Predictors of flow diverter stent in large and giant unruptured intracranial aneurysms, single-center experience.

BACKGROUND: Flow diversion with or without coiling has been established as the treatment of choice for large unruptured aneurysms. This study aims to assess possible predictors for radiological and clinical outcome such as location of the aneurysm (anterior or posterior circulation), complexity by a branching artery, bifurcation, and adjuvant coiling. METHODS: This study was conducted on 65 consecutive patients with 65 large, unruptured intracranial aneurysms (size ≥ 10 mm) treated with flow diverters. Follow-up angiography was done for 60 patients (92.3%) at 12 ± 8.6 months range from 3 to 36 months. RESULTS: Complete occlusion was achieved in 50 from 60 aneurysms (83.4%), while 8 aneurysms (13.3%) had neck remnant, and another two aneurysms (3.3%) remained with aneurysmal remnant. Periprocedural complications were encountered in 14 patients (21.5%) with morbidity in six patients (9.2%) and mortality in one patient (1.5%). In a multivariate logistic regression, anterior versus posterior location was less likely associated with worse outcome; adjusted OR (95% CI) of 0.16 (0.07-0.01), p = 0.006. Complete occlusion in complex aneurysms with branching artery was 60% versus 88% in simple aneurysms without branching artery (p-value = 0.04). CONCLUSIONS: Flow diverter deployment of a large, unruptured aneurysm in the anterior circulation might have a better outcome than one in the posterior circulation. Flow diverter of aneurysms with branching artery or at bifurcation might be associated with aneurysm persistence and complications respectively.

Y-stenting with braided stents for wide-neck intracranial bifurcation aneurysms. A single-center initial experience.

INTRODUCTION: The treatment of wide-neck bifurcation aneurysms is still challenging despite the use of new techniques, such as Y-stenting, the waffle-cone technique and intrasaccular flow disrupters, in recent years. Moreover, the use of flow diverter stents in bifurcation aneurysms has been proposed by several teams, although the results remain controversial. This study aims to evaluate the feasibility and efficacy of Y-stent assisted coiling of bifurcation aneurysms with braided stents. METHODS: We retrospectively reviewed all patients in whom Y-stenting with braided stents had been performed in our center. Six patients were identified and analyzed. Technical success, complications, angiographic outcomes, procedural data, and follow-up controls are reported here. This study was approved by our local ethical committee. RESULTS: Technical success was achieved in all procedures. Overall procedure-related morbidity and mortality was 0%. In the immediate post-treatment angiography, adequate occlusion (neck remnant or total occlusion) was observed in all patients. Short- and long-term follow-up angiography showed adequate occlusion of the aneurysms. CONCLUSIONS: In this small, retrospective single-center analysis we showed that Y-stent assisted coiling with braided stents is a safe and feasible technique. Moreover, it has a high immediate occlusion rate and very good long-term stability.

The blood pressure variability in patients with cryptogenic stroke.

BACKGROUND: Increased nighttime BP variability (BPV) was associated with stroke. Left atrial (LA) enlargement is the default clinical hallmark of structural remodeling that often occurs in response to LA pressure and volume overload. Blood pressure has proven to be an essential determinant of LA enlargement. We aimed to evaluate the influence of BPV as a risk factor for cryptogenic stroke and highlight the importance of including the (APBM) in the workup for those patients and test the relation between BPV and LA remodeling in these patients, which could be used as a clue to add APM monitoring to their workup. Also, LA remodeling may be a substrate for occult atrial fibrillation (AF). We included Group I (108 consecutive patients with cryptogenic ischemic stroke) and Group II (100 consecutive adult participants without a history of stroke or any structural heart disease). We measured the maximal LA volume index (Max LAVI) and minimal LA volume index (Min LAVI). We calculated the left atrial ejection fraction (LAEF). All the participants were subjected to ABPM. RESULTS: In our prospective, cross-sectional cohort study, the patients in Group I had statistically significantly higher Min LAVI and Max LAVI and Less LA EF than Group II, with a P value of (0.001, 0.001, and 0.008), respectively. The Group I patients had higher BPV as measured by SD parameters than patients in Group II, with a P value of 0.001 for all SD parameters. The BPV parameters, as measured by SD parameters, were positively related to the LA remodeling parameters in both groups. After adjusting all variables, we found that age, night systolic SD, and night diastolic SD parameters were independent predictors of LA remodeling. CONCLUSIONS: The patients with cryptogenic stroke had higher short-term BPV, Min LAVI, and Max LAVI but lower LA EF. Careful monitoring of BPV may be of value for both primary and secondary preventions of ischemic stroke.

