inflammation and able to stimulate factors for periodontal and alveolar bone destruction. Aim of this study was to investigate the inflammatory response and synthesis of proteinases by human periodontal ligament fibroblast (HPdLF) dependent on different strengths of static tensile strain (STS). MATERIALS AND METHODS: HPdLFs were loaded with different STS strengths (1, 5, and 10 %) in vitro. Gene expressions of cyclooxygenase (COX)-2 and interleukin (IL)-6 were analyzed by quantitative real-time polymerase chain reaction. Production of IL-6, prostaglandin E2 (PGE2), matrix metalloproteinase (MMP)-8, and tissue inhibitors of matrix metalloproteinase (TIMP)-1 were measured by enzyme-linked immunosorbent assay. Receptor activator of nuclear factor-kappa ligand (RANKL) synthesis was detected by immunocytochemical staining. RESULTS: Ten percent STS led to an increased gene expression of IL-6 and COX-2 (34.4-fold) in HPdLF, and 1 and 5 % STS slightly reduced the gene expression of IL-6. Synthesis of IL-6 was significantly reduced by 1 % STS and stimulated by 10 % STS. Ten percent STS significantly induced PGE2 production. RANKL was not detectable at any strength of STS. MMP-8 synthesis showed significantly higher values only at 10 % STS, but TIMP-1 was stimulated by 5 and 10 % STS, resulting into highest TIMP-1/MMP-8 ratio at 5 % STS. CONCLUSIONS: High-strength STS is a potent inducer of periodontal inflammation and MMP-8, whereas low-strength STS shows an anti-inflammatory effect. Moderate-strength STS causes the highest TIMP-1/MMP-8 ratio, leading to appropriate conditions for reformation of the extracellular matrix. CLINICAL RELEVANCE: Furthermore, this study points out that the strength of force plays a pivotal role to achieve orthodontic tooth movement without inducing periodontal inflammation and to activate extracellular matrix regeneration.

Effect of anesthetic strategies on distal stroke thrombectomy in the anterior and posterior cerebral artery.

BACKGROUND: Numerous questions regarding procedural details of distal stroke thrombectomy remain unanswered. This study assesses the effect of anesthetic strategies on procedural, clinical and safety outcomes following thrombectomy for distal medium vessel occlusions (DMVOs). METHODS: Patients with isolated DMVO stroke from the TOPMOST registry were analyzed with regard to anesthetic strategies (ie, conscious sedation (CS), local (LA) or general anesthesia (GA)). Occlusions were in the P2/P3 or A2-A4 segments of the posterior and anterior cerebral arteries (PCA and ACA), respectively. The primary endpoint was the rate of complete reperfusion (modified Thrombolysis in Cerebral Infarction score 3) and the secondary endpoint was the rate of modified Rankin Scale score 0-1. Safety endpoints were the occurrence of symptomatic intracranial hemorrhage and mortality. RESULTS: Overall, 233 patients were included. The median age was 75 years (range 64-82), 50.6% (n=118) were female, and the baseline National Institutes of Health Stroke Scale score was 8 (IQR 4-12). DMVOs were in the PCA in 59.7% (n=139) and in the ACA in 40.3% (n=94). Thrombectomy was performed under LA±CS (51.1%, n=119) and GA (48.9%, n=114). Complete reperfusion was reached in 73.9% (n=88) and 71.9% (n=82) in the LA±CS and GA groups, respectively (P=0.729). In subgroup analysis, thrombectomy for ACA DMVO favored GA over LA±CS (aOR 3.07, 95% CI 1.24 to 7.57, P=0.015). Rates of secondary and safety outcomes were similar in the LA±CS and GA groups. CONCLUSION: LA±CS compared with GA resulted in similar reperfusion rates after thrombectomy for DMVO stroke of the ACA and PCA. GA may facilitate achieving complete reperfusion in DMVO stroke of the ACA. Safety and functional long-term outcomes were comparable in both groups.

Estimated low risk of rupture of small-sized unruptured intracranial aneurysms (UIAs) in relation to intracranial aneurysms in patients with subarachnoid haemorrhage.

