Experimental evaluation of the performance of large bore aspiration catheters.

BACKGROUND AND PURPOSE: Mechanical thrombectomy using an aspiration catheter (AC) is widely performed in patients with acute ischemic stroke due to large vessel occlusion. AC diameter directly impacts aspiration performance, which has led device companies to develop large bore ACs. The purpose of this study was to evaluate the in vitro performance of several commercially available large bore ACs. MATERIALS AND METHODS: We conceived an experimental set up to assess tracking force, aspiration flow rate, and distal end tensile force pre- and post-thrombectomy of ACs including Sofia 6 (Microvention Inc., California, USA), React 71 (Medtronic Neurovascular, Irvine, California, USA), Jet 7 (Penumbra Inc, Alameda, California, USA), Catalyst 7 (Stryker Neurovascular, Kalamazoo, Michigan, USA) and Embovac 071 (Johnson & Johnson Medical Ltd, UK). RESULTS: React 71 and Sofia 6 had significantly lower trackability force compared to the other ACs tested. Distal AC segment tensile force was highest for React 71 and lowest for Jet 7. Jet 7 had the highest internal diameter and the highest aspiration flow rate. CONCLUSION: The data from this comparative analysis may assist clinicians in selecting the appropriate AC and highlights the need for key performance criteria during the development of next-generation large-bore ACs for optimal AC performance.

Safety and effectiveness of the LVIS and LVIS Jr devices for the treatment of intracranial aneurysms: Final results of the LEPI multicenter cohort study.

BACKGROUND: The Low profile visualized intraluminal support (LVIS)/LVIS Jr is a self-expanding braiding stent for the treatment of intracranial aneurysm. This study is to determine the safety and effectiveness of the LVIS/LVIS Jr for the treatment of intracranial aneurysms in a real-world setting. METHODS: This prospective, observational, multicenter study enrolled patients with unruptured, ruptured and recanalized intracranial aneurysms treated with the LVIS stents, between February 2018 to December 2019. Primary endpoint was the cumulative morbidity and mortality rate (CMMR) assessed at 12 months follow-up (FU). RESULTS: A total of 130 patients were included (62.3 % women, mean age 55.9 ± 11.4) on an intention-to-treat basis. Four patients (3.1 %) had 2 target aneurysms; 134 total aneurysms were treated. The aneurysms were mainly located on the middle cerebral artery (41/134; 30.6 %) and the anterior communicating artery (31/134; 23.1 %). The CMMR at 1 year linked to the procedure and/or device was 4.6 % (6/130). The overall mortality was 1.5 % (2/130), none of these deaths adjudged as being linked to the procedure and/or device. All aneurysms (134/134, 100 %) were successfully treated with LVIS stent and/or other devices. At a mean FU of 16.8 months post-procedure, complete/nearly complete occlusion was achieved in 112 aneurysms (92.6 %), and only 3 patients (2.5 %) required aneurysm retreatment. CONCLUSION: This study provides evidence that the LVIS/LVIS Jr devices are safe and effective in the treatment of complex intracranial aneurysms, with very high rates of adequate occlusion at FU. These angiographic results are stable over time with an acceptable complication rate. TRIAL REGISTRATION: ClinicalTrial.gov under NCT03553771.

Acute Stenting and Concomitant Tirofiban Administration for the Endovascular Treatment of Acute Ischemic Stroke Related to Intracranial Artery Dissections: A Single Center Experience and Systematic Review of the Literature.

