Polyvinyl Alcohol Sponges to Facilitate Cerebral Bypass Surgery: Technical Note.

OBJECTIVE: The standard way of isolating bypass vessels from surrounding structures during cerebral bypass surgery has been to use a rubber dam or neurosurgical patty. Here, the use of polyvinyl alcohol (PVA) sponges is described as a possible upgrade from these traditional bypass dams. METHODS: PVA sponges were used to isolate bypass arteries from surrounding tissues during microvascular anastomosis in 25 patients undergoing bypass surgery at our institution. RESULTS: There were no adverse events related to the use of PVA for microvascular anastomosis. PVA sponges offered some specific advantages when compared with rubber and cottonoid dams. CONCLUSIONS: Although preliminary, our experience using PVA sponges during microvascular anastomosis suggests some of their properties can facilitate cerebral bypass surgery.

Endovascular Transcarotid Artery Revascularization Using the Walrus Balloon Guide Catheter: Preliminary Experience.

BACKGROUND: The Walrus Balloon Guided System Catheter is a new generation of balloon guide catheter (BGC) designed to bypass some technical limitations of conventional BGC devices. Their utility in cervical carotid disease treatment has not been reported. We report our preliminary experience in cervical carotid treatment using the Walrus BGC to perform a modified endovascular transcarotid artery revascularization technique. METHODS: Patients with cervical carotid disease undergoing endovascular treatment using the Walrus BGC at our institution were identified. The pertinent baseline demographics and procedural outcomes were collected and analyzed. RESULTS: Twelve patients were included (median age, 70; 58.3% females). All patients had an imaging-confirmed cervical carotid disease that indicated intervention: 6 with high-grade cervical arteriosclerotic carotid stenosis, 2 with intraluminal thrombi, 1 with traumatic carotid dissection, and 3 patients with cervical carotid tandem occlusion along with acute ischemic stroke secondary to large vessel occlusion that required mechanical thrombectomy. Carotid artery stenting was performed in all cases, except 2 of the 3 mechanical thrombectomy cases (angioplasty only). All patients had at least periprocedural follow-up of 30 days, with no stroke, myocardial infarction, or death encountered. CONCLUSIONS: We describe a modified endovascular transcarotid artery revascularization technique. We used a standard femoral access to navigate the Walrus catheter in the common carotid artery, followed by balloon inflation for proximal flow arrest or flow reversal (when connected to the aspiration pump) to deploy the carotid stent across the stenosis, while avoiding distal external carotid artery balloon occlusion. Successful treatment was achieved in all cases, with no periprocedural complications encountered.

Additional Revascularization Using Multiple Burr Holes for PCA Involvement in Moyamoya Disease.

In specific cases of moyamoya disease (MMD), posterior cerebral artery (PCA) stenosis can develop after treatment of the anterior circulation and require additional revascularization. Here, we report two cases that underwent additional posterior indirect revascularization with multiple burr holes for PCA involvement after bilateral revascularization treatment of the anterior circulation. They presented with transient ischemic attack even after bilateral superficial temporal artery-middle cerebral artery bypass, and magnetic resonance angiography (MRA) showed that PCA stenosis had worsened. Indirect revascularization with multiple burr holes using Benz-marked skin incisions was performed. After surgery, the symptoms improved without perioperative complications, and cerebral angiography showed collateral circulation via the burr hole. Indirect revascularization for MMD is often combined with direct revascularization, and there are only a few reports on the use of multiple burr hole surgery alone. In addition, there are few reports of posterior circulation, despite the emphasis on the importance of PCA involvement in MMD. Indirect revascularization with multiple burr holes alone can be performed in multiple areas and applied to patients who cannot undergo direct revascularization using the occipital artery. The procedure is simple and less invasive than traditional direct revascularization procedures. Therefore, it can be effective, especially in pediatric cases of MMD with PCA involvement.

Thrombectomy Using the EmboTrap II Device in Late Treatment Patients in the Real-World Setting.

