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.

First multicenter experience using the Silk Vista flow diverter in 60 consecutive intracranial aneurysms: technical aspects.

BACKGROUND: The aim of this study was to assess the technical success and procedural safety of the new Silk Vista device (SV) by evaluating the intraprocedural and periprocedural complication rate after its use in several institutions worldwide. METHODS: The study involved a retrospective review of multicenter data regarding a consecutive series of patients with intracranial aneurysms, treated with the SV between September 2020 and January 2021. Clinical, intra/periprocedural and angiographic data, including approach, materials used, aneurysm size and location, device/s, technical details and initial angiographic aneurysm occlusion, were analyzed. RESULTS: 60 aneurysms were treated with SV in 57 procedures. 66 devices were used, 3 removed and 63 implanted. The devices opened instantaneously in 60 out of 66 (91%) cases and complete wall apposition was achieved in 58 out of 63 (92%) devices implanted. In 4 out of 66 (6%) devices a partial opening of the distal end occurred, and in 5 (8%) devices incomplete apposition was reported. There were 3 (5%) intraprocedural thromboembolic events managed successfully with no permanent neurological morbidity, and 4 (7%) postprocedural events. There was no mortality in this study. The initial occlusion rates in the 60 aneurysms were as follows: O'Kelly-Marotta (OKM) A in 34 (57%) cases, OKM B in 15 (25%) cases, OKM C in 6 (10%) cases, and OKM D in 5 (8%) cases. CONCLUSIONS: Our study demonstrated that the use of the new flow diverter Silk Vista for the treatment of intracranial aneurysms is feasible and technically safe.

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.

Arm-only access for combined transarterial and transvenous neurointerventional procedures.

A simultaneous arterial and venous approach has been widely described for the endovascular treatment of dural arteriovenous fistula (DAVFs) and recently for arteriovenous malformation (AVMs). Conventional venous approaches are performed by direct internal jugular puncture or by femoral access. Although complication rates are low, there are potential life-threatening complications that should be avoided. The advantages of radial artery access have been widely proven, nevertheless the use of upper limb veins in neurointervention are rarely reported. We present five cases of the simultaneous arteriovenous approach through the radial artery and superficial veins of the forearm for the treatment of intracranial neurovascular diseases.

Estudio de las gestantes de edad avanzada en el Hospital Universitario de Caracas / Advanced maternal age studies in the Hospital Universitario de Caracas

Se realizó un estudio retrospectivo, descriptivo, comparativo en 436 pacientes embarazadas atendidas en el Servicio de Obstetricia del Hospital Universitario de Caracas, durante el período comprendido entre enero de 2000 y diciembre de 2003. Fueron distribuidas en dos grupos, el grupo "A" constituido por 212 embarazadas de 35 años o más, atendidas en la consulta de alto riesgo obstétrico y el grupo "B" conformado por 224 embarazadas menores de 35 años atendidas en la consulta prenatal de bajo riesgo. Los objetivos del estudio fueron determinar si es cierto que la edad materna avanzada es un factor de alto riesgo y determinar si el control prenatal, el control del parto y el puerperio hecho en la gestante de edad avanzada disminuye el grado de riesgo materno - fetal haciendo que su pronóstico sea similar al de las gestantes de menor edad con menos riesgo. En el grupo estudio hubo mayor porcentaje de complicaciones prenatales, destacándose la hipertensión. La cesárea tuvo una proporción del 45,29 por ciento, siendo más frecuentes las de emergencia. Las cifras de amenaza de parto pretérmino fueron semejantes en ambos grupos. El puerperio fue de evolución satisfactoria con un número menor de casos para el grupo estudio. No hubo muertes maternas en ambos grupos. El peso de los recién nacidos fue adecuado muestra en ambos grupos con un porcentaje mayor de recién nacidos macrosómicos en el grupo estudio. La evolución neonatal tuvo un porcentaje mayor de casos no satisfactorios en las gestantes de edad avanzada. Se concluye que a pesar de ser las gestantes de edad avanzada un grupo de alto riesgo, el control adecuado y frecuente para la detección oportuna de las complicaciones y una conducta más intervencionista en la resolución de los casos y a una mayor atención de las madres en el posparto, así como de sus hijos en forma inmediata, hacen que los índices de morbimortalidad perinatal no muestren diferencias significativas con respecto al grupo control catalogado.

A retrospective, comparative study control case was performed in 436 pregnant women assisted on the Hospital Universitario de Caracas, between January 2000 and December 2003. They were distributed in two groups, group "A" with 212 pregnant women 35 or more old years, assisted on Obstetrical High Risk Consultation and group "B" conformed by 224 pregnant women minor 35 year old. The objective was to determine if true than advanced age in pregnant women is a high risk factor; and the prenatal control, intrapartum and puerperal care in the pregnant women 35 or more years old minimizes the risk, making it similar to control group. In study group there were a larger percentage of prenatal complications, principally hypertension. Cesarean section was done a in 45.29 percent, often as emergencies. The premature delivery threat numbers were similar in both groups. Puerperal evolution was satisfactory with fewer cases for the study group. There were not maternal deaths in both groups. Weight of newborns showed in both groups a large percentage with standard weight, with a double incidence for macrosomics in the study group. Neonatal evolution had more unsatisfactory cases for the patients with advanced maternal age. We conclude that advanced age in pregnant patients is a high risk factor. Pregnant women with good health and an adequate prenatal care can reduce risks, resulting in a good maternal-fetal prognostic similar to the low risk group.