Performance assessment of the Surpass Evolve flow diverter for the treatment of intracranial aneurysms: A systematic review and meta-analysis.

BACKGROUND: The Surpass Evolve (SE) has emerged as a promising alternative treatment from the flow diverter series. The utilization of the SE has gradually increased, however, there is a scarcity of comprehensive data on the solidity of this technology in the endovascular treatment of intracranial aneurysms (IAs). This meta-analysis aimed to evaluate the safety and effectiveness of the SE flow diverter. METHODS: A systematic literature search from inception to April 2024 was conducted across five databases for studies involving IAs treated with the SE. The primary effectiveness outcome was the proportion of complete aneurysm occlusion at the final follow-up, and the primary safety outcome comprised a composite of early and delayed complications. Subgroup analyses based on aneurysm size, anatomical location, and rupture status were also conducted. RESULTS: Our analysis included nine studies with 645 patients and 722 IAs. Effectiveness outcomes revealed an overall complete aneurysm occlusion rate of 69% (95% confidence interval (CI) = 58%-78%; I2 = 72%) and a favorable aneurysm occlusion rate of 91% (95% CI = 82%-96%; I2 = 49%). Safety outcomes demonstrated an overall complications rate of 6% (95% CI = 3%-12%; I2 = 66%), with an early complications rate of 6% (95% CI = 4%-11%; I2 = 0%), and a delayed complications rate of 0% (95% CI = 0%-7%; I2 = 0%). CONCLUSIONS: Our findings suggest a favorable outcome with a high rate of complete aneurysm occlusion at the last follow-up, with acceptable rates of neurological complications. Future research efforts should focus on larger, prospective studies with standardized outcome measures to further elucidate the clinical utility of the SE flow diverter in the management of IAs.

Multiple brain arteriovenous malformations: systematic review and individual patient data meta-analysis.

Multiple brain arteriovenous malformations (bAVM) are rare neurovascular lesions usually related to genetic syndromes. Its management is not well established given its rarity. The objective of this study was to describe the clinical and angiographic features of published cases and to explore their associations with treatment outcomes. We performed a literature search of published cases in Medline and the Regional Index Medici. Additional cases were searched in our single-center registry. Data on the proportions of patients and clinical and angiographic characteristics were extracted. The study outcomes were nidal instability in patients who underwent staged treatment and radiological cure in patients who underwent treatment using any treatment modality. Logistic regression models for the study outcomes were analyzed. Data on the proportions of multiple bAVM patients were summarized with meta-analyses of proportions. We included 118 patients (reported in 68 studies) from the literature and 6 cases identified in our registry. A total of 124 patients harboring 339 bAVM nidi were included in the analyses. Differences between syndromic and non-syndromic cases were observed. The logistic regression analyses showed that angiographically occult untreated bAVM was associated (OR 14.37; 95% CI 2.17 to 95.4) with nidal instability after staged treatment, and deep (OR 5.11; 95% CI 1.51 to 17.27) and eloquent (OR 3.91; 95% CI 1.22 to 12.52) locations were associated with residual disease after treatment. Inconsistent reporting of relevant data throughout the included studies undermined the planned analyses. Some prognostic factors were found to be related to the study outcomes. Study Registration: The protocol of the systematic review was registered in PROSPERO as CRD42021245814.

Clinically Approximated Hypoperfused Tissue in Large Vessel Occlusion Stroke.

Background and Purpose: Patient selection for thrombectomy of acute ischemic stroke caused by large vessel occlusion in the delayed time window (>6 hours) is dependent on delineation of clinical-core mismatch or radiological target mismatch using perfusion imaging. Selection paradigms not involving advanced imaging and software processing may reduce time to treatment and broaden eligibility. We aim to develop a conversion factor to approximately determine the volume of hypoperfused tissue using the National Institutes of Health Stroke Scale (NIHSS) score (clinically approximated hypoperfused tissue [CAT] volume) and explore its ability to identify patients eligible for thrombectomy in the late-time window. Methods: We performed a retrospective analysis of anterior circulation large vessel occlusion strokes at 3 comprehensive stroke centers. Demographic, clinical, and imaging (computed tomography perfusion processed using RAPID, IschemaView) information was analyzed. A conversion factor, which is a multiple of the NIHSS score (for NIHSS score <10 and ≥10), was derived from an initial cohort to calculate CAT volumes. Accuracy of CAT-based thrombectomy eligibility criteria (using CAT volume instead of Tmax >6 seconds volume) was tested using DEFUSE-3 criteria (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke 3) eligibility as a gold standard in an independent cohort. Results: Of the 309 large vessel occlusion strokes (age, 70±14, 46% male, median NIHSS 16 [12­20]) included in this study, 38% of patients arrived beyond 6 hours of time from last known well. Conversion factors derived (derivation cohort-center A: 187) based on median values of Tmax>6 second volume for NIHSS score <10 subgroup was 15 and for NIHSS score ≥10 subgroup was 6. Subsequently calculated CAT volume­based eligibility criteria yielded a sensitivity of 100% and specificity of 92% in detecting DEFUSE-3 eligible patients (area under the curve, 0.92 [95% CI, 0.82­1]) in the validation cohort (center B and C:122). Conclusions: Clinical severity of stroke (NIHSS score) may be used to calculate the volume of hypoperfused tissue during large vessel occlusion stroke. CAT volumes for NIHSS score <10 (using a factor of 15) and ≥10 (using a factor of 6) subgroups can accurately identify DEFUSE-3-eligible patients.