Intravenous thrombolysis before thrombectomy in acute ischemic stroke: a dual centre retrospective cohort study.

First pass effect (FPE) is a successful recanalization (mTICI ≥ 2b) after the first trial of thrombectomy. It is associated with good functional outcomes. Few studies discussed the effect of BT (bridging therapy: combined I.V. thrombolysis and mechanical thrombectomy) on FPE and clinical outcomes. In our study, we would like to report the effect of MT with or without preceding IVT on FPE and the functional outcome of AIS (Acute Ischemic Stroke) of anterior circulation in real practice. A dual-center retrospective cohort study enrolled 201 patients with AIS of anterior circulation and was divided into a bridging therapy (BT) group of 150 patients who received alteplase preceding thrombectomy, and a direct mechanical thrombectomy (dMT) group of 51 patients. Comparisons between both groups regarding the clinical and radiological outcome. Early better clinical outcome (mRS ≤ 2) at day seven with BT group (39.3%) rather than dMT (23.5%) with P value = 0.044. No significant differences as regard puncture to revascularization time, successful revascularization (mTICI) ≥ 2b and FPE between both groups (P value: 0.328, 0.538, and 0.708, respectively). No differences as regards hemorrhagic transformation, mortality rate, and 90-day favorable outcome between both groups (P value 0.091, 0.089, and 0.192, respectively). BT might have better early outcome than dMT but no difference as regards 90-day favorable outcomes, mortality, sICH, FPE, recanalization rate and procedure time. It might be reasonable to go directly to mechanical thrombectomy without IVT for AIS with large vessel occlusion.

Basilar Artery Thrombectomy Between Evidence-Based Medicine and the Real-World Practice: A Single-Center Experience.

Background and Aim: Basilar artery occlusion (BAO) is known for its catastrophic outcomes, whether death or disability, in approximately 70% of patients. Mechanical thrombectomy (MT) has been approved as an intervention in large vessel occlusion of anterior circulation, based on multiple randomized controlled trials (RCTs) and meta-analyses. Even though two RCTs appeared recently, there is still uncertainty about the effect of MT in BAO. Our study aims to report the outcome of MT in BAO and the variables affecting good outcomes and mortality rate. Materials and Methods: We retrospectively collected the clinical and radiological data of 30 BAO patients treated in our center by MT between July 2016 and July 2021. A favorable clinical outcome was considered if mRS was ≤2. A favorable radiological result was considered if modified Thrombolysis in Cerebral Infarction (mTICI) was ≥2b at the end of the intervention. Multiple variables were tested for their effects on favorable clinical outcomes and mortality. Results: The mean age of the 30 patients was 61.23 ± 16.81 years; 20/30 (66.7%) were male. A favorable functional outcome was achieved in 40.7%. Successful revascularization was achieved in 26 patients (86.7%). Mortality at 90 days was observed in 11 patients (36.7%). The presenting National Institute of Health and Stroke Scale (NIHSS) was the only predictor of mortality, and the optimal cut-off value for death was 15 with area under the curve (AUC) = 0.758 (sensitivity 91% and specificity 59%) and P value = 0.02. Conclusion: Thrombectomy is an effective procedure in BAO which has naturally a bad outcome. The presenting NIHSS might be the only predictor of mortality in our study.

Awake surgery for lesions near eloquent brain under scalp block and clinical monitoring: experience of single center with limited resources.

BACKGROUND: Surgery of the brain tumors near eloquent areas carries the risk of either disabling neurological deficit or inadequate resection with bad prognosis in both situations. Awake surgery is the gold standard procedure for such lesions. However, it requires certain anesthetic drugs, advanced techniques, and trained teams that are not available in every neurosurgical institute. This work aims to evaluate safety, feasibility, and outcome of operating on patients with space occupying lesions near eloquent areas under scalp block being continuously examined by a neurologist through retrospective study of 20 cases with supratentorial lesions related to language or sensorimotor cortex. RESULTS: There were 12 males and 8 females with mean age 36.8 years. Forty percent of patients were presented by motor weakness. Tumors were related to motor cortex in 11 patients and to language areas in 9 patients. Mean operative time was 210 min. Gross or near total resection was achieved in 15cases, four cases had subtotal resection and biopsy only was done in 1 case. Two patients suffered from intraoperative seizures and conversion to general anesthesia was required in one patient. CONCLUSION: Operating on tumors near eloquent brain areas under scalp block and continuous neurological examination during tumor resection proved to be effective in early detection and prevention of permanent major deficits especially in the developing countries with limited resources.