OBJECTIVE: We aimed to evaluate the safety and efficacy of endovascular thrombectomy (EVT) using the EmboTrap Revascularization Device (EmboTrap) in patients with ischemic stroke treated >6-24 hours after stroke onset. METHODS: We performed a retrospective analysis of data from a prospective registry of consecutive patients with stroke with anterior circulation large vessel occlusion treated by stent-retriever thrombectomy with EmboTrap II in a single stroke center in France from 2016 to 2017. Patients were divided into late treatment window (>6-24 hours after stroke onset) or early treatment window (≤6 hours) groups. Baseline clinical and imaging characteristics, rates of successful recanalization (modified Thrombolysis in Cerebral Infarction score ≥2b), complications, 3 months good functional outcome (modified Rankin Scale score 0-2), and mortality were analyzed. RESULTS: Of the 225 patients (mean age, 71.5 ± 14.5 years; 55.6% [125/225] female) included in the study, 54 were treated in the late treatment window, with a mean time from last known well to treatment of 651 ± 223 minutes. Compared with the early treatment window group, there were no significant differences in baseline characteristics, successful recanalization (83.3% [45/54] vs. 81.3% [139/171]; P = 0.734), 3 months good functional outcome (37.0% [20/54] vs. 37.4% [64/171]; P = 0.959), or mortality (24.1% [13/54] vs. 27.5% [47/171]; P = 0.621). CONCLUSIONS: This real-world study provides evidence that EVT using EmboTrap is safe and effective in the late treatment window in patients with large vessel occlusion.

Extracranial/Intracranial Vascular Bypass in the Treatment of Head and Neck Cancer - Related Carotid Blowout Syndrome.

OBJECTIVE/HYPOTHESIS: To investigate the endovascular intervention or extracranial/intracranial (EC/IC) vascular bypass in the management of patients with head and neck cancer-related carotid blowout syndrome (CBS). STUDY DESIGN: Retrospective case series. METHODS: Retrospective analysis of clinical data of patients with head and neck cancer-related CBS treated by endovascular intervention and/or EC/IC vascular bypass, analysis of its bleeding control, neurological complications, and survival results. RESULTS: Thrity-seven patients were included. Twenty-five were associated with external carotid artery (ECA); twelve were associated with internal or common carotid artery (ICA/CCA). All patients with ECA hemorrhage were treated with endovascular embolization. Of the 12 patients with ICA/CCA hemorrhage, 9 underwent EC/IC bypass, 1 underwent endovascular embolization, and 3 underwent endovascular stenting. For patients with ECA-related CBS, the median survival was 6 months, and the 90-day, 1-year, and 2-year survival rates were 67.1%, 44.7%, and 33.6%, respectively; the estimated rebleeding risk at 1-month, 6-month, and 2-year was 7.1%, 20.0%, and 31.6%, respectively. For patients with ICA/CCA-related CBS, the median survival was 22.5 months, and the 90-day, 1-year, and 2-year survival rates were 92.3%, 71.8%, and 41.0%, respectively; the estimated rebleeding risk at 1 month, 6 months, and 2 years is 7.7%,15.4%, and 15.4%, respectively. ICA/CCA-related CBS patients have significantly longer survival time and lower risk of rebleeding, which may be related to the more use of EC/IC vascular bypass as a definite treatment. CONCLUSIONS: For patients with ICA/CCA-related CBS, if there is more stable hemodynamics, longer expected survival, EC/IC vascular bypass is preferred. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:1548-1556, 2021.

Long-term feasibility of the new sutureless excimer laser-assisted non-occlusive anastomosis clip in a pig model.

BACKGROUND: High flow bypass surgery can be a last resort procedure for patients suffering from complex neurovascular pathology. Temporary occlusion of a recipient artery in these patients could result in debilitating neurological deficits. We developed a sutureless, mechanical anastomotic connection device, the SELANA clip (Sutureless Excimer Laser-Assisted Non-occlusive Anastomosis clip: SEcl). In the present study, we aim to determine the long-term non-inferiority of the SEcl technique compared with historical data of the conventional ELANA anastomosis technique. METHODS: A total of 18 SEcl bypasses were created on the carotid artery in a porcine model in 6 different survival groups. Mean application times, flap retrieval rates, hemostasis, patency, flow, endothelialization, and remodeling were assessed. RESULTS: The mean application time of the SEcl anastomoses was 15.2 ± 9.6 min, which was faster compared with the conventional ELANA anastomoses. The flap retrieval rate of the SEcl anastomoses was 86% (32/37). Direct hemostasis was achieved in 89% (33/37) SEcl anastomoses. Patency in all surviving animals was 94% (17/18). Bypass flow after six months was 156.5 ± 24.7 mL/min. Full endothelialization of the SEcl pins was observed after 3 weeks. CONCLUSION: The SEcl technique is not inferior to the ELANA technique regarding patency, flap retrieval rate, flow, and endothelialization. On the basis of a significantly shorter application time and superior hemostasis, the SEcl technique could be preferable over the ELANA technique. A pilot study in patients is a logical next step based on our current results.