BACKGROUND: Intracranial artery dissection is an uncommon cause of acute ischemic stroke. Although acute stenting of the dissected arterial segment is a therapeutic option, the associated antiplatelet regimen remains a matter of debate. OBJECTIVES: To evaluate the efficacy and safety of acute intracranial stenting together with concomitant intravenous administration of tirofiban and to perform a systematic review of the literature. MATERIALS AND METHODS: A single-center, retrospective study of the clinical and radiological records of all patients treated at our center by intracranial stenting in the setting of acute ischemic stroke between January 2010 and December 2020. A systematic review of the literature was conducted according to the PRISMA-P guidelines for relevant publications from January 1976 to December 2020 on intracranial artery dissection treated by stent. RESULTS: Seven patients with intracranial artery dissections underwent acute stenting with concomitant tirofiban during the study period. Mid-term follow-up showed parent artery patency in 6/7 cases (85.7%). The modified Rankin Score was ≤ 0-2 at 3 months in 5/7 cases (71.4%). The literature review identified 22 patients with intracranial artery dissection treated with acute stenting in association with different antithrombotic therapies. Complete revascularization was obtained in 86.3% of cases with a modified Rankin Score of ≤ 0-2 in 68% of patients at 3-month follow-up. CONCLUSIONS: Acute intracranial stenting together with intravenous tirofiban administration could be a therapeutic option in patients with intracranial artery dissection and a small ischemic core.

Single-hole, ruptured parenchymal arteriovenous fistula of the mesencephalon: not known vascular malformation of the brain or a posthemorrhagic entity?

The subtypes of brain arteriovenous malformations, with direct, single-hole fistulas without co-existing nidus are not described as existing entities inside the brain parenchyma but on the pial surface. True parenchymal arteriovenous malformations present with nidal structure, even if they are small, whereas surface lesions may present a direct fistulous configuration. In this case of midbrain haemorrhage a direct arteriovenous fistula was detected at the level of the red nucleus between a paramedian midbrain perforator artery and a paramedian parenchymal vein, with pseudo-aneurysm formation at the fistulous connection, without signs of adjacent nidus structure. The hypothesis whether a pre-existing arteriovenous fistula ruptured or a spontaneous haemorrhage has caused the fistulous connection is discussed.

Clot-Based Radiomics Predict a Mechanical Thrombectomy Strategy for Successful Recanalization in Acute Ischemic Stroke.

BACKGROUND AND PURPOSE: Mechanical thrombectomy (MTB) is a reference treatment for acute ischemic stroke, with several endovascular strategies currently available. However, no quantitative methods are available for the selection of the best endovascular strategy or to predict the difficulty of clot removal. We aimed to investigate the predictive value of an endovascular strategy based on radiomic features extracted from the clot on preinterventional, noncontrast computed tomography to identify patients with first-attempt recanalization with thromboaspiration and to predict the overall number of passages needed with an MTB device for successful recanalization. METHODS: We performed a study including 2 cohorts of patients admitted to our hospital: a retrospective training cohort (n=109) and a prospective validation cohort (n=47). Thrombi were segmented on noncontrast computed tomography, followed by the automatic computation of 1485 thrombus-related radiomic features. After selection of the relevant features, 2 machine learning models were developed on the training cohort to predict (1) first-attempt recanalization with thromboaspiration and (2) the overall number of passages with MTB devices for successful recanalization. The performance of the models was evaluated on the prospective validation cohort. RESULTS: A small subset of radiomic features (n=9) was predictive of first-attempt recanalization with thromboaspiration (receiver operating characteristic curve-area under the curve, 0.88). The same subset also predicted the overall number of passages required for successful recanalization (explained variance, 0.70; mean squared error, 0.76; Pearson correlation coefficient, 0.73; P<0.05). CONCLUSIONS: Clot-based radiomics have the ability to predict an MTB strategy for successful recanalization in acute ischemic stroke, thus allowing a potentially better selection of the MTB strategy, as well as patients who are most likely to benefit from the intervention.

Acute Stroke Management During the COVID-19 Pandemic: Does Confinement Impact Eligibility for Endovascular Therapy?

