Aspiration tubing diameter is a key determinant of vacuum pressure and is associated with procedural outcome in mechanical thrombectomy for large vessel occlusion: An experimental and cohort study.

BACKGROUND: We (1) evaluated the effect of aspiration tubing diameter on intraluminal pressure and (2) compared thrombectomy outcomes in patients treated using small diameter tubing versus those treated using large diameter vacuum tubing. METHODS: Intraluminal negative pressure was measured in a validated benchtop set up where consistency of negative pressure (inHg) was measured between static and dynamic aspiration. Static aspiration refers to activation of vacuum once the catheter is engaged with the clot. Dynamic aspiration refers to activation of vacuum when the catheter is slightly proximal to the clot. Four different sizes of vacuum tubing were trialed. We performed a retrospective analysis of consecutive patients who underwent mechanical thrombectomy. Procedural and functional outcomes were compared. RESULTS: The large diameter aspiration tubing held a consistent high negative pressure in static and dynamic aspiration (p = 0.152). Tubing types I to III were associated with a significant fall off in negative pressure between static and dynamic technique (p < 0.05). Two-hundred and five patients were included in the retrospective analysis; 124 (60%) underwent thrombectomy using small diameter vacuum tubing, and 81 (40%) using the large tubing. Mean thrombectomy time was shorter with the larger tubing [25.9 (17.9) minutes] versus the small tubing [37.5 (28.5) minutes, p = 0.002]. A greater proportion of patients had a thrombolysis in cerebral infarction score ≥2b in the group treated using the large tubing (78, 99%) than those with the small tubing (96, 78%, p < 0.001). CONCLUSION: Vacuum tubing diameter is linearly associated with intraluminal aspiration pressure. These findings have clinical significance as shown by increased recanalization rates and decreased thrombectomy times when large-diameter aspiration tubing is used. Shifting the paradigm toward a flow-based technique using large-bore vacuum tubing ought to be considered.

Transradial versus transfemoral access for mechanical thrombectomy in acute ischemic stroke: A retrospective cohort study.

BACKGROUND: The objective of this study was to compare procedural and clinical outcomes in patients with acute ischemic stroke (AIS) treated via transradial access (TRA) mechanical thrombectomy (MT) versus conventional transfemoral access (TFA). METHODS: We performed a retrospective analysis of consecutive patients with AIS treated with TRA versus TFA MT at our tertiary comprehensive stroke center. Access choice was individualized based on occlusion site, aortic and arch anatomy. Outcomes were extracted from our institutional stroke registry and included procedural time, Thrombolysis in Cerebral Infarction (TICI) reperfusion score, NIHSS, 90-day mRS and 90-day mortality. Comparisons were performed using Student t-Test and Fischer's exact test as appropriate. RESULTS: 175 mechanical thrombectomies were performed during the study interval; 39 (22%) were performed via TRA and 136 (79%) TFA. Access to reperfusion time was 36.3 ± 24.5 minutes in the TRA group and 21.9 ± 17.6 in the TFA group (p<0.001). The proportion of patients with a TICI reperfusion score of 2b or 3 was similar in both groups (TRA: 34 (87%) vs. TFA: 121 (89%) p=0.559. The median 90-day mRS was similar between both groups (p=0.170), as was the 90-day mortality (p = 0.509). CONCLUSIONS: While TFA is faster in our cohort, TFA and TRA are both safe and effective for MT in acute ischemic stroke. While TFA remains mainstay, TRA can be valuable in variant anatomy despite its technical limitations. Individualizing access based on advanced imaging and patient factors may improve practice; however, updates in catheter and access technology are necessary to optimize outcomes with TRA.

Push and Fluff technique for optimization of clot integration with stent-retriever: An in vitro model.