The novel Tenzing 7 delivery catheter designed to deliver intermediate catheters to the face of embolus without crossing: clinical performance predicted in anatomically challenging model.

BACKGROUND: In large vessel occlusionstroke, navigation of aspiration catheters (AC) can be impeded by vessel tortuosity and the ophthalmic artery origin. A novel tapered delivery catheter was designed to facilitate delivery without disturbing the embolus. We assessed AC deliverability in vitro and validated the observations in a first-in-human experience. METHODS: In a vascular model with three challenging craniocervical scenarios, two commercial AC were advanced from the carotid to the middle cerebral artery by four neurointerventionalists. Catheter deliverability with standard microwire and microcatheter (MC) combinations and the Tenzing 7 (T7) Delivery Catheter (Route 92 Medical, San Mateo, CA) were compared. Operators rated aspects of catheter deliverability on a 5-point scale. Results were compared with device delivery patterns at a neurovascular center before and after clinical introduction of T7. RESULTS: In vitro, success rate and speed were higher with T7 (96%; mean 30±10 s) than with MC (65%; 72±47 s, p<0.001 each), with fewer interactions with the occlusion site (T7: 54% vs MC: 77%, p=0.004). T7 received superior ratings regarding carotid artery deflection (T7: 2, IQR1-3 vs MC: 3, IQR2-3, p<0.001), guide catheter pushback (T7: 2, IQR1-3 vs MC: 3, IQR3-3, p<0.001) and ophthalmic artery passage (T7: 1.5, IQR1-2 vs MC: 4, IQR3-5, p<0.001). Before introduction of T7 at a single center, delivery of AC to a large vessel occlusion without crossing was achieved in 15/123 cases (12%). With T7, this rate was 28/31 patients (90.3%). CONCLUSION: Compared with microcatheter and microwire combinations, T7 improves aspiration catheter delivery in vitro, minimizing the need to cross the occlusion. Initial clinical experience appears to validate the model's observations.

MeVO SAVE technique: initial experience with the 167 cm long NeuroSlider 17 for a combined approach in medium vessel occlusions (MeVOs).

Goyal et al described occlusions in M2/3, A2/3 and P2/3 as medium vessel occlusions (MeVOs); the only available controlled data of mechanical thrombectomy (MT) in MeVOs is limited to the middle cerebral artery M2 segment, suggesting that MT may be effective and safe with high functional independence and recanalization rates. The Stent retriever Assisted Vacuum-locked Extraction (SAVE) technique in mechanical thrombectomy consists of the simultaneous use of a stent retriever and a distal aspiration catheter (DAC), with the removal of both as a unit when performing the thrombectomy pass; however, so far the low-profile (0.035 inch distal inner diameter) DACs were longer (160 cm) than conventional 0.017 inch microcatheters for MeVOs. We present a case of a combined approach MT in MeVO with the use of the new 167 cm long NeuroSlider 17 (Acandis, Pforzheim, Germany) 0.0165 inch microcatheter and 3MAX (Penumbra, Alameda, CA) through the SAVE technique-the MeVO SAVE technique. (video 1). neurintsurg;13/8/768/V1F1V1video 1.

Intentional Stent Stenosis to Prevent Hyperperfusion Syndrome after Carotid Artery Stenting for Extremely High-Grade Stenosis.