During the coronavirus disease 2019 (COVID-19) pandemic, the World Health Organization recommended measures to mitigate the outbreak such as social distancing and confinement. Since these measures have been put in place, anecdotal reports describe a decrease in the number of endovascular therapy (EVT) treatments for acute ischemic stroke due to large vessel occlusion. The purpose of our study was to determine the effect on EVT for patients with acute ischemic stroke during the COVID-19 confinement. In this retrospective, observational study, data were collected from November 1, 2019, to April 15, 2020, at 17 stroke centers in countries where confinement measures have been in place since March 2020 for the COVID-19 pandemic (Switzerland, Italy, France, Spain, Portugal, Germany, Canada, and United States). This study included 1600 patients treated by EVT for acute ischemic stroke. Date of EVT and symptom onset-to-groin puncture time were collected. Mean number of EVTs performed per hospital per 2-week interval and mean stroke onset-to-groin puncture time were calculated before confinement measures and after confinement measures. Distributions (non-normal) between the 2 groups (before COVID-19 confinement versus after COVID-19 confinement) were compared using 2-sample Wilcoxon rank-sum test. The results show a significant decrease in mean number of EVTs performed per hospital per 2-week interval between before COVID-19 confinement (9.0 [95% CI, 7.8-10.1]) and after COVID-19 confinement (6.1 [95% CI, 4.5-7.7]), (P<0.001). In addition, there is a significant increase in mean stroke onset-to-groin puncture time (P<0.001), between before COVID-19 confinement (300.3 minutes [95% CI, 285.3-315.4]) and after COVID-19 confinement (354.5 minutes [95% CI, 316.2-392.7]). Our preliminary analysis indicates a 32% reduction in EVT procedures and an estimated 54-minute increase in symptom onset-to-groin puncture time after confinement measures for COVID-19 pandemic were put into place.

Thoracic aggressive vertebral hemangiomas: multidisciplinary management in a hybrid room.

PURPOSE: Vertebral hemangiomas (VH) account for 2-3% of all spinal tumors. The majority is incidentally found on radiographic studies: 1% present with pain and/or neurologic deficits. We report our experience with the multidisciplinary management of aggressive symptomatic thoracic VH by concomitant intraoperative sclerotization with sodium tetradecyl sulfate (STS), vertebroplasty, posterior decompression (with/without fusion) and surgical resection in a hybrid operating room (HR) equipped with a rotational scanner and a radiolucent operating table. METHODS: Patients admitted with aggressive spinal VH between 2007 and 2018 were included. Data regarding demographics, presenting symptoms, location of the lesion, preoperative embolization, length of the surgery, estimated blood loss (EBL) as well as follow-up (FU) were retrieved. RESULTS: Five patients were included (three females, mean age 65 years; range 59-75). Three patients presented with a myelopathy and two mechanical thoracic pain. All patients underwent a single-stage percutaneous sclerotization and vertebroplasty followed by a surgical decompression associated with epidural intralesional injection of STS and subtotal resection of the epidural lesion. Two patients had preoperative embolization. Mean procedural duration was 338 min (range 210-480 min). Four patients had marginal EBL, one patient had 500 ml EBL. Patients had no evidence of lesion recurrence or progression at the end of the follow-up. CONCLUSIONS: The single-stage multimodal management of aggressive symptomatic VH is safe and effective. It allows for a direct intraoperative sclerotherapy combined with maximal tumor resection, resulting in reduced blood loss. The use of STS as a direct intraoperative sclerotizing agent is safe and reliable.

Neurovascular stent artifacts in 3D-TOF and 3D-PCMRI: Influence of stent design on flow measurement.