BACKGROUND: For stent-retriever (SR) thrombectomy, technical developments such as the Push and Fluff technique (PFT) appear to have a significant impact on procedural success. This study aimed to (1) quantify the enhancement in clot traction when using PFT as compared to the standard unsheathing technique (SUT) and (2) to evaluate the performance of PFT in new versus established users of the technique. METHODS: Operators were divided between established PFT and SUT users. Each experiment was labeled according to the SR size, utilized technique, and operator experience. A three-dimensional-printed chamber with a clot simulant was used. After each retriever deployment, the SR wire was connected to a force gauge. Tension was applied by pulling the gauge until clot disengagement. The maximal force was recorded. RESULTS: A total of 167 experiments were performed. The median overall force to disengage the clot was 1.11 pounds for PFT and 0.70 pounds for SUT (an overall 59.1% increment with PFT; p < 0.001). The PFT effect was consistent across different retriever sizes (69% enhancement with the 3 × 32mm device, 52% with the 4 × 28mm, 65% with the 4 × 41mm, 47% with the 6 × 37mm). The ratio of tension required for clot disengagement with PFT versus SUT was comparable between physicians who were PFT versus SUT operators (1.595 [0.844] vs. 1.448 [1.021]; p: 0.424). The PFT/SUT traction ratio remained consistent from passes 1 to 4 of each technique in SUT users. CONCLUSION: PFT led to reproduceable improvement in clot engagement with an average ∼60% increase in clot traction in this model and was found not to have a significant learning curve.

Laser Interstitial Thermal Therapy for the Treatment of a Pineal Region Glioma Through an Infratentorial Approach: A Case Report.

Laser interstitial thermal therapy (LITT) is a minimally invasive surgical option for the treatment of brain tumors introduced in 1983. The innovative technique was welcomed for its ability to access deep-seated supratentorial and posterior cranial fossa lesions. Surgical approaches to pineal region tumors are challenging and require a high degree of precision since the critical vasculature, such as the vein of Galen and precentral vein, in the area pose significant anatomical challenges to operating surgeons. To minimize the risk of damaging this key venous anatomy, an infratentorial approach may be more advantageous. We present a case where LITT was utilized through an infratentorial approach to a pineal region tumor. A 62-year-old male with no significant past medical history presented to his primary care physician complaining of ataxia and headaches for the past four weeks. An MRI was concerning for multicentric glioma within the cerebellar hemispheres, brainstem extending to the middle cerebellar peduncle, upper cervical spinal cord, and pineal region. An enhancing lesion of the midbrain tectum was concerning for a high-grade tumor. We decided to proceed with stereotactic biopsy and magnetic resonance-guided LITT via an infratentorial approach. Supratentorial trajectory planning did not allow for a safe corridor due to the venous anatomy; thus, it was decided to proceed with an infratentorial approach. The patient was positioned prone, had his bone fiducial CT fused with MRI, and the tumor was targeted using robotic guidance (ROSA, Zimmer Biomet, Warsaw, Indiana). Postoperatively, he suffered from transient diplopia due to cranial nerve VI palsy. Additionally, the postoperative MRI revealed a decrease in the size of the enhancing lesion and the hyperintense T2 signal within the brainstem. Open surgical approaches to tumors within the pineal region often pose an anatomic and neurovascular challenge. We describe the safe utilization of a novel, previously unreported infratentorial approach utilizing LITT with promising treatment, morbidity, and efficacy outcomes. A larger series will be necessary to ensure the safety and efficacy of this approach.

Radial Access Intervention.

Leveraging from the interventional cardiology experience, the transradial access (TRA) for neurointervention has also started to become more used for both diagnostic and therapeutic procedures. A growing body of evidence is showing a superiority of the TRA compared with the conventional transfemoral access (TFA) in terms of access site complications (ACSs), patient satisfaction and preference, hospital length of stay, and cost. Outcomes via the transradial are noninferior, and at times superior, in select neuroendovascular procedures. Future advancements in technology with radial-specific catheters and further operator experience will aid in the full adoption of the TRA for endovascular procedures.

Combined Decompressive Hemicraniectomy and Port-Based Minimally Invasive Parafascicular Surgery for the Treatment of Subcortical Intracerebral Hemorrhage: Case Series, Technical Note, and Review of Literature.