BACKGROUND AND PURPOSE: Intracranial hemorrhage due to hyperperfusion syndrome is a severe carotid artery stent placement complication of extremely high-grade stenosis, causing hemodynamic insufficiency. To prevent hyperperfusion syndrome, we attempted intentional residual stent stenosis and implemented "gentle" carotid artery stent placement, defined as carotid artery stent placement using a closed-cell stent coupled with slight balloon predilation, without balloon postdilation. Gradual stent expansion was expected. We investigated the incidence of hyperperfusion syndrome and long-term outcomes after gentle carotid artery stent placement. MATERIALS AND METHODS: We included patients who underwent carotid artery stent placement for extremely high-grade stenosis from January 2015 to March 2019. We defined extremely high-grade stenosis as carotid stenosis with conventional angiographic "slow flow" and a reduced MCA signal intensity on MRA. A reduced MCA signal intensity was defined as MCA with a relative signal intensity of <0.9 in the ipsilateral compared with the contralateral MCA. We evaluated the stent diameter, CBF on SPECT, hyperperfusion syndrome, and intracranial hemorrhage. We defined hyperperfusion syndrome as a triad of ipsilateral headache, seizure, and hemiparesis. RESULTS: Twenty-eight of the 191 patients met our inclusion criteria. After carotid artery stent placement, their median minimal stent diameter was 2.9 mm, which expanded to 3.9 mm at 4 months. Neither cerebral hyperperfusion syndrome nor intracranial hemorrhage occurred. CONCLUSIONS: The gentle carotid artery stent placement strategy for intentional residual stent stenosis may prevent hyperperfusion syndrome in high-risk patients. Stents spontaneously dilated in 4 months.

Microsurgical clipping of multiple cerebral aneurysms in the acute phase of aneurysmal subarachnoid hemorrhage through a minipterional approach: The Chilean experience.

OBJECTIVE: The minipterional craniotomy (MPTc) has been widely accepted as a minimally invasive alternative to the pterional approach for the treatment of certain small non-ruptured anterior circulation aneurysms. The aim of this study was to determine the effectiveness and safety of the MPTc in the context of a complex and potentially harmful scenario: acute onset of subarachnoid hemorrhage (SAH) in patients harboring multiple intracranial aneurysms (MIA). METHODS: Patients harboring MIA clipped through a unilateral MPTc were selected from four retrospective databases of four high-volume neurosurgical centers. Patients with a Hunt & Hess score 4 or 5 were not considered candidates for clipping through a MPTc. Medical records and radiological images were retrospectively reviewed. Epidemiological, clinical and radiological data, as well as short-term outcome (modified Rankin scale at 6 month-follow-up) were analyzed. RESULTS: 16 patients harboring 33 aneurysms (16 ruptured, 17 non ruptured) met the inclusion criteria. Each aneurysm size was 5.7 ± 2.1 mm (range 3-11). 12 out of 33 aneurysms were located in the middle cerebral artery (MCA). Anterior communicating (ACom) and MCA aneurysms were the aneurysm locations most commonly ruptured (5 each, 62 %). Complete occlusion was achieved in 32 aneurysms (97 %) and near-complete occlusion in 1 (3%). 13 patients (93 %) were independent at 6 month-follow-up. Mortality rate was 0%. Complications included 1 cerebrospinal-fluid leakage. CONCLUSION: When indicated (Hunt Hess < 4), performing a MPTc is safe and effective in aSAH cases with multiple aneurysms.

Rescue Surgery in the Flow Diverter Era: Partial Trapping Plus Revascularization Technique for a Giant Carotid-Ophthalmic Aneurysm.

BACKGROUND: Flow diverters (FDs) are an excellent option for the management of giant carotid artery aneurysms. However, in a nonnegligible percent of cases, the aneurysm may continue to grow despite multiple endovascular treatments and apparent occlusion on the angiogram. Due to the recent introduction of FDs, surgical experience after their failure is scarce and neurosurgeons have to face these challenging cases without much previous reference. Here we describe a giant ophthalmic-carotid aneurysm that presented with new severe mass effect 5 years after initially successful treatment with FDs and coils. We investigate the likely advantages of partial trapping versus complete trapping in this particular type of case. CASE DESCRIPTION: A 63-year-old patient with a subarachnoid hemorrhage from a 26-mm left carotid-ophthalmic aneurysm was initially embolized with coils. One year later a recanalization was observed and treated with an FD. Five years afterward, the patient's mild cognitive impairment prompted a magnetic resonance image that showed significant aneurysm growth despite apparent occlusion on angiogram. Rescue surgery consisted of partial trapping + extracranial-intracranial bypass and aneurysm debulking. The patient recovered from his deficits and remains asymptomatic 2 years later. CONCLUSIONS: In selected patients with previous long-term FDs, partial trapping may be a choice even if aneurysm debulking is needed. After years of stent placement, some endothelialization and neointimal membrane formation could have a summing effect to facilitate surgical exclusion and enable a safe thrombectomy. Classic revascularization techniques must be rethought and retested in this new FD era scenario.