PURPOSE: The morphological and hemodynamic evaluations of neurovascular diseases treated with stents would benefit from noninvasive imaging techniques such as 3D time-of-flight MRI (3D-TOF) and 3D phase contrast MRI (3D-PCMRI). For this purpose, a comprehensive evaluation of the stent artifacts and their impact on the flow measurement is critical. METHODS: The artifacts of a representative sample of neurovascular stents were evaluated in vitro with 3D-TOF and 3D-PCMRI sequences. The dependency of the artifacts with respect to the orientation was analyzed for each stent design as well as the impact on the flow measurement accuracy. Furthermore, the 3D-PCMRI data of four patients carrying intracranial aneurysms treated with flow diverter stents were analyzed as illustrative examples. RESULTS: The stent artifacts were mainly confined to the stent lumen therefore indicating the leading role of shielding effect. The influence of the stent design and its orientation with respect to the transmitting MR coils were highlighted. The artifacts impacted the 3D-PCMRI velocities mainly in the low magnitude domains, which were discarded from the analysis ensuring reliable near-stent velocities. The feasibility of in-stent flow measurements was confirmed in vivo on two patients who showed strong correlation between flow and geometric features. In two other patients, the consistency of out-of-stent velocities was verified qualitatively through intra-aneurysmal streamlines except when susceptibility artifacts occurred. CONCLUSION: The present results motivate the conception of low inductance or nonconductive stent design. Furthermore, the feasibility of near-stent 3D-PCMRI measurements opens the door to clinical applications like the post-treatment follow-up of stenoses or intracranial aneurysms.

Correction to: Ruptured posterior circulation aneurysms: epidemiology, patterns of care, and outcomes from the Swiss SOS national registry.

The name of Roy Thomas Daniel was incorrectly captured in the original manuscript.

Ruptured posterior circulation aneurysms: epidemiology, patterns of care, and outcomes from the Swiss SOS national registry.

BACKGROUND: The treatment of ruptured posterior circulation aneurysms remains challenging despite progresses in the endovascular and neurosurgical techniques. OBJECTIVE: To provide epidemiological characterization of subjects presenting with ruptured posterior circulation aneurysms in Switzerland and thereby assessing the treatment patterns and neurological outcomes. METHODS: This is a retrospective analysis of the Swiss SOS registry for patients with aneurysmal subarachnoid hemorrhage. Patients were divided in 3 groups (upper, lower, and middle third) according to aneurysm location. Clinical, radiological, and treatment-related variables were identified and their impact on the neurological outcome was determined. RESULTS: From 2009 to 2014, we included 264 patients with ruptured posterior circulation aneurysms. Endovascular occlusion was the most common treatment in all 3 groups (72% in the upper third, 68% in the middle third, and 58.8% in the lower third). Surgical treatment was performed in 11.3%. Favorable outcome (mRS ≤ 3) was found in 56% at discharge and 65.7% at 1 year. No significant difference in the neurological outcome were found among the three groups, in terms of mRS at discharge (p = 0.20) and at 1 year (p = 0.18). High WFNS grade, high Fisher grade at presentation, and rebleeding before aneurysm occlusion (p = 0.001) were all correlated with the risk of unfavorable neurological outcome (or death) at discharge and at 1 year. CONCLUSIONS: In this study, endovascular occlusion was the principal treatment, with a favorable outcome for two-thirds of patients at discharge and at long term. These results are similar to high volume neurovascular centers worldwide, reflecting the importance of centralized care at specialized neurovascular centers.

Ruptured PICA aneurysms: presentation and treatment outcomes compared to other posterior circulation aneurysms. A Swiss SOS study.