BACKGROUND: Intracerebral hemorrhage (ICH) is a neurosurgical emergency. Combined decompressive hemicraniectomy (DHC) and minimally invasive parafascicular surgery (MIPS) may provide a practical method of managing subcortical ICH. OBJECTIVE: 1) To present a case series of combined DHC-MIPS for the treatment of subcortical-based ICH; 2) to describe technical nuances of DHC-MIPS; and 3) to provide a literature overview of MIPS for ICH. METHODS: The following inclusion criteria were used: 1) Glasgow Coma Scale (GCS) score <3-4; 2) admission within 6 hours of onset; 3) increased intracranial pressure caused by hemorrhage; 4) patient unresponsive to medical management; 5) hemorrhage >30 cm3; 6) subcortical location; and 7) midline shift (mm). Before DHC, sulcal cannulation used the following coordinates: intersection of tragus-frontal bone and midpoint of midpupillary line and midline; coronal suture: 3-4 cm posterior to this point). RESULTS: Three patients were selected: a 62-year old woman, a 45-year old woman, and a 36-year-old man. GCS and ICH scores on admission were 7 and 3, 3 and 4, and 3 and 4, respectively. ICH was located in left basal ganglia in patients 1 and 3 and right basal ganglia in patient 2, all with intraventricular extension. ICH volume was 81.7, 68.2, and 42.3 cm3, respectively. The postoperative GCS score was 11, 10, and 6, respectively. There were no intraoperative complications or mortalities. Evacuation was within 15 minutes in all patients. The modified Rankin Scale score was 3, 4, and 5, respectively, with semi-independence in case 1. CONCLUSIONS: Combined DHC-MIPS, with the use of craniometric points, can provide a unique and simple surgical option for the management of subcortical ICH.

Mechanical Thrombectomy for Acute Stroke: Early versus Late Time Window Outcomes.

BACKGROUND AND PURPOSE: Recent trials have shown benefit of thrombectomy in patients selected by penumbral imaging in the late (>6 hours) window. However, the role penumbral imaging is not clear in the early (0-6 hours) window. We sought to evaluate if time to treatment modifies the effect of endovascular reperfusion in stroke patients with evidence of salvageable tissue on CT perfusion (CTP). METHODS: We retrospectively analyzed consecutive patients who underwent thrombectomy in a single center. Demographics, comorbidities, National Institute of Health Stroke Scale (NIHSS), rtPA administration, ASPECTS, core infarct volume, onset to skin puncture time, recanalization (mTICI IIb/III), final infarct volume were compared between patients with good and poor 90-day outcomes (mRS 0-2 vs. 3-6). Multivariable logistic regression analyses were used to identify independent predictors of a good (mRS 0-2) 90-day outcome. RESULTS: A total of 235 patients were studied, out of which 52.3% were female. Univariate analysis showed that the groups (early vs. late) were balanced for age (P = .23), NIHSS (P = .63), vessel occlusion location (P = .78), initial core infarct volume (P = .15), and recanalization (mTICI IIb/III) rates (P = .22). Favorable outcome (mRS 0-2) at 90 days (P = .30) were similar. There was a significant difference in final infarct volume (P = .04). Shift analysis did not reveal any significant difference in 90-day outcome (P = .14). After adjustment; age (P < .001), NIHSS (P = .01), recanalization (P = .008), and final infarct volume (P < .001) were predictive of favorable outcome. CONCLUSIONS: Penumbral imaging-based selection of patients for thrombectomy is effective regardless of onset time and yields similar functional outcomes in early and late window patients.

Giant carotid pseudoaneurysm amenable to pipeline stenting in a patient with Ehlers-Danlos type IV.