STA-enhanced vascularized galeal flap for revascularization of moyamoya disease: technical report.

BACKGROUND: A variety of revascularization techniques have been reported for the management of moyamoya disease to prevent risks of stroke. STA (superficial temporal artery)-MCA (middle cerebral artery) microanastomosis, single or double bypass, with temporal muscle or galeal onlay graft has been the standard operative procedure. METHOD: Our rationale of revascularization surgery has been a combination of STA-MCA double bypass using the frontal and the parietal branches of STA and transfer of a highly vascularized thick galeal flap with maintained STA vasculature. CONCLUSION: This STA-enhanced vascularized galeal flap graft is extremely effective for revascularization of moyamoya disease.

Natural Y-shaped radial artery graft bypass for a complex middle cerebral artery aneurysm: A case report.

Giant thrombosed middle cerebral artery (MCA) aneurysms are difficult to treat and sometimes require complex revascularization using allografts. We describe a technical method using revascularization with a natural Y-shaped graft that provides a normal variation for a complex MCA aneurysm. A 65-year-old man with a giant thrombosed MCA aneurysm presented with right hemiparesis and aphasia. The patient had a history of clipping surgery for the ipsilateral side of the MCA aneurysm 25 years before, and a de novo aneurysm developed over the previous 18 years. For the giant thrombosed aneurysm, trapping and revascularization were performed. A natural radial artery Y-graft was used as the graft and anastomosed to both M2 trunks. The symptoms improved after surgery, and the patient was discharged 3 weeks later. This is the first report of a double-barrel bypass using a natural Y-graft. This method attained a normal variation, and the flow of the Y-graft was physiological. For the radical cure of giant thrombosed MCA aneurysms, multiple revascularizations might be required. With this natural Y-graft, complex transpositions could be avoided.

Does Device Selection Impact Recanalization Rate and Neurological Outcome?: An Analysis of the Save ChildS Study.

Background and Purpose- The recent Save ChildS study provides multicenter evidence for the use of mechanical thrombectomy in children with large vessel occlusion arterial ischemic stroke. However, device selection for thrombectomy may influence rates of recanalization, complications, and neurological outcomes, especially in pediatric patients of different ages. We, therefore, performed additional analyses of the Save ChildS data to investigate a possible association of different thrombectomy techniques and devices with angiographic and clinical outcome parameters. Methods- The Save ChildS cohort study (January 2000-December 2018) analyzed data from 27 European and United States stroke centers and included all pediatric patients (<18 years), diagnosed with arterial ischemic stroke who underwent endovascular recanalization. Patients were grouped into first-line contact aspiration (A Direct Aspiration First Pass Technique [ADAPT]) and non-ADAPT groups as well as different stent retriever size groups. Associations with baseline characteristics, recanalization rates (modified Treatment in Cerebral Infarction), complication rates, and neurological outcome parameters (Pediatric National Institutes of Health Stroke Scale after 24 hours and 7 days; modified Rankin Scale and Pediatric Stroke Outcome Measure at discharge, after 6 and 24 months) were investigated. Results- Seventy-three patients with a median age of 11.3 years were included. Currently available stent retrievers were used in 59 patients (80.8%), of which 4×20 mm (width×length) was the most frequently chosen size (36 patients =61%). A first-line ADAPT approach was used in 7 patients (9.6%), and 7 patients (9.6%) were treated with first-generation thrombectomy devices. In this study, a first-line ADAPT approach was neither associated with the rate of successful recanalization (ADAPT 85.7% versus 87.5% No ADAPT) nor with the complication rate or the neurological outcome. Moreover, there were no associations of stent retriever sizes with rates of recanalization, complication rates, or outcome parameters. Conclusions- Our study suggests that neurological outcomes are generally good regardless of any specific device selection and suggests that it is important to offer thrombectomy in eligible children regardless of technique or device selection. Registration- URL: https://www.drks.de/; Unique identifier: DRKS00016528.