BACKGROUND AND PURPOSE: Aneurysms of the posterior inferior cerebellar artery (PICA) are relatively uncommon and evidence is sparse about patients presenting with ruptured PICA aneurysms. We performed an analysis of the Swiss SOS national registry to describe clinical presentation, treatment pattern, and neurological outcome of patients with ruptured PICA aneurysms compared with other ruptured posterior circulation (PC) aneurysms. METHODS: This was a retrospective analysis of anonymized data from the Swiss SOS registry (Swiss Study on Aneurysmal Subarachnoid Hemorrhage; 2009-2014). Patients with ruptured PC aneurysms were subdivided into a PICA and non-PICA group. Clinical, radiological, and treatment-related variables were identified, and their impact on the neurological outcome was determined in terms of modified Rankin score at discharge and at 1 year of follow-up for the two groups. RESULTS: Data from 1864 aneurysmal subarachnoid hemorrhage patients were reviewed. There were 264 patients with a ruptured PC aneurysm. Seventy-four PICA aneurysms represented 28% of the series; clinical and radiological characteristics at admission were comparable between the PICA and non-PICA group. Surgical treatment was accomplished in 28% of patients in the PICA group and in the 4.8% of patients in the non-PICA group. No statistically significant difference was found between the two groups in terms of complications after treatment. Hydrocephalus requiring definitive shunt was needed in 21.6% of PICA patients (p = 0.6); cranial nerve deficit was present in average a quarter of the patients in both PICA and non-PICA group with no statistical difference (p = 0.3). A more favorable outcome (66.2%) was reported in the PICA group at discharge (p < 0.05) but this difference faded over time with a similar neurological outcome at 1-year follow-up (p = 0.09) between both PICA and non-PICA group. The Kaplan-Meyer estimation showed no significant difference in the mortality rate between both groups (p = 0.08). CONCLUSIONS: In the present study, patients with ruptured PICA aneurysms had a favorable neurological outcome in more than two thirds of cases, similar to patients with other ruptured PC aneurysms. Surgical treatment remains a valid option in a third of cases with ruptured PICA aneurysms.

Correction to: Ruptured PICA aneurysms: presentation and treatment outcomes compared to other posterior circulation aneurysms. A Swiss SOS study.

Incorrect authorgroup and authorname.

Experimental evaluation of the NeVa™ thrombectomy device a novel stent retriever conceived to improve efficacy of organized clot removal.

BACKGROUND AND PURPOSE: Stent retrievers are recognized as the most effective devices for intracranial thrombectomy. Although highly effective, such devices fail in clot removal when the brain vessel occlusion is due to organized, firm clots. The mechanism of failure is that during the retrieval, devices remain compressed by the organized clot and slide between it and the vessel wall without any removal effect. The aim of the current study is to present the preclinical evaluation of the Neva™ device, a novel stent retriever designed to improve the incorporation and removal of organized thrombi. MATERIALS AND METHODS: Preclinical evaluation of the Neva™ device was divided in three main chapters: efficacy analysis, mechanical analysis and safety analysis. Efficacy and mechanical analysis aimed to investigate the behavior during the retrieval of the Neva™ device and its interaction with experimental organized clots. Safety analysis was conducted on animals in order to investigate the effect of the Neva™ device on real arteries after simulated thrombectomy maneuvers. RESULTS: Neva™ device showed a high rate of "optimal clot integration" and "effective clot removal" which was related to constant cohesion to the vessel wall during retrievals. Safety analysis showed as the most frequent finding the disruption of the intima of the tested vessels with, in some cases, minimal disruption of the internal elastic lamina. CONCLUSIONS: The Neva™ device has demonstrated safety and efficacy in a pre-clinical study. Such encouraging, preliminary results have to be compared with those of clinical trials.

Second-Generation Hydrogel Coils for the Endovascular Treatment of Intracranial Aneurysms: A Randomized Controlled Trial.