BACKGROUND: Ehlers-Danlos type IV primarily affects collagen synthesis in the vasculature, increasing the risk of these patients to have dissection and pseudoaneurysm formation. Due to friable vessels, antiplatelet or anticoagulation has been the treatment of choice. However, newer intravascular surgical devices may be promising for future management. CASE DESCRIPTION: A 24-year-old man with a history of Ehlers-Danlos type IV with multiple vascular and bleeding complications presented after recurrent, unprovoked presyncopal episodes. Patient was found to have dissection of bilateral internal carotid arteries (ICA) and right vertebral artery. Left ICA pseudoaneurysm was found in the proximal cervical segment. Patient was stabilized as an inpatient and discharged with outpatient follow-up with neurointerventional surgery. Follow-up imaging showed growth of the left ICA aneurysm. Patient elected to have pipeline stenting of the left ICA pseudoaneurysm. The procedure was performed without complication. Patient was discharged on dual antiplatelet therapy. At 7-month follow-up appointment, patient noted no neurological deficits. Follow-up digital subtraction angiogram at 7 months documented near-complete resolution of the pseudoaneurysm secondary to pipeline stenting. CONCLUSION: Pipeline stent implantation may be a viable corrective surgical option for patients with connective tissue disorders (specifically Ehlers-Danlos type IV) who present with pseudoaneurysm formation.

The Role of CT Perfusion in Defining the Clinically Relevant Core Infarction to Guide Thrombectomy Selection in Patients with Acute Stroke.

BACKGROUND AND PURPOSE: Infarct core assessment on presentation is important to evaluate salvageable tissue to select patients for thrombectomy. Our study aims to evaluate the correlation between infarct core volume measured by computed tomography (CT) perfusion (CTP) and magnetic resonance diffusion-weighted imaging (MR-DWI) in patients with acute large-vessel occlusion. METHODS: We studied patients who underwent CTP on presentation to the emergency department for stroke symptoms. National Institute of Health Stroke Scale (NIHSS), collateral status, symptomatic vessels, and modified Rankin scale (mRS) at 90 days were collected. Admission infarct core volume was measured on initial relative cerebral blood volume and final infarct core volume on follow-up DWI. The correlation between two measures was assessed using Pearson's correlation coefficient. RESULTS: Seventy-four patients were studied of which 41.9% were female. Median NIHSS was 13 (2-30). Middle cerebral artery occlusion was present in 53 (71.6%) patients and 54 (72.9%) had good collaterals. Good functional outcome of mRS 0-2 was achieved by 60.8% at 90 days. There was a strong correlation between CTP and MR-DWI (r = .94). There was no significant difference between volume (in milliliters) on CTP (54.1 ± 69.8) and volume on DWI (50.3 ± 59.7; P = .18) using the paired t-test. CONCLUSION: CTP provides a good estimation of the core infarct volume. It performs well within the clinically relevant thresholds for patient selection for thrombectomy.

Endovascular Treatment of Complex Distal Posterior Cerebral Artery Aneurysms with the Pipeline Embolization Device.

OBJECTIVE: To assess the safety and efficacy of the Pipeline Embolization Device (PED) for endovascular treatment of complex, distal posterior cerebral artery (PCA) aneurysms. METHODS: We conducted a retrospective review of patients who underwent endovascular treatment of complex PCA aneurysms with PED from November 2012 to December 2015. A total of 4 patients were identified and treated. Twelve-month angiographic and clinical follow-up was available for all patients. RESULTS: Mean aneurysm size (largest diameter) was 10.0 mm, and all aneurysms originated at the P2 segment or beyond. Technical success was achieved in all patients. All patients were treated with a single PED; adjunctive intrasaccular coil was also placed in one patient. All patients achieved a favorable postprocedural outcome (modified Rankin Scale score = 0) with no new neurologic deficits. No patients experienced neurologic complications or perforator infarction, and presenting symptoms resolved in all patients. Follow-up cerebral angiography at 12 months in 3 patients showed complete occlusion (Raymond-Roy Occlusion Classification class 1) and minimal residual aneurysm filling (Raymond-Roy Occlusion Classification class 2) in 1 patient. A small degree of focal stenosis was present in 2 patients within the PED at 12-month follow-up that was associated with mild decrease in flow within the distal PCA branches. CONCLUSIONS: PED use provides a practical and viable treatment option for complex, distal PCA aneurysms. Based on our limited institutional experience, PED use for treatment of complex, distal PCA aneurysms in select patients appears safe and effective.