How I do it: superficial temporal artery to middle cerebral artery bypass for treatment of giant middle cerebral artery aneurysm.

BACKGROUND: Giant middle cerebral artery aneurysms are frequently anatomically complicated. Trapping may yield poor outcome, and bypass revascularization is often necessary as an adjunctive treatment to preserve flow. METHOD: The technical nuances of superficial temporal artery to middle cerebral artery bypass are described in the setting of clip reconstruction of giant middle cerebral artery (MCA) aneurysm. In addition to an operative video, the anatomy and surgical technique are demonstrated in virtual reality to enhance the didactic clarity. CONCLUSION: Meticulous technique is paramount for successful superficial temporal artery MCA bypass. Along with clip reconstruction, it is a critical part of the treatment of complex, giant MCA aneurysms.

Dissection of the Superficial Temporal Artery: Significance and Performance with Bipolar Forceps.

BACKGROUND: Adequate bypass harvesting of the superficial temporal artery (STA) is a standard procedure for every neurosurgeon, so mastery of techniques for its management and care is mandatory. METHODS: Here, we report the effectiveness of using the bipolar forceps as a novel procedure. RESULTS: This procedure improves safety, efficiency, and bleeding compared to the usual dissection. CONCLUSIONS: In cases requiring an STA donor, this technique may be as useful as the traditional method and could become part of the neurosurgeon's armamentarium.

Final Results of the Prospective Multicenter Excimer Laser-Assisted High-Flow Bypass Study on the Treatment of Giant Anterior Circulation Aneurysms.

BACKGROUND: Both conventional bypass utilizing temporary recipient vessel occlusion and the excimer laser-assisted nonocclusive anastomosis (ELANA) bypass technique are possible strategies in the treatment of giant aneurysms. These treatments have only been studied in single institutional retrospective studies. The potential advantage of the ELANA technique is the absence of temporary occlusion of major arteries, decreasing the risk of intraoperative ischemia. OBJECTIVE: To investigate the risks and potential benefits of high-flow bypass surgery for giant and complex aneurysms of the anterior cerebral circulation. In addition, the effectiveness of the ELANA bypass procedure in the treatment of these aneurysms is determined. METHODS: A total of 37 patients were included in 8 vascular neurosurgical centers in the United States, Canada, and Europe. A 30-d postoperative bypass follow-up was studied by using digital subtraction angiography and/or magnetic resonance angiography and computed tomography angiography to assess patency as well as by clinical monitoring in all patients. RESULTS: In 35 patients, an ELANA high-flow bypass was performed and the aneurysm treated. Four patients had remaining neurological deficits after 30 d caused by stroke (11.4%). These strokes were not related to the ELANA anastomosis device. CONCLUSION: This study does not prove that the ELANA technique has an advantage over conventional bypass techniques, but it appears to be an acceptable alternative to conventional transplanted high-flow bypass in this very-difficult-to-treat patient group, especially in select patients whom cannot be bypassed using conventional means in which temporary occlusion is considered to be not recommended.

Feasibility of the new sutureless excimer laser-assisted non-occlusive anastomosis clip in a rabbit model.

