Tenecteplase versus alteplase before mechanical thrombectomy: experience from a US healthcare system undergoing a system-wide transition of primary thrombolytic.

BACKGROUND: Tenecteplase (TNK) is a genetically modified variant of alteplase (TPA) and has been established as a non-inferior alternative to TPA in acute ischemic stroke (AIS). Whether TNK exerts distinct benefits in large vessel occlusion (LVO) AIS is still being investigated. OBJECTIVE: To describe our first-year experience after a healthcare system-wide transition from TPA to TNK as the primary thrombolytic. METHODS: Patients with AIS who received intravenous thrombolytics between January 2020 and August 2022 were retrospectively reviewed. All patients with LVO considered for mechanical thrombectomy (MT) were included in this analysis. Spontaneous recanalization (SR) after TNK/TPA was a composite variable of reperfusion >50% of the target vessel territory on cerebral angiography or rapid, significant neurological recovery averting MT. Propensity score matching (PSM) was performed to compare SR rates between TNK and TPA. RESULTS: A total of 148 patients were identified; 51/148 (34.5%) received TNK and 97/148 (65.5%) TPA. The middle cerebral arteries M1 (60.8%) and M2 (29.7%) were the most frequent occlusion sites. Baseline demographics were comparable between TNK and TPA groups. Spontaneous recanalization was significantly more frequently observed in the TNK than in the TPA groups (unmatched: 23.5% vs 10.3%, P=0.032). PSM substantiated the observed SR rates (20% vs 10%). Symptomatic intracranial hemorrhage, 90-day mortality, and functional outcomes were similar. CONCLUSIONS: The preliminary experience from a real-world setting demonstrates the effectiveness and safety of TNK before MT. The higher spontaneous recanalization rates with TNK are striking. Additional studies are required to investigate whether TNK is superior to TPA in LVO AIS.

Perioperative Continuous Noninvasive Arterial Pressure Monitoring for Neuroendovascular Interventions: Prospective Study for Evaluation of the Vascular Unloading Technique.

BACKGROUND: Blood pressure monitoring is crucial during neuroendovascular procedures. Intraoperative hemodynamic instability is associated with complications, which underscores the importance of continuous monitoring. Although direct measurement with an intra-arterial catheter is the gold standard for determining arterial pressure, it is costly, time-consuming, and associated with complications. The novel ClearSight system offers a noninvasive technique for monitoring arterial pressure via a finger cuff. This study compared noninvasive arterial pressure measurements with the gold standard method. METHODS: Simultaneous recording of noninvasive and invasive arterial pressure was performed in patients undergoing neuroendovascular interventions. Both techniques were compared employing linear regression, Lin's correlation coefficient, Bland-Altman, and error grid analysis. RESULTS: The study enrolled 24 consecutive patients. The concordance correlation coefficient between both methods was 0.3526 (95% confidence interval [0.3134, 0.3906]) for mean arterial pressure and 0.4680 (95% confidence interval [0.4353, 0.4995]) and for systolic arterial pressure. The mean (SD) of the differences was 0.81 (17.86) mm Hg (95% limits of agreement [-52.52, 54.14]) for mean arterial pressure and 5.38 (14.64) mm Hg (95% limits of agreement [-45.12, 56.08]) for systolic arterial pressure. Error grid analysis demonstrated that the majority of measurements lie in regions with no or low risk for patients (mean arterial pressure, 71.0% and 24.4%; systolic arterial pressure, 59.2% and 25.8%). CONCLUSIONS: The ClearSight system provided accurate measurements of arterial blood pressure compared with invasive methods and within safe clinical parameters. This method may serve as a safe and reliable alternative for invasive blood pressure monitoring during neuroendovascular procedures.

Comparison of PED and FRED flow diverters for posterior circulation aneurysms: a propensity score matched cohort study.