Spanning from the West to East: An Updated Review on Endovascular Treatment of Intracranial Atherosclerotic Disease.

Ischemic stroke is a major cause of morbidity and mortality, incurring significant cost. Intracranial atherosclerotic disease (ICAD) accounts for 10-15% of ischemic stroke in Western societies, but is an underlying pathology in up to 54% of ischemic strokes in Asian populations. ICAD has largely been treated with medical management, although a few studies have examined outcomes following endovascular treatment. Our objective was to summarize the major trials that have been performed thus far in regard to the endovascular treatment of ICAD and to provide direction for future management of this disease process. Systematic review of the literature from 1966 to 2015, was conducted in regard to intracranial angioplasty and stenting. Studies were analyzed from PubMed, American Heart Association and Society of Neurointerventional Surgery databases. SAMMPRIS and VISSIT are the only randomized controlled trials from which Western guidelines of intracranial stenting have been derived, which have displayed the superiority of medical management. However, pooled reviews of smaller studies and other nonrandomized trials have shown better outcomes with endovascular therapy in select patient subsets, such as intracranial vertebrobasilar stenosis or in the presence of robust collaterals. Suboptimal cases, including longer lesions, bifurcations and significant tortuosity tend to fair better with medical management. Medical management has been shown to be more efficacious with less adverse outcomes than endovascular therapy. However, the majority of studies on endovascular management included a diverse patient population without ideal selection criteria, resulting in higher adverse outcomes. Population analyses and selective utilization of endovascular therapy have shown that the treatment may be superior to other management in select patients.

Endovascular management of fusiform aneurysm of anterior temporal artery: Technical report.

BACKGROUND: The treatment of a rare, nontraumatic, fusiform aneurysm of the anterior temporal artery (ATA) via endovascular techniques is presented, and procedural nuances are highlighted. METHODS: We performed a retrospective chart review and collected demographic and clinical data on the patient presented here; procedural details were extracted from operative notes. RESULTS: Following successful balloon test occlusion (BTO) of the ATA, complete coil embolization of the ATA, and its associated fusiform aneurysm was performed. Postprocedurally, the patient did not suffer any adverse neurological sequelae. CONCLUSION: Selective BTO of intracranial branch vessels is safe, technically feasible, and could serve as a useful technical tool in the treatment of complex, fusiform intracranial aneurysms.

Key determinants of short-term and long-term glioblastoma survival: a 14-year retrospective study of patients from the Hermelin Brain Tumor Center at Henry Ford Hospital.

OBJECTIVE: Glioblastoma (GBM) is a heterogeneous neoplasm with a small percentage of long-term survivors. Despite aggressive surgical resection and advances in radiotherapy and chemotherapy, the median survival for patients with GBM is 12-14 months. Factors associated with a favorable prognosis include young age, high performance status, gross resection >98%, non-eloquent tumor location and O6-methylguanine methyltransferase (MGMT) promoter methylation. We retrospectively analyzed the relationship of clinical, epidemiologic, genetic and molecular characteristics with survival in patients with GBM. METHODS: This retrospective analysis of overall survival looked at the outcomes of 480 patients diagnosed with GBM over 14 years at a single institution. Multivariate analysis was performed examining multiple patient characteristics. RESULTS: Median survival time improved from 11.8 months in patients diagnosed from 1995 to 1999 to 15.9 months in those diagnosed from 2005 to 2008. Factors associated with survivor groups were age, KPS, tumor resection, treatment received and early progression. 18 cancer-related genes were upregulated in short-term survivors and five genes were downregulated in short-term survivors. CONCLUSIONS: Epidemiologic, clinical, and molecular characteristics all contribute to GBM prognosis. Identifying factors associated with survival is important for treatment strategies as well as research for novel therapeutics and technologies. This study demonstrated improved survival for patients over time as well as significant differences among survivor groups.