Safety and effectiveness assessment of the surpass evolve (SEASE): a post-market international multicenter study.

BACKGROUND: Flow diverters are the first-line treatment for specific intracranial aneurysms (iA). Surpass Evolve (SE) is a new-generation 64-wire flow diverter with a high braid angle. Current literature on the SE is limited. We aimed to report the first international real-world experience evaluating the safety and effectiveness of the SE. METHODS: The Safety and Effectiveness Assessment of the Surpass Evolve (SEASE) was a multicenter retrospective international post-marketing cohort study including consecutive patients treated with SE for iAs between 2020 and 2022. Demographic, clinical, and angiographic data were collected. Primary effectiveness was independent core lab adjudicated complete occlusion rates (Raymond-Roy Class 1) at last follow-up. Primary safety were major ischemic/hemorrhagic events and mortality. RESULTS: In total, 305 patients with 332 aneurysms underwent SE implantation. The patients had a median age of 59 [50-67] years, and 256 (83.9%) were female. The baseline modified Rankin scale score was 0-2 in 291 patients (96.7%). Most aneurysms were unruptured (285, 93.4%) and saccular (309, 93.1%). Previous treatment was present in 76 (22.9%) patients. The median aneurysm size was 5.1 [3.4-9.0] mm, and the median neck width was 3.6 [2.7-5.1] mm. Most aneurysms were in the internal carotid artery C6 ophthalmic segment (126, 38.0%), followed by the communicating segment (58, 17.5%). At median 10.2 [6.4-12.9] months follow-up, 233 (73.0%) aneurysms achieved complete occlusion. After adjusting for confounders, complete occlusion remained consistent. Major stroke and procedure-related mortality were reported in 6 (2%) and 2 (0.7%) cases, respectively. CONCLUSION: These results demonstrate that SE has a consistently high effectiveness and favorable safety for the treatment of iAs.

Onyx cast thrombectomy: bailout during thalamic AVM embolization.

Microsurgical resection, radiosurgery, and endovascular embolization are the three different treatment approaches to cerebral arteriovenous malformations (AVMs). Although microsurgical resection remains the most desirable curative option and radiosurgery is often first choice in deep located/eloquent unruptured AVMs, transarterial or transvenous embolization may be pursued for ruptured AVMs not amenable to surgical resection. Most complications during endovascular treatment are related to hemorrhage; however, liquid embolic fragment migration or parent vessel occlusion are also possible and can lead to ischemic events. We present a case of endovascular Onyx (Medtronic, Minnesota, USA) embolization of a ruptured thalamic AVM complicated by Onyx reflux into the proximal posterior cerebral artery causing complete vascular occlusion. We demonstrate a bailout technique1-4 using combined stent-retriever and aspiration catheter to dislodge and retrieve the refluxed Onyx cast while maintaining total occlusion of the initially targeted arterial AVM feeder (video 1).neurintsurg;jnis-2023-020832v1/V1F1V1Video 1.

Incidence and outcome of perforations during medium vessel occlusion compared with large vessel occlusion thrombectomy.

BACKGROUND: Vessel perforation during thrombectomy is a severe complication and is hypothesized to be more frequent during medium vessel occlusion (MeVO) thrombectomy. The aim of this study was to compare the incidence and outcome of patients with perforation during MeVO and large vessel occlusion (LVO) thrombectomy and to report on the procedural steps that led to perforation. METHODS: In this multicenter retrospective cohort study, data of consecutive patients with vessel perforation during thrombectomy between January 1, 2015 and September 30, 2022 were collected. The primary outcomes were independent functional outcome (ie, modified Rankin Scale 0-2) and all-cause mortality at 90 days. Binomial test, chi-squared test and t-test for unpaired samples were used for statistical analysis. RESULTS: During 25 769 thrombectomies (5124 MeVO, 20 645 LVO) in 25 stroke centers, perforation occurred in 335 patients (1.3%; mean age 72 years, 62% female). Perforation occurred more often in MeVO thrombectomy (2.4%) than in LVO thrombectomy (1.0%, p<0.001). More MeVO than LVO patients with perforation achieved functional independence at 3 months (25.7% vs 10.9%, p=0.001). All-cause mortality did not differ between groups (overall 51.6%). Navigation beyond the occlusion and retraction of stent retriever/aspiration catheter were the two most common procedural steps that led to perforation. CONCLUSIONS: In our cohort, perforation was approximately twice as frequent in MeVO than in LVO thrombectomy. Efforts to optimize the procedure may focus on navigation beyond the occlusion site and retraction of stent retriever/aspiration catheter. Further research is necessary in order to identify thrombectomy candidates at high risk of intraprocedural perforation and to provide data on the effectiveness of endovascular countermeasures.