BACKGROUND AND PURPOSE: Endovascular embolization of intracranial aneurysms with hydrogel-coated coils lowers the risk of major recurrence, but technical limitations (coil stiffness and time restriction for placement) have prevented their wider clinical use. We aimed to assess the efficacy of softer, second-generation hydrogel coils. METHODS: A randomized controlled trial was conducted at 22 centers in France and Germany. Patients aged 18 to 75 years with untreated ruptured or unruptured intracranial aneurysms measuring 4 to 12 mm in diameter were eligible and randomized (1:1 using a web-based system, stratified by rupture status) to coiling with either second-generation hydrogel coils or bare platinum coils. Assist devices were allowed as clinically required. Independent imaging core laboratory was masked to allocation. Primary end point was a composite outcome measure including major aneurysm recurrence, aneurysm retreatment, morbidity that prevented angiographic controls, and any death during treatment and follow-up. Data were analyzed as randomized. RESULTS: Randomization began on October 15, 2009, and stopped on January 31, 2014, after 513 patients (hydrogel, n=256; bare platinum, n=257); 20 patients were excluded for missing informed consent and 9 for treatment-related criteria. Four hundred eighty-four patients (hydrogel, n=243; bare platinum, n=241) were included in the analysis; 208 (43%) were treated for ruptured aneurysms. Final end point data were available for 456 patients. Forty-five out of 226 (19.9%) patients in the hydrogel group and 66/230 (28.7%) in the control group had an unfavorable composite primary outcome, giving a statistically significant reduction in the proportion of an unfavorable composite primary outcome with hydrogel coils-adjusted for rupture status-of 8.4% (95% confidence interval, 0.5-16.2; P=0.036). Adverse and serious adverse events were evenly distributed between groups. CONCLUSIONS: Our results suggest that endovascular coil embolization with second-generation hydrogel coils may reduce the rate of unfavorable outcome events in patients with small- and medium-sized intracranial aneurysms. CLINICAL TRIAL REGISTRATION: URL: https://www.drks.de/drks_web/. Unique identifier: DRKS00003132.

Trans-venous embolization of a basal ganglia ruptured arteriovenous malformation with open surgical arterial control: A hybrid technique.

Treatment of ruptured deep-seated arteriovenous malformations is challenging and associated with elevated risks. This is due to the proximity or involvement of critical brain structures and the specifically fine and delicate angioarchitecture of these lesions, making both endovascular and surgical access technically complicated. We present the advantages of a true combined, open surgical and endovascular transvenous approach in a hybrid operating room. The technique may overcome in part the difficulties and may improve safety and risk related concerns.

The Catch Mini stent retriever for mechanical thrombectomy in distal intracranial occlusions.

OBJECTIVE: Mechanical thrombectomy (MTB) is a treatment of reference for acute ischemic stroke due to large brain vessel occlusion but some concerns remain about its use in small distal branches. In the present study, we assessed the efficacy and the safety of distal MTB using the Catch Mini (CM) stent retriever. METHODS: We retrospectively reviewed a prospectively maintained database of all consecutive patients who underwent MTB for a distal intracranial occlusion with the Catch Mini device at our hospital. RESULTS: Forty-one patient underwent MTB for distal intracranial occlusions using the CM stent retriever. Good capillary reperfusion (TICT≥2b) was observed in 32 out of 41 patients (78%). Focal ischemia within the territory vascularized by the artery addressed by the CM was observed in 8 patients (19.5%). Post-procedural vasospasm was observed in 8 patients, all responding rapidly to vasodilatator administration. Two asymptomatic hemorrhages (4.9%) were noted on follow-up imaging (one patechial hemorrhage and one parenchymal hematoma) in patients with M2 occlusions. No vessel rupture were observed. Overall, good neurological outcome at three months (mRS≤2) was observed in 28 (out of 34 patients followed; 82.4%) of patients. CONCLUSIONS: Our single-center experience shows that the CM stent retriever is safe and effective for the recanalization of small diameter distal branches feeding eloquent brain areas.

GREAT-a randomized controlled trial comparing HydroSoft/HydroFrame and bare platinum coils for endovascular aneurysm treatment: procedural safety and core-lab-assessedangiographic results.