BACKGROUND: The excimer laser-assisted non-occlusive anastomosis (ELANA) technique facilitates the construction of anastomoses without temporary occlusion of the recipient artery. Experiments aimed at simplifying the technique eventually resulted in a sutureless ELANA slide (SEsl) anastomosis. After the first clinical use, new insights lead to the application of a clip at the back of the device, the SELANA clip (SEcl). The SEcl offers a distinct advantage over the SEsl since no sealant is necessary. In this study, we determine the feasibility of the SEcl anastomosis in an in vivo rabbit model. METHODS: 15 SEcl anastomoses and 15 conventional ELANA anastomoses were created on the abdominal aorta in 5 rabbits. Mean application times, flap retrieval rates, hemostasis, and burst pressures were assessed. RESULTS: The mean application time of the SEcl anastomoses was 11.4 min versus 39.0 min for the ELANA anastomoses (mean difference, 27.6 min; 95% CI, 20.6-34.7). The flap retrieval rate of the SEcl anastomoses (14/15) was not inferior to the flap retrieval rate of the ELANA anastomoses (13/15). Direct hemostasis was achieved in 13/15 (87%) SEcl anastomoses and in 14/15 (94%) ELANA anastomoses. All SEcl anastomoses were resistant to provoked pressures until 250 mmHg. CONCLUSION: The SEcl anastomosis is technically feasible in in vivo experiments. Mean application time, flap retrieval rate, hemostasis, and burst pressure are not inferior to the conventional ELANA anastomosis. Further long term experiments should be performed to assess safety, patency, and reendothelialization.

Simultaneous revascularization of the occluded internal carotid artery using the Solitaire as a workhorse wire during acute ischemic stroke intervention.

INTRODUCTION: Tandem lesions involving a large vessel occlusion intracranially with concomitant cervical carotid critical stenosis or occlusion are a common presentation of acute ischemic stroke. These lesions are both challenging and time-consuming but can be extremely beneficial for patients when successful. We present a technique utilizing the pusher wire of the stent retriever used for intracranial thrombectomy as the workhorse wire for carotid intervention using a monorail system to perform cervical carotid angioplasty. METHODS: We reviewed four successive patients who presented with a tandem occlusion and underwent thrombectomy and simultaneous carotid artery intervention using this technique. RESULTS: All four patients had radiographically successful intracranial thrombectomy and cervical carotid revascularization. Time from groin puncture to intracranial stent retriever deployment was 63 min on average. Then, using the pusher wire as a monorail workhorse, time from stent retriever deployment to carotid angioplasty was on average 6 min. DISCUSSION: This technique allows for cervical carotid revascularization to begin during the recommended 5-min wait time after stent retriever deployment, allowing for rapid near-simultaneous revascularization across both lesions. This technique has been reported briefly in the past for management of a cervical dissection. There is continued debate regarding the management of tandem occlusions, as to which lesion should be managed first. CONCLUSION: As the management paradigms of tandem occlusions continue to evolve, this technique may improve outcomes by expediting endovascular intervention. Using the stent retriever wire provides a method of expediting the management of the proximal lesion after addressing the more distal intracranial occlusion first.

Retrospective analysis of central venous catheters in elective intracranial surgery - Is there any benefit?

BACKGROUND: It remains unclear whether the use of central venous catheters (CVC) improves a patient's clinical outcome after elective intracranial supratentorial procedures. METHODS: This two-armed, single-center retrospective study sought to compare patients undergoing elective intracranial surgery with and without CVCs. Standard anaesthesia procedures were modified during the study period resulting in the termination of obligatory CVC instrumentation for supratentorial procedures. Peri-operative adverse events (AEs) were evaluated as primary endpoint. RESULTS: The data of 621 patients in total was analysed in this study (301 with and 320 without CVC). Patient characteristics and surgical procedures were comparable between both study groups. A total of 132 peri-operative AEs (81 in the group with CVC vs. 51 in the group without CVC) regarding neurological, neurosurgical, cardiovascular events and death were observed. CVC patients suffer from AEs almost twice as often as non CVC patients (ORadjusted = 1.98; 95%CI[1.28-3.06]; p = 0.002). Complications related to catheter placement (pneumothorax and arterial malpuncture) were observed in 1.0% of the cases. The ICU treatment period in patients with CVC was 22 (19;24) vs. 21 (19;24) hours (p = 0.413). The duration of hospital stay was also similar between groups (9 (7;13) vs. 8 (7;11) days, p = 0.210). The total time of ventilation (350 (300;440) vs. 335 (281;405) min, p = 0.003) and induction time (40 (35;50) vs. 30 (25;35) min, p<0.001) was found to be prolonged significantly in the group with CVCs. There were no differences found in post-operative inflammatory markers as well as antibiotic treatment. CONCLUSION: The data of our retrospective study suggests that patients undergoing elective neurosurgical procedures with CVCs do not demonstrate any additional benefits in comparison to patients without a CVC.