BACKGROUND: Flow diversion is a common endovascular treatment for cerebral aneurysms, but studies comparing different types of flow diverters are scarce. OBJECTIVE: To perform a propensity score matched cohort study comparing the Pipeline Embolization Device (PED) and Flow Redirection Intraluminal Device (FRED) for posterior circulation aneurysms. METHODS: Consecutive aneurysms of the posterior circulation treated at 25 neurovascular centers with either PED or FRED were collected. Propensity score matching was used to control for age, duration of follow-up imaging, adjunctive coiling, and aneurysm location, size, and morphology; previously ruptured aneurysms were excluded. The two devices were compared for the following outcomes: procedural complications, aneurysm occlusion, and functional outcome. RESULTS: A total of 375 aneurysms of the posterior circulation were treated in 369 patients. The PED was used in 285 (77.2%) and FRED in 84 (22.8%) procedures. Aneurysms treated with the PED were more commonly fusiform and larger than those treated with FRED. To account for these important differences, propensity score matching was performed resulting in 33 PED and FRED unruptured aneurysm pairs. No differences were found in occlusion status and neurologic thromboembolic or hemorrhagic complications between the two devices. The proportion of patients with favorable functional outcome was higher with FRED (100% vs 87.9%, p=0.04). CONCLUSION: Comparative analysis of PED and FRED for the treatment of unruptured posterior circulation aneurysms did not identify significant differences in aneurysm occlusion or neurologic complications. Variations in functional outcomes warrant additional investigations.

Experience With the Pipeline Embolization Device for Posterior Circulations Aneurysms: A Multicenter Cohort Study.

BACKGROUND: The Pipeline Embolization Device (PED; Medtronic) has been used off-label for the treatment of challenging posterior circulation aneurysms. Data on this modality are primarily limited to small retrospective single-center series. OBJECTIVE: To assess safety and efficacy of this treatment by establishing an international, multicenter collaboration. METHODS: Consecutive posterior circulation aneurysms treated with the PED from 2012 to 2019 across 11 neurovascular centers were retrospectively reviewed. Baseline demographics, aneurysm and treatment characteristics, complications, occlusion status, and functional outcome were assessed. RESULTS: There were 149 posterior circulation aneurysms treated with PED in 146 patients. A total of 24 (16.4%) patients presented with subarachnoid hemorrhage. Most aneurysms were dissecting/blister (36.2%) in morphology, followed by saccular (35.6%) and fusiform (28.2%). The most common locations were the vertebral (51.7%) and basilar arteries (22.8%). Complete or near-complete occlusion (>90%) was achieved in 90.9% of aneurysms at a median follow-up of 12 mo. Dissecting/blister aneurysms were most likely to occlude (P = .06). Symptomatic neurologic complications occurred in 9.4% of aneurysms, associated with larger size, ruptured presentation, presentations with brain stem compression, cranial nerve palsy, or stroke. Favorable functional outcome (modified Rankin Score 0-2) was achieved in 86.2% of patients. There were 6 fatalities of which 4 occurred in aneurysmal subarachnoid hemorrhage patients. CONCLUSION: This multicenter study shows that PED for the treatment of posterior circulation is preferentially used for the treatment of fusiform and dissecting/blister aneurysm morphologies. Despite the challenges presented by these less-common morphologies, flow diversion may be performed with a neurologic complication rate of about 10% and favorable long-term aneurysm occlusion rates.

Intraoperative 3-Dimensional Rotational Angiography in Cerebrovascular Surgery: A Case Series.

OBJECTIVE: Intraoperative imaging is critical in cerebrovascular surgery to assess the technical success of the operation. This case series aimed to evaluate the safety and efficacy of 3-dimensional rotational angiogram (3D-RA) in addition to 2-dimensional intraoperative angiography (2D-IOA) during cerebrovascular surgery in the hybrid operating room. METHODS: All consecutive patients who underwent open cerebrovascular surgery and intraoperative 2D-IOA with 3D-RA in a hybrid operating room at 2 academic centers between August 2018 and December 2019 were identified from a prospectively maintained institutional database. Medical charts and operative videos including intraoperative angiography were reviewed, and clinical and angiographic outcomes assessed. RESULTS: A total of 40 cerebrovascular surgeries in 39 patients (mean age, 53 ± 13 years; 51% female) were carried out with the addition of 3D-RA to 2D-IOA in the hybrid operating room. After 3D-RA in addition to 2D-IOA, 1 (2.5%) surgical alteration occurred in an aneurysm clipping. Other procedures were not altered with the addition of 3D-RA to 2D-IOA. There were no complications from the addition of 3D-RA to 2D-IOA. CONCLUSIONS: Using a combination of 3D-RA and 2D-IOA in the hybrid operating room may enhance the likelihood of achieving an optimal result when employing microsurgical cerebrovascular surgery and avoid unanticipated incomplete outcomes, complications, and returns to the operating room. Whereas the addition of 3D-RA elucidated residual aneurysm not otherwise visualized on the 2D-IOA, in other cerebrovascular procedures studied, there was no additional value of the 3D-RA over the 2D-IOA.

