Ultra-Long Transfers for Endovascular Thrombectomy-Mission Impossible?: The Australia-New Zealand Experience.

BACKGROUND: Endovascular thrombectomy (EVT) access in remote areas is limited. Preliminary data suggest that long distance transfers for EVT may be beneficial; however, the magnitude and best imaging strategy at the referring center remains uncertain. We hypothesized that patients transferred >300 miles would benefit from EVT, achieving rates of functional independence (modified Rankin Scale [mRS] score of 0-2) at 3 months similar to those patients treated at the comprehensive stroke center in the randomized EVT extended window trials and that the selection of patients with computed tomography perfusion (CTP) at the referring site would be associated with ordinal shift toward better outcomes on the mRS. METHODS: This is a retrospective analysis of patients transferred from 31 referring hospitals >300 miles (measured by the most direct road distance) to 9 comprehensive stroke centers in Australia and New Zealand for EVT consideration (April 2016 through May 2021). RESULTS: There were 131 patients; the median age was 64 [53-74] years and the median baseline National Institutes of Health Stroke Scale score was 16 [12-22]. At baseline, 79 patients (60.3%) had noncontrast CT+CT angiography, 52 (39.7%) also had CTP. At the comprehensive stroke center, 114 (87%) patients underwent cerebral angiography, and 96 (73.3%) proceeded to EVT. At 3 months, 62 patients (48.4%) had an mRS score of 0 to 2 and 81 (63.3%) mRS score of 0 to 3. CTP selection at the referring site was not associated with better ordinal scores on the mRS at 3 months (mRS median of 2 [1-3] versus 3 [1-6] in the patients selected with noncontrast CT+CT angiography, P=0.1). Nevertheless, patients selected with CTP were less likely to have an mRS score of 5 to 6 (odds ratio 0.03 [0.01-0.19]; P<0.01). CONCLUSIONS: In selected patients transferred >300 miles, there was a benefit for EVT, with outcomes similar to those treated in the comprehensive stroke center in the EVT extended window trials. Remote hospital CTP selection was not associated with ordinal mRS improvement, but was associated with fewer very poor 3-month outcomes.

Revisiting the surface anatomy of the sciatic nerve in the gluteal region in children using computed tomography.

No anatomy text specifically describes the course of the sciatic nerve (SN) in the gluteal region in children. Anatomical information is largely derived from cadaveric studies of adults, so accurate anatomical information about the location of the SN in children is required. The aim of this study is to assess the surface anatomy of the SN in children using computed tomography (CT). After excluding studies with pelvic pathology, 75 CT scans were analyzed. Three groups were selected for analysis (0-2, 4-6, and 8-10 years). The position of the SN was measured between the posterior superior iliac spine (PSIS) and the ischial tuberosity (IT) and between the IT and the greater trochanter (GT) using 3-dimensional images. In the 0-2 age group, the SN crossed the middle third of a line between the PSIS and the IT in 94% and the GT and the IT in 80% of cases. In the 4-6 age group, the SN crossed the middle third of a line between the PSIS and the IT in 96% and the GT and the IT in 87%. In the 8-10 age group, the SN crossed the middle third of a line between the PSIS and the IT in 100% and the GT and the IT in 71%. The findings indicate that the SN in children is most accurately located in the middle third along a line drawn from the PSIS to the IT and the GT to the IT. Our study is the first to provide anatomical CT data from living children to guide interventions in the gluteal region.

Intracranial venous stenting for idiopathic intracranial hypertension.

INTRODUCTION: There is increasing evidence in the literature to support venous sinus stenting in patients with idiopathic intracranial hypertension who fail first-line therapy. Venous sinus stenting is a safe and successful technique compared with cerebrospinal fluid diversion procedures. This study examines the clinical outcomes of patients post intracranial venous stenting for intracranial hypertension across three tertiary hospitals in Western Australia. METHODS: A retrospective analysis was performed on 83 consecutive patients treated with intracranial venous stenting for IIH at three tertiary hospitals from October 2013 to March 2020. Data were collected from outpatient clinic letters, electronic discharge letters, electronic radiological imaging and procedural reports. RESULTS: 89.2% patients were able to cease Acetazolomide post stenting. 78.3% patients reported resolution of headaches. 84.3% patients demonstrated resolution of their papilloedema. 91.6% patients demonstrated improvement of their visual acuity. Compared with a recent meta-analysis by Satti and Chaudry in 2015, our results demonstrated a higher technical success rate and lower complication rates. CONCLUSION: Our study findings support the paradigm shift from CSF diversion procedures to venous sinus stenting in patients with IIH who fail first-line therapy. Venous sinus stenting has a high technical success rate and significantly lower complication rates than other invasive treatments.