Flow cytometry improves the diagnostic value of fine needle aspiration cytology in a spleen with neuroendocrine tumor: A case report.

Fine needle aspirations are infrequently performed on the spleen due to concerns for hemorrhagic complications. As a result, splenic lesions can be challenging to diagnose given the limited amount of available specimen. Metastasis to the spleen is rare and metastatic neuroendocrine tumors to the spleen are scarce in literature. The diagnosis of splenic lesions from fine needle aspirate entails processing which prolongs the turnaround time, particularly if the cytomorphology is non-typical and a limited sample can further complicate this process. We describe a case in which flow cytometry performed on fine needle aspiration of a splenic lesion suggested a diagnosis of neuroendocrine neoplasm involving the spleen. Further workup confirmed this diagnosis. Flow cytometry can recognize neuroendocrine tumors involving the spleen in a timely manner so that appropriate immunohistochemistry tests on limited specimens can be performed to aid in their accurate diagnosis.

Validation of an automated machine learning algorithm for the detection and analysis of cerebral aneurysms.

OBJECTIVE: Machine learning algorithms have shown groundbreaking results in neuroimaging. The authors herein evaluated the performance of a newly developed convolutional neural network (CNN) to detect and analyze intracranial aneurysms (IAs) on CTA. METHODS: Consecutive patients with CTA studies between January 2015 and July 2021 at a single center were identified. The ground truth determination of cerebral aneurysm presence or absence was made from the neuroradiology report. The primary outcome was the performance of the CNN in detecting IAs in an external validation set, measured using area under the receiver operating characteristic curve statistics. Secondary outcomes included accuracy for location and size measurement. RESULTS: The independent validation imaging data set consisted of 400 patients with CTA studies, median age 40 years (IQR 34 years) and 141 (35.3%) of whom were male; 193 patients (48.3%) had a diagnosis of IA on neuroradiologist evaluation. The median maximum IA diameter was 3.7 mm (IQR 2.5 mm). In the independent validation imaging data set, the CNN performed well with 93.8% sensitivity (95% CI 0.87-0.98), 94.2% specificity (95% CI 0.90-0.97), and a positive predictive value of 88.2% (95% CI 0.80-0.94) in the subgroup with an IA diameter ≥ 4 mm. CONCLUSIONS: The described Viz.ai Aneurysm CNN performed well in identifying the presence or absence of IAs in an independent validation imaging set. Further studies are necessary to investigate the impact of the software on detection rates in a real-world setting.

Detection of Malpositioned VP Shunt Catheter by Radionuclide CSF Cisternography.

ABSTRACT: A 37-year-old man presented with a 2-week history of abdominal pain, headaches, nausea, vomiting, and leukocytosis. Medical history includes congenital hydrocephalus, with a ventriculoperitoneal shunt placed several years ago. Radionuclide cerebrospinal fluid cisternography shows curvilinear activity in the abdomen, in the pattern of small and large bowel loops, suggesting that the tip of the catheter is inside a small bowel loop. No activity is seen in the intraperitoneal compartment. CT of the abdomen and pelvis followed by laparoscopic surgery confirmed the findings.

The Rationale Behind Transcirculation Neuroendovascular Interventions: Literature Review Through a Case-Series Approach.

BACKGROUND: With the development of advanced endovascular techniques and materials, neurointerventionalists can perform challenging and complex cases that were previously difficult to perform. Transcirculation approaches could be a useful tool used in complicated cases, providing access to the target vessel, through the contralateral or opposite circulation, when anterograde access is difficult or nonachievable. OBJECTIVE: To retrospectively review cerebrovascular interventions performed through a transcirculation approach performed by staff at our Institution. METHODS: English-language studies, published until August 2022, reporting transcirculation interventions in the cerebrovascular circulation were retrospectively collected. Type of intervention, number of cases, rationale, and complications were analyzed. Furthermore, similar cases performed by staff currently at our institution were also reviewed and described. RESULTS: Including our cases, a total of 273 transcirculation treatment approaches have been reported. Intracranial aneurysm embolization, stroke thrombectomies, intra-arterial ophthalmic chemotherapy, arteriovenous malformationss, arteriovenous fistulas embolizations, and intracranial angioplasty and stenting are common indications. Reason for using a retrograde approach were stent/balloon-assisted coiling of wide neck aneurysm in 116 cases, difficult angulation of branch in 91 cases, occlusion of parent vessel in 55 cases, and bailout/other in 11 cases. CONCLUSION: Transcirculation approaches can be considered for cases where conventional anterograde treatment options are not feasible or as a bailout strategy in failed or complicated treatment attempts. They represent a strategy to consider when facing challenging cases, and if performed by experienced and dedicated neurointerventionalists, they can represent a safe alternative.

Transradial embolization of a life-threatening tooth extraction socket hemorrhage and pseudoaneurysm.