Pharmacy-Mediated Antiplatelet Management Protocol Compared to One-time Platelet Function Testing Prior to Pipeline Embolization of Cerebral Aneurysms: A Propensity Score-Matched Cohort Study.

BACKGROUND: There is ongoing controversy regarding the optimal antiplatelet regimen, and extent or even need for platelet function testing surrounding Pipeline flow diverter (Medtronic Inc, Dublin, Ireland) embolization of cerebral aneurysms. OBJECTIVE: To compare a unique pharmacy-mediated antiplatelet medication management protocol to a 1-time platelet function testing strategy prior to Pipeline placement. METHODS: A retrospective review of patients with cerebral aneurysms who underwent Pipeline embolization at 2 academic institutions was performed. The first line antiplatelet regimen consisted of aspirin and clopidogrel at both institutions. At institution A, the pharmacy-mediated antiplatelet medication management protocol consisted of repeat platelet function testing using VerifyNow (Accriva Diagnostics, San Diego, California), and dosing adjustments prior to and after Pipeline placement. At institution B, a 1-time platelet function test using light transmission aggregometry was obtained prior to Pipeline placement. Both strategies were compared using propensity score matching. RESULTS: A total of 63 and 165 Pipeline embolization procedures were performed at institutions A and B, respectively. Baseline characteristics differed in aneurysm location and aneurysm maximal diameter. Propensity score matching resulted in 25 matched pairs and demonstrated that the number of procedures in which the patient was switched to an alternative platelet agent was significantly smaller at institution A. There were no differences between the sites with regard to aneurysm occlusion rate, the incidence of thromboembolic and hemorrhagic complications, and modified Rankin scale at last follow-up after propensity score matching. CONCLUSION: Pharmacy-mediated antiplatelet management using VerifyNow is a safe and efficacious alternative to a more traditional approach, and significantly reduces the need to utilize other, potentially more expensive antiplatelet agents.

Pipeline Embolization Device with Shield Technology for Intracranial Aneurysms: An Initial U.S. Experience.

BACKGROUND: Thromboembolic complications remain a major reason for morbidity and mortality after flow diversion, in addition to hemorrhagic complications not limited to the brain predicated on the prolonged need for dual antiplatelet therapy. Surface modification to decrease thrombogenicity and accelerate aneurysm occlusion is a promising alteration to mitigate those risks. The Pipeline embolization device with Shield Technology possesses such characteristics; however, it has not yet been approved in the United States. CASE DESCRIPTION: We present the case of a 38-year-old woman with a Spetzler-Martin grade 4 left parietal arteriovenous malformation with a total of 8 feeding vessel aneurysms and recent rupture of 1 of those aneurysms that was treated with balloon-assisted coil embolization. Four M1-segment middle cerebral artery aneurysms and 1 supraclinoid internal carotid artery aneurysm were treated with 2 Pipeline embolization Shield devices after a compassionate use request was approved. At 3 weeks after the procedure, the patient experienced a minor ischemic stroke after having missed the prescribed dual antiplatelet therapy. At the 3-month follow-up examination, the patient was neurologically intact and all the aneurysms were occluded. Dual antiplatelet therapy was discontinued. CONCLUSIONS: Flow diverters with surface modification to decrease thrombogenicity and accelerate aneurysm occlusion are promising endovascular tools for patients at high risk of complications with dual antiplatelet therapy. The present case represents one of the first cases performed in the United States using such a device. Despite the favorable outcome in the present case, the question of whether such technology obviates the need for dual antiplatelet therapy remains to be determined.

Lateral Medullary Ischemic Infarct Caused by Posterior Inferior Cerebellar Artery Aneurysm.

Posterior inferior cerebellar artery (PICA) aneurysms are rare. The most common complication of intracranial aneurysms is rupture causing subarachnoid hemorrhage. Ischemic infarct, although more common in giant thrombosed aneurysms, is a very rare manifestation of small intracranial aneurysms. Here we describe a patient who presented with lateral medullary acute infarction associated with an ipsilateral, small (4 × 3.5 mm), unruptured and non-thrombosed PICA aneurysm.