Intraoperative angiography in neurosurgery: temporal trend, access site, and operative indication considerations from a 6-year institutional experience.

BACKGROUND: Historically, the transfemoral approach (TFA) has been the most common access site for cerebral intraoperative angiography (IOA). However, in line with trends in cardiac interventional vascular access preferences, the transradial approach (TRA) and transulnar approach (TUA) have been gaining popularity owing to favorable safety and patient satisfaction outcomes. OBJECTIVE: To compare the efficacy and safety of TRA/TUA and TFA for cerebral and spinal IOA at an institutional level over a 6-year period. METHODS: Between July 2016 and December 2022, 317 angiograms were included in our analysis, comprising 60 TRA, 10 TUA, 243 TFA, and 4 transpopliteal approach cases. Fluoroscopy time, contrast dose, reference air kerma, and dose-area products per target vessel catheterized were primary endpoints. Multivariate regression analyses were conducted to evaluate predictors of elevated contrast dose and radiation exposure and to assess time trends in access site selection. RESULTS: Contrast dose and radiation exposure metrics per vessel catheterized were not significantly different between access site groups when controlling for patient position, operative region, 3D rotational angiography use, and different operators. Access site was not a significant independent predictor of elevated radiation exposure or contrast dose. There was a significant relationship between case number and operative indication over the study period (P<0.001), with a decrease in the proportion of cases for aneurysm treatment offset by increases in total cases for the management of arteriovenous malformation, AVF, and moyamoya disease. CONCLUSIONS: TRA and TUA are safe and effective access site options for neurointerventional procedures that are increasingly used for IOA.

Feasibility and safety of transradial intraoperative angiography for neurosurgery: An institutional experience.

BACKGROUND: Transradial approach for neuroangiography is becoming increasingly popular because of the advantages demonstrated by interventional cardiology. Many advantages of radial access could be applied to intraoperative angiography. OBJECTIVE: To report our institutional experience with transradial and transulnar intraoperative angiography, and evaluate its safety and feasibility. METHODS: Intraoperative angiography through upper extremity vessels was attempted in 70 consecutive patients between April 2019 and December 2022. Data on patient characteristics and surgical indications, procedural variables, and complications were collected. RESULTS: Of the 70 patients who underwent intraoperative angiography, 58.6% were female, and the mean age was 52.9 ± 14.0 years. The reason for surgery was aneurysm clipping in 42 (60.0%) cases. In total, 55 patients (78.6%) were positioned supine, 13 (18.6%) prone, and two (2.9%) were positioned three-quarters prone. Access was attempted via the radial artery in 60 (85.7%) patients and the ulnar artery in 10 (14.3%) patients. The procedure was successful in 69 of 70 cases (98.6%), as one required conversion to transfemoral approach due to significant spasm in the proximal right radial artery. The median fluoroscopy time was 8 min. No procedure was aborted, and no patient experienced access-site or angiography-related complications. Intraoperative angiography altered the surgical management in 3 (4.3%) cases. Re-access for follow-up angiography was unsuccessful in three (13.6%) of 22 due to radial artery occlusion. CONCLUSIONS: Our institutional experience supports that transradial and transulnar intraoperative angiography is safe and feasible during neurovascular procedures for various indications and positions.

The impact of Verapamil for radial access in diagnostic cerebrovascular angiograms: A retrospective case-control study.

INTRODUCTION: Different combinations of medications are utilized during wrist access for radial artery (RA) or ulnar artery (UA) catheterization in neuroendovascular procedures to preclude vasospasm. These "cocktails" commonly include the calcium channel blocker Verapamil, without established benefit. We analyze outcomes in patients with and without Verapamil in their "cocktail" by using a case-control cohort of our single-center experience. METHODS: A prospective log of consecutive patients who underwent diagnostic cerebral angiograms using RA/UA access was retrospectively reviewed, and patients were grouped into Verapamil and non-Verapamil cohorts. The primary outcomes assessed were the presence of forearm skin rashes (hives) and RA/UA spasms. Our initial management included Verapamil (5 mg) in the cocktail, but Verapamil was removed after we noticed the development of hives in multiple patients immediately following its injection. RESULTS: A total of 221 patients underwent 241 RA/UA diagnostic cerebral angiograms and were included in our analysis. One hundred and forty-nine patients (61.8%) underwent catheterization with Verapamil and 92 (38.2%) were catheterized without it. Four of the 149 patients in the Verapamil group (2.7%) developed hives during the procedure and were treated with Benadryl (25 mg). Of the 92 patients who did not receive Verapamil, there were zero (0%) cases of hives and one (1.1%) case of vasospasm. CONCLUSION: Verapamil in the "cocktail" for wrist access diagnostic cerebral angiograms was associated with periprocedural hives, but not associated with a significant reduction in spasm compared to the non-Verapamil group. Our findings suggest that the administration of prophylactic Verapamil for these procedures may not be necessary.

Dexamethasone and Statins in Patients Undergoing Primary Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: A Propensity-Matched Study in the TriNetX Research Network.

OBJECTIVE: Middle meningeal artery embolization (MMAE) is an effective minimally invasive option for chronic subdural hematoma (cSDH). Dexamethasone and statins have been reported to improve the resolution of cSDH and reduce its recurrence. However, only 1 study has investigated the role of statins in patients treated with MMAE, and there is no such study on dexamethasone. Thus, we used the TriNetX research network to determine whether adding dexamethasone or statin along with primary MMAE is associated with a benefit in outcomes. METHODS: We queried all primary MMAE cases for cSDH between January 1st, 2012, and July 1st, 2022, in the TriNetX research network. We included patients greater than or equal to 18 years old and separated them regarding statin and dexamethasone use around the time of MMAE. Outcomes were evaluated within 6 months and 3 years after MMAE, and analyses were performed before and after propensity score matching. RESULTS: The study included 372 patients with chronic subdural hematoma who underwent MMAE and were on dexamethasone, 339 not on dexamethasone, 391 on statins, and 278 not on statins. After propensity score matching, the dexamethasone cohorts included 250 patients each and only headache remained more prevalent in the dexamethasone cohort at both 6 months (21.2% vs. 10.0%, P = 0.001) and 3 years (23.6% vs. 12.4%, P = 0.001). After propensity score matching, the statin cohorts included 150 patients each and no differences in outcomes were found at both 6 months and 3 months after MMAE. CONCLUSIONS: Patients treated with primary MMAE and were on dexamethasone or statins had no differences in mortality and functional/provider dependence compared to those who were not on dexamethasone or statins. Patients on dexamethasone had a higher prevalence of headaches.