OBJECTIVE: International guidelines for the management of unruptured intracranial aneurysms (UIAs) recommend observation in aneurysms <10 mm due to the estimated low risk of rupture. The aim of our study was analyse the data of recently treated patients with ruptured cerebral aneurysms with the special focus on size and configuration in view of the frequency scale in a daily routine setting. METHODS: We reviewed the data of all patients with aneurysmal subarachnoid haemorrhage (SAH) during the last 24 months at our institution. Configuration and size of the aneurysms were measured. Clinical data were collected using the following classifications for analysis: Hunt and Hess (H&H), modified Rankin Scale (mRS) and Fisher classification. RESULTS: Data of 135 patients with aneurysmal SAH (98 women, 37 men; ratio 2.6:1) were analysed. Analysis showed that 19 aneurysms (14 %) were >10 mm (mean size, 19.2 mm) and 116 aneurysms (85.9 %) <10 mm (mean size, 6.2 mm). In total, 112 were categorised as berry-like configured aneurysms (n = 113 <10 mm, n = 3 >10 mm), 18 as multi-lobar (n = 16 <10 mm, n = 2 >10 mm) and 5 as fusiform (n = 4 <10 mm, n = 1, >10 mm). CONCLUSION: Since the results of our study showed that the majority of the aneurysms are <10 mm (mean, 6.2 mm), it is justified to challenge the recommendations of the international guidelines in a daily routine setting. We believe that the published data are not convincing enough to play a guidance role in daily routine. Due to improving surgical and endovascular techniques with satisfying results and the high number of ruptured small aneurysms, we believe a change in attitude in management of small-sized aneurysms is needed. Further diagnostic models are needed to determine the risk of rupture of intracranial aneurysms properly to obtain adequate treatment for UIAs.

Feasibility and safety of ADAPT in acute distal posterior cerebral artery occlusions.

PURPOSE: The direct aspiration first pass technique (ADAPT) is an effective and safe endovascular treatment for distal medium vessel occlusions (DMVO) of the anterior circulation. Clinical experience with ADAPT in the distal posterior circulation, however, is still limited and published data is scarce. In this original work, feasibility, safety and efficacy of ADAPT with distal access catheters (DAC) for treatment of acute distal posterior cerebral artery occlusions (DPCAOs) is evaluated. METHOD: All acute ischemic stroke patients between 2017 and 2022 with primary or secondary DPCAOs in the P2 or P3 segment, that underwent thrombectomy of the DPACO using ADAPT with DACs as frontline therapy, were identified. Demographic data, recanalization rates, procedural safety, and clinical outcome were assessed. RESULTS: Twenty-four patients with primary (n = 6) or secondary (n = 18) DPCAOs (P2: 21/24; P3: 3/24) were included. Median NIHSS score at admission was 14.5 (IQR 9.5). In all cases, the DPCAO could be reached with the DAC. Successful revascularization (DMVO-p-TICI ≥ 2b) with ADAPT was achieved in 79.2% (19/24), including a first pass effect of 62.5% (15/24), leading to complete recanalization (DMVO-p-TICI 3). Median number of passes was 1 (range 1-2). No complications related to distal PCA aspiration thrombectomy occurred. Median NIHSS and mRS scores at discharge were 4 (IQR 8) and 3 (IQR 2), respectively. CONCLUSIONS: ADAPT appears to be feasible, safe and effective for the treatment of acute DPCAOs in the setting of different occlusion patterns. High revascularization rates without procedural complications can be achieved. Further studies are needed to consolidate these results.

The persistent primitive marginal sinus-observations in children with Vein of Galen malformation.

INTRODUCTION: Knowledge of venous anatomy and drainage in children with neurovascular diseases is crucial. The primitive marginal sinuses (PMS) are embryonic sinuses forming the later superior sagittal sinus. Their angiographic persistence has not been reported before. The purpose of this study is to demonstrate the angiographic characteristics in children with Vein of Galen malformation and to discuss their embryology and clinical significance. METHODS: We retrospectively reviewed digital subtraction angiography and magnetic resonance venography of 102 Vein of Galen malformations (VGM) from the database of two high-load centres for paediatric neurovascular diseases. RESULTS: We found 10 persistent PMS in 102 children indicating a frequency of 9.8 %. Illustrative cases are shown to demonstrate the vast spectrum of venous variability. The PMS becomes visualised in situations of high-flow arteriovenous shunt in children and can even disappear or remodel after successful shunt reduction or closure. CONCLUSION: Knowledge and recognition of the PMS are important for neurointerventionalists in endovascular treatment planning using the transvenous route and can help neurosurgeons in avoiding severe surgical complications.

Vein of Galen aneurysmal malformation: combined transvenous and transarterial method using a "kissing microcatheter technique".