INTRODUCTION: Hybrid hydrogel-platinum coils (HydroCoil) have proven effective for endovascular aneurysm treatment. To overcome technical limitations (coil stiffness, time restriction for placement), a second generation of softer hydrogel coils has been brought to clinical practice (HydroSoft, HydroFrame). We report on procedural safety and core-lab-assessed angiographic results from an open-label multicenter randomized controlled trial. METHODS: Web-based randomization occurred in 15 medical centers in France and seven in Germany between coil embolization with second-generation hydrogel coils and treatment with any bare platinum coil. Assist devices could be used as clinically required. Primary endpoint is a composite outcome including major aneurysm recurrence and poor clinical outcome at 18 months follow-up. RESULTS: Five hundred thirteen patients were randomized (hydrogel n = 256, bare platinum n = 257). Twenty patients were excluded for missing informed consent and nine patients for treatment related criteria. Four hundred eighty-four patients were analyzed as randomized (hydrogel n = 243, bare platinum n = 241). Two hundred eight had ruptured aneurysms (43 %). Prespecified procedural complications occurred in 58 subjects (hydrogel n = 28, bare platinum n = 30, p = 0.77). The 14-day mortality rate was 2.1 % in both arms of the study. The median calculated packing densities for aneurysms assigned to hydrogel and bare platinum were 39 and 31 % respectively (p < 0.001). No statistically significant differences were found between arms in the post procedural angiographic occlusion rate (p = 0.8). CONCLUSION: Second-generation hydrogel coils can be used in a wide spectrum of aneurysms with a risk profile equivalent to bare platinum. Packing density was significantly higher in aneurysms treated with hydrogel coils. TRIAL REGISTRATION: http://www.germanctr.de , DRKS00003132.

Double Stent Retriever Technique for Mechanical Thrombectomy: A Systematic Review and Meta-Analysis.

BACKGROUND: Mechanical thrombectomy using a double stent retriever technique has recently been described for the treatment of acute ischemic stroke, but its efficacy and safety are not well-established. PURPOSE: The aim of this systematic review and meta-analysis was to evaluate reports of the use of a double stent retriever technique during the endovascular treatment of patients with ischemic stroke. DATA SOURCES: The PubMed, EMBASE, Web of Science, and Scopus databases were searched to identify all studies (clinical trials, cohort series, and case reports) investigating the utility of a double stent retriever technique for the treatment of stroke. The study is reported in accordance with PRISMA 2020 guidelines and was prospectively registered in PROSPERO (CRD42023482691). STUDY SELECTION: Seventeen studies involving a total of 128 patients with large-vessel occlusions predominantly in the anterior circulation (93.0%) were identified. DATA ANALYSIS: Outcomes of interest were the prevalence of successful recanalization (modified TICI ≥2b) and a first-pass effect following the double stent retriever technique as well as complications such as iatrogenic dissections and SAH. Data were pooled using a random effects model. DATA SYNTHESIS: The double stent retriever technique was used as a rescue strategy in occlusions refractory to conventional endovascular treatment in 68.7% (88/128) of patients and as a first-line strategy in 31.3% (40/128) of patients. The double stent retriever technique achieved an overall final modified TICI ≥2b in 92.6% cases, with a first-pass effect of 76.6%. The complication rate remained low, with 0.37% dissection and 1.56% SAH. LIMITATIONS: Limitations of the study include the following: 1) a large number of case reports or small series, 2) a meta-analysis of proportions with no statistical comparison with a control group, and 3) the lack of access to patient-level data. CONCLUSIONS: Our findings suggest that double stent retriever thrombectomy may be safe and associated with good recanalization outcomes, but prospective comparative studies are needed to determine which patients may benefit from this endovascular procedure.

A proposed modern standardized technical approach for symptomatic chronic carotid total occlusion management.

Chronic carotid total occlusion (CCTO) is a known cause of ischemic stroke and transient ischemic attack. Symptomatic CCTO is associated with up to 30% risk of recurrent ischemic stroke, despite optimal medical treatment. Notably, a randomized controlled trial reported that previous surgical management did not improve the overall prognosis of these patients. Endovascular treatment of CCTO has been proposed as a feasible strategy to re-establish cerebral perfusion in symptomatic patients. However, its use is controversial and not supported by evidence from randomized clinical trials. Recently, a meta-analysis reported a reasonably high procedural success without an excess periprocedural complication rate, but several steps are needed before the procedure is mature enough to be tested in randomized controlled trials. This review highlights the developments in the endovascular recanalization of CCTO and emphasizes key steps towards standardizing the procedure.