Transradial versus transfemoral access for anterior circulation mechanical thrombectomy: analysis of 375 consecutive cases.

OBJECTIVE: To compare transradial artery access (TRA) to the gold standard of transfemoral artery access (TFA) in mechanical thrombectomy (MT) for stroke caused by anterior circulation large vessel occlusion. METHODS: The clinical outcomes, procedural speed, angiographic efficacy and safety of both techniques were analysed in 375 consecutive cases over an 18-month period in a high volume statewide neurointerventional service. RESULTS: There was no significant difference in patient characteristics, stroke parameters, imaging techniques or intracranial techniques. The median time elapsed between CT scanning and reperfusion was 96.5 min (IQR 68-123) in the TFA group and 95 min (IQR 68-123) in the TRA group (p=0.456). Of 336 patients who were independent at presentation 58% (124/214) of the TFA group and 67% (82/122) of the TRA group had a modified Rankin score of 0-2 at 90-day follow-up (p=0.093). Cross-over from radial to femoral was 4.6% (4/130) compared with 1.6% cross-over from femoral to radial (4/245), but did not meet the predetermined level of statistical significance (OR 2.92, 95% CI 0.81 to 10.52), p=0.088) and did not impact median procedural speed. Adequate angiographic reperfusion, first pass reperfusion, embolisation to new territory and symptomatic intracranial haemorrhage were similar in both groups. There was a significant difference in major access site complications requiring an additional procedure. None of the TRA cases had a major access site complication but 6.5% (16/245) of the TFA cases did (p=0.003). CONCLUSION: This study suggests that using TRA for anterior circulation MT is fast, efficacious, safe and not inferior to the gold standard of TFA.

Upper extremity transvenous access for neuroendovascular procedures: an international multicenter case series.

BACKGROUND: Radial artery access for transarterial procedures has gained recent traction in neurointerventional due to decreased patient morbidity, technical feasibility, and improved patient satisfaction. Upper extremity transvenous access (UETV) has recently emerged as an alternative strategy for the neurointerventionalist, but data are limited. Our objective was to quantify the use of UETV access in neurointerventions and to measure failure and complication rates. METHODS: An international multicenter retrospective review of medical records for patients undergoing UETV neurointerventions or diagnostic procedures was performed. We also present our institutional protocol for obtaining UETV and review the existing literature. RESULTS: One hundred and thirteen patients underwent a total of 147 attempted UETV procedures at 13 centers. The most common site of entry was the right basilic vein. There were 21 repeat puncture events into the same vein following the primary diagnostic procedure for secondary interventional procedures without difficulty. There were two minor complications (1.4%) and five failures (ie, conversion to femoral vein access) (3.4%). CONCLUSIONS: UETV is safe and technically feasible for diagnostic and neurointerventional procedures. Further studies are needed to determine the benefit over alternative venous access sites and the effect on patient satisfaction.

Transradial intracranial aneurysm treatment via an aberrant right subclavian artery.

We report two cases of successfully treated intracranial saccular aneurysms via transradial access with aberrant right subclavian artery anatomy. Two patients aged 74 and 82 years with anterior communicating artery aneurysms deemed suitable for endovascular treatment and anomalous aortic arch anatomy (aberrant right subclavian artery) underwent successful treatment with transradial access. Transradial access was obtained in both patients, in the first patient, without prior knowledge of the aortic arch anatomy. Aberrant right subclavian artery anatomy was negotiated, and the aneurysms were successfully treated in both cases with intrasaccular flow disrupting devices (WEB-SL).

First line transradial access for posterior circulation stroke intervention; initial 12-month experience at a high volume thrombectomy center.

BACKGROUND: The Neurointerventional Surgery Standards and Guidelines Committee has advocated the use of transradial access in the setting of posterior circulation stroke intervention, however there is a paucity of published data on this approach. The purpose of this study is to present 12-months of prospectively collected data from a high volume thrombectomy center following the adoption of a first line transradial approach for posterior circulation stroke intervention. METHODS: A range of data on patient characteristics, procedural metrics, complications and outcomes was prospectively collected between August 2018 - August 2019 following the adoption of first line transradial access for posterior circulation stroke intervention at a high volume thrombectomy center. RESULTS: Transradial access was successful in 22/23 cases (96%), median arteriotomy to reperfusion time was 24 min (IQR 18-40), good angiographic outcome (mTICI 2b-3) was achieved in all cases and good clinical outcome (mRs 0-2) was achieved in 61% of cases. No intracranial or radial artery access site complications occurred. CONCLUSION: The fast procedure times, excellent outcomes and low complication rates achieved in this prospective 12-month study indicate that transradial access is a viable first line strategy in posterior circulation stroke intervention.