Embolization of oral hemorrhages due to tooth extraction, although rare, has been previously described.1-4 In this video we present a unique case in which a life-threatening tooth extraction hemorrhage was incontrollable with local compression or surgical cauterization. The patient underwent emergent transradial coil embolization5 of the posterior lateral nasal branches of the sphenopalatine artery. However, the patient returned 11 days later with a lower volume bleed at the original site. Computed tomography angiography showed a pseudoaneurysm at the orthognathic surgery crater retrogradely recanalized through the greater palatine arcade. Surgical options were deemed too invasive, and the decision was made to attempt percutaneous direct puncture embolization. This was unsuccessful and repeat embolization with Onyx was performed through the contralateral greater palatine artery. The patient had complete resolution of symptoms.

SOFIA Nonwire Advancement techniKE 35 Technique: A Minimalist Approach to Stroke Thrombectomy.

BACKGROUND: The Soft Torqueable Catheter Optimized for Intracranial Access (SOFIA) is a catheter designed to enable intracranial access, allowing for advancement, at least partially, without a microcatheter by a technique called SOFIA Nonwire Advancement techniKE (SNAKE). We propose a variation of this technique, called SOFIA Nonwire Advancement techniKE 35 (SNAKE35), in which the catheter is navigated by the intracatheter support of a 0.035-inch guidewire, allowing for rapid, distal intracranial access through a biaxial technique. OBJECTIVE: To assess the performance of a modified navigation technique in the setting of acute stroke thrombectomy. METHODS: Consecutive patients who underwent a thrombectomy procedure between January 2017 and February 2019 were retrospectively identified at our institution. The primary end point was defined as successful positioning of the catheter at the proximal end of the occlusion with the sole use of the SNAKE35 technique. Secondary end points were defined as complications, reperfusion times, and thrombolysis in cerebral infarction scores. RESULTS: Among 140 patients, SNAKE35 was attempted in 79 patients (SNAKE35 group), while traditional navigation was used in the remaining 61 patients (conventional group). Of the total 79 cases, SNAKE35 was successful in positioning the catheter at the proximal end of the occlusion in 66 cases (84%). Of these, 54 cases were completed solely with aspiration techniques. Groin puncture to revascularization time averaged 26 minutes in the SNAKE35 group and 37 minutes in the conventional group ( P < .05), despite older age ( P < .001) and increased use of conscious sedation ( P < .001) in the SNAKE35 group. CONCLUSION: SNAKE35 is an effective and safe technique for SOFIA navigation up to the site of intracranial occlusion in the anterior circulation leading to significant decrease of procedural times.

Citrullinated Inhibitor of DNA Binding 1 Is a Novel Autoantigen in Rheumatoid Arthritis.

OBJECTIVE: To explore the intrinsic role of inhibitor of DNA binding 1 (ID-1) in rheumatoid arthritis (RA) fibroblast-like synoviocytes (FLS) and to investigate whether ID-1 is citrullinated and autoantigenic in RA. METHODS: RA patient serum ID-1 levels were measured before and after infliximab treatment. RA FLS were transfected with a clustered regularly interspaced short palindromic repeat (CRISPR)/CRISPR-associated protein 9 construct targeting ID-1 to examine the effects of ID-1 deletion. RA synovial fluid (SF) and homogenized synovial tissue (ST) were immunoprecipitated for ID-1 and measured for citrullinated residues using an enzyme-linked immunosorbent assay and Western blotting. Liquid chromatography tandem mass spectrometry (LC-MS/MS) was performed on in vitro-citrullinated recombinant human ID-1 (cit-ID-1) to localize the sites of citrullination. Normal and RA sera and SF were analyzed by immunodot blotting for anti-citrullinated protein antibodies (ACPAs) to cit-ID-1. RESULTS: RA patient serum ID-1 levels positively correlated with several disease parameters and were reduced after infliximab treatment. RA FLS displayed reduced growth and a robust increase in interleukin-6 (IL-6) and IL-8 production upon deletion of ID-1. ID-1 immunodepletion significantly reduced the levels of citrullinated residues in RA SF, and citrullinated ID-1 was detected in homogenized RA ST (n = 5 samples; P < 0.05). Immunodot blot analyses revealed ACPAs to cit-ID-1 but not to native ID-1, in RA peripheral blood (PB) sera (n = 30 samples; P < 0.001) and SF (n = 18 samples; P < 0.05) but not in normal PB sera. Following analyses of LC-MS/MS results for citrullination sites and corresponding reactivity in immunodot assays, we determined the critical arginines in ID-1 for autoantigenicity: R33, R52, and R121. CONCLUSION: Novel roles of ID-1 in RA include regulation of FLS proliferation and cytokine secretion as well as autoantigenicity following citrullination.