INTRODUCTION: Vein of Galen aneurysmal malformation (VGAM) is a severe pediatric neurovascular disease. Children often present with congestive heart failure in the neonatal period. In the last decades, endovascular treatment became the first therapeutic option. The purpose of this study is to report our results in the treatment of VGAM with a combined transvenous and transarterial method in the last ten years. METHODS: In our cohort of 28 patients with VGAM, 22 patients were treated endovascularly between 1992 and 2010. In the last 10 years, a consecutive series of 14 children were treated with a combined transvenous and transarterial method. The therapeutic goal was immediate shunt reduction of the arteriovenous malformation, especially in the neonatal period. Closure of the fistulous connections was achieved by coiling using a combined transvenous and transarterial approach, called "kissing microcatheter technique". RESULTS: Eight of 14 children presented in the neonatal period with severe congestive heart failure. The other six patients presented between the age of 2 and 17 months. One patient died due to a non-procedural complication in another hospital 2 years after the last treatment. Complete or >90% of angiographically confirmed closure of the malformation was documented in 11 of 14 patients. Normal or near-normal outcome was achieved in 9 of 13 surviving children, a non-favorable outcome was observed in four children. Control of heart failure was achieved in all patients. CONCLUSION: Endovascular treatment of VGAM using a combined transvenous and transarterial method is a safe procedure with a low complication rate. The overall outcome can be improved, especially in the high-risk neonatal group with congestive heart failure.

Coarctation of the aorta and vein of Galen malformation - treatment considerations in a severely compromised patient.

A vein of Galen malformation - a rare cause of cardiac insufficiency in neonates - is sometimes associated with coarctation of the aorta, two diseases requiring urgent therapy in the neonatal period. We report on a term neonate in whom we first palliated the coarctation by stent implantation, providing time to treat the vein of Galen malformation by endovascular embolisation. Following this, the coarctation was surgically repaired and the stent was explanted.

Endovascular treatment of distal medium vessel occlusions using microcatheter aspiration thrombectomy.

BACKGROUND AND PURPOSE: Recent studies suggest that endovascular treatment (EVT) in distal medium vessel occlusion (DMVO) stroke is beneficial even beyond middle cerebral artery (MCA) - M2 segment. However, data about aspiration thrombectomy of DMVOs is scarce since common state-of-the-art aspiration catheters are usually too large for small distal intracranial arteries. We report our initial experiences using the microcatheter aspiration thrombectomy (MAT) technique as frontline therapy for acute DMVOs in the MCA territory. METHODS: We retrospectively analyzed all acute ischemic stroke (AIS) patients that underwent MAT of a primary or secondary DMVO in the M3 or M4 segment between January 2019 and October 2021. Recanalization rates, procedural safety and outcome data were recorded. RESULTS: MAT of acute M3 and M4 occlusions was performed in 19 patients with AIS. Six had isolated DMVO strokes, 13 had secondary DMVOs during EVT of a proximal large vessel occlusion. Successful revascularization to DMVO TICI ≥ 2b was achieved in 58% (11/19) with a single pass in all of them. The median National Institutes of Health Strokes Scale (NIHSS) score at admission and discharge was 12 and 3, respectively. 68% (13/19) of the patients had a good clinical outcome at discharge (modified Rankin Scale 0-2). No symptomatic complications related to MAT occurred. CONCLUSIONS: MAT of DMVOs in the MCA territory is technically feasible and effective. Compared to stent retriever-based thrombectomy in DMVOs the hemorrhagic complication rate appears notably lower. Further studies are needed to validate the benefit of mechanical thrombectomy in the distal intracranial vasculature.

MRS SOFIA: a multicenter retrospective study for use of Sofia for revascularization of acute ischemic stroke.

BACKGROUND: Over the past several years there has been increased interest in the use of the Sofia aspiration system (MicroVention, Tustin, California) as a primary aspiration catheter. OBJECTIVE: To perform a multicenter retrospective study examining the efficacy of the Sofia aspiration catheter as a standalone aspiration treatment for large vessel occlusion. METHODS: Consecutive cases in which the Sofia catheter was used for aspiration thrombectomy for large vessel occlusion were included. Exclusion criteria were the following: (1) Sofia not used for first pass, and (2) a stent retriever used as an adjunct on the first pass. The primary outcome of the study was first pass recanalization (Thrombolysis in Cerebral Infarction (TICI) 2c/3). Secondary outcomes included first pass TICI 2b/3, crossover to other thrombectomy devices, number of passes, time from puncture to recanalization, and complications. RESULTS: 323 patients were included. First pass TICI 2c/3 was achieved in 49.8% of cases (161/323). First pass TICI 2b/3 was achieved in 69.7% (225/323) of cases. 74.8% had TICI 2b/3 with the Sofia alone. Crossover to other thrombectomy devices occurred in 29.1% of cases (94/323). The median number of passes was 1 (IQR=1-3). Median time from puncture to recanalization was 26 min (IQR=17-45). Procedure related complications occurred in 3.1% (10/323) of cases. CONCLUSION: Our study highlights the potential advantage of the Sofia aspiration catheter for primary aspiration thrombectomy in acute ischemic stroke. High rates of first pass recanalization with low crossover rates to other thrombectomy devices were achieved. Median procedure time was low, as were procedural complications.