Neuroemergencies in South America: How to Fill in the Gaps?

South America is a subcontinent with 393 million inhabitants with widely distinct countries and diverse ethnicities, cultures, political and societal organizations. The epidemiological transition that accompanied the technological and demographic evolution is happening in South America and leading to a rise in the incidence of neurodegenerative and cardiovascular diseases that now coexist with the still high burden of infectious diseases. South America is also quite heterogeneous regarding the existence of systems of care for the various neurological emergencies, with some countries having well-organized systems for some diseases, while others have no plan of action for the care of patients with acute neurological symptoms. In this article, we discuss the existing systems of care in different countries of South America for the treatment of neurological emergencies, mainly stroke, status epilepticus, and traumatic brain injury. We also will address existing gaps between the current systems and recommendations from the literature to improve the management of such emergencies, as well as strategies on how to solve these disparities.

Angiographic Features of Intracranial Aneurysms in Ecuador.

BACKGROUND: Most of the literature describing morphological features of intracranial aneurysms (IAs) is from North-America, East-Asia, and Europe. There is limited data from South-America. We describe the epidemiologic and angiographic features of ruptured and unruptured IAs in a cohort of patients from Ecuador. METHODS: We conducted a retrospective analysis of prospectively acquired databases from 3 different tertiary hospitals over a 3-year period (2014-2017). In a per-patient basis, odd ratios (ORs) of ruptured presentation for each variable using a univariate logistic regression model were calculated. An aneurysm-based multivariate analysis was performed to calculate rupture ORs for each variable. RESULTS: Our sample included 557 patients with 761 IAs. Mean patient age was 52.2 years (range 18-82). Sixty-eight percent were women, and almost 90% presented with ruptured aneurysms and concomitant subarachnoid hemorrhage (SAH). Mean size of all the IAs was 6.4 mm ± 3.98 mm. Most IAs were located in anterior circulation (96.6%): 28.4% medial cerebral artery, 24.4% anterior cerebral artery or anterior communicating artery (ACOM), and 23.5% posterior communicating artery (PCOM). Only 6 basilar tip aneurysms (0.8%) were reported. In the adjusted analysis, aneurysms located in the ACOM (OR 1.89, 95% CI 1.29-2.78) and PCOM (OR 1.84, 95% CI 1.25-2.71), size larger than 5 mm (OR 2.84, 95% CI 2.04-3.93) and 7 mm (OR 2.28, 95% CI 1.64-3.19), and those with non-saccular morphology (OR 9.87, 95% CI 2.21-44.14) were significantly associated with ruptured presentation. CONCLUSIONS: The prevalence of posterior circulation IAs in Ecuador, particularly basilar tip aneurysms, is low when compared to previous reports from developed countries. In our sample, IAs greater than 5 mm (and ≥7 mm) in size, ACOM and PCOM locations, and IAs with nonsaccular morphologies (blister and fusiform) were significantly associated with SAH presentation.

Endovascular treatment of PICA aneurysms with a Low-profile Visualized Intraluminal Support (LVIS Jr) device.

OBJECTIVE: To describe the treatment of posterior inferior cerebellar artery (PICA) aneurysms with the Low-profile Visualized Intraluminal Support Device (LVIS Jr) stent. MATERIALS AND METHODS: The databases of three institutions were retrospectively reviewed. Patients who underwent endovascular treatment of PICA aneurysms using a reconstructive technique where the LVIS Jr stent was totally or partially deployed into the PICA were included in the analysis. Clinical presentation, aneurysm and PICA sizes, procedural complications, and clinical and angiographic follow-up information was recorded and analyzed. RESULTS: Seven patients who underwent endovascular treatment of PICA aneurysms with an LVIS Jr stent were identified. Four aneurysms were treated in the acute phase of subarachnoid hemorrhage (SAH). There were no symptomatic complications. One patient had spasm distal to the stent as a result of mechanical straightening of the vessel. One patient was treated in the acute phase of SAH and required a gycoprotein IIb/IIIa inhibitor after the stent was implanted. This patient needed to be re-treated to complete embolization. All patients had good clinical outcomes (Glasgow Outcome Scale 5). No in-stent stenosis or occlusion was seen on short-term angiographic follow-up and the aneurysms were occluded. CONCLUSIONS: This small series suggests that the use of a reconstructive technique with the LVIS Jr stent for the treatment of PICA aneurysms is feasible, safe and effective in the short term.