RESUMO
BACKGROUND AND PURPOSE: Bioresorbable flow diverters are under development to mitigate complications associated with conventional flow-diverter technology. One proposed advantage is the ability to reduce metal-induced artifacts in follow-up medical imaging. In the current work, the medical imaging compatibility of magnesium- and iron-based bioresorbable flow diverters is assessed relative to an FDA-approved control in phantom models. MATERIALS AND METHODS: Bioresorbable flow diverters, primarily composed of braided magnesium or antiferromagnetic iron alloy wires, were compared with an FDA-approved control flow diverter. The devices were assessed for MR imaging safety in terms of magnetically induced force and radiofrequency heating using 1.5T, 3T, and 7T field strength clinical scanners. The devices were deployed in phantom models, and metal-induced image artifacts were assessed in the 3 MR imaging scanners and a clinical CT scanner following clinical scan protocols; device visibility was assessed under fluoroscopy. RESULTS: The magnesium-based bioresorbable flow diverter, iron-based bioresorbable flow diverter, and the control device all demonstrated MR imaging safety in terms of magnetically induced force and radiofrequency heating at all 3 field strengths. The bioresorbable flow diverters did not elicit excessive MR imaging artifacts at any field strength relative to the control. Furthermore, the bioresorbable flow diverters appeared to reduce blooming artifacts in CT relative to the control. The iron-based bioresorbable flow diverter and control device were visible under standard fluoroscopy. CONCLUSIONS: We have demonstrated the baseline medical imaging compatibility of magnesium and antiferromagnetic iron alloy bioresorbable flow diverters. Future work will evaluate the medical imaging characteristics of the bioresorbable flow diverters in large-animal models.
Assuntos
Aneurisma Intracraniano , Animais , Aneurisma Intracraniano/diagnóstico por imagem , Magnésio , Ferro , Implantes Absorvíveis , Radiografia , LigasRESUMO
BACKGROUND AND PURPOSE: Wrong-level spinal surgery, especially in the thoracic spine, remains a challenge for a variety of reasons related to visualization, such as osteopenia, large body habitus, severe kyphosis, radiographic misinterpretation, or anatomic variation. Preoperative fiducial marker placement performed in a dedicated imaging suite has been proposed to facilitate identification of thoracic spine vertebral levels. In this current study, we report our experience using image-guided percutaneous gold fiducial marker placement to enhance the accuracy and safety of thoracic spinal surgical procedures. MATERIALS AND METHODS: A retrospective review was performed of all fluoroscopy- or CT-guided gold fiducial markers placed at our institution between January 3, 2019, and March 16, 2022. A chart review of 179 patients was performed detailing the procedural approach and clinical information. In addition, the method of gold fiducial marker placement (fluoroscopy/CT), procedure duration, spinal level of the gold fiducial marker, radiation dose, fluoroscopy time, surgery date, and complications (including whether wrong-level surgery occurred) were recorded. RESULTS: A total of 179 patients (104 female) underwent gold fiducial marker placement. The mean age was 57 years (range, 12-96 years). Fiducial marker placement was performed by 13 different neuroradiologists. All placements were technically successful without complications. All 179 (100%) operations were performed at the correct level. Most fiducial markers (143) were placed with fluoroscopy with the most common location at T6-T8. The most common location for placement in CT was at T3 and T4. CONCLUSIONS: All operations guided with gold fiducial markers were performed at the correct level. There were no complications of fiducial marker placement.
Assuntos
Marcadores Fiduciais , Ouro , Humanos , Feminino , Pessoa de Meia-Idade , Tomografia Computadorizada por Raios X/métodos , Coluna Vertebral/diagnóstico por imagem , Coluna Vertebral/cirurgia , Fluoroscopia/métodosRESUMO
Because osteoporosis is under-recognized in patients with vertebral fractures, we evaluated characteristics associated with osteoporosis identification. Most patients with vertebral fractures did not receive evaluation or treatment for osteoporosis. Black, younger, and male participants were particularly unlikely to have had recognized osteoporosis, which could increase their risk of negative outcomes. INTRODUCTION: Vertebral fractures may be identified on imaging but fail to prompt evaluation for osteoporosis. Our objective was to evaluate characteristics associated with clinical osteoporosis recognition in patients who had vertebral fractures detected on their thoracolumbar spine imaging reports. METHODS: We prospectively identified individuals who received imaging of the lower spine at primary care clinics in 4 large healthcare systems who were eligible for osteoporosis screening and lacked indications of osteoporosis diagnoses or treatments in the prior year. We evaluated characteristics of participants with identified vertebral fractures that were associated with recognition of osteoporosis (diagnosis code in the health record; receipt of bone mineral density scans; and/or prescriptions for anti-osteoporotic medications). We used mixed models to estimate adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs). RESULTS: A total of 114,005 participants (47% female; mean age 65 (interquartile range: 57-72) years) were evaluated. Of the 8579 (7%) participants with vertebral fractures identified, 3784 (44%) had recognition of osteoporosis within the subsequent year. In adjusted regressions, Black participants (OR (95% CI): 0.74 (0.57, 0.97)), younger participants (age 50-60: 0.48 (0.42, 0.54); age 61-64: 0.70 (0.60, 0.81)), and males (0.39 (0.35, 0.43)) were less likely to have recognized osteoporosis compared to white participants, adults aged 65 + years, or females. CONCLUSION: Individuals with identified vertebral fractures commonly did not have recognition of osteoporosis within a year, particularly those who were younger, Black, or male. Providers and healthcare systems should consider efforts to improve evaluation of osteoporosis in patients with vertebral fractures.
Assuntos
Osteoporose , Fraturas por Osteoporose , Fraturas da Coluna Vertebral , Adulto , Idoso , Densidade Óssea , Feminino , Humanos , Masculino , Programas de Rastreamento , Osteoporose/complicações , Osteoporose/diagnóstico , Osteoporose/epidemiologia , Fraturas por Osteoporose/complicações , Fraturas por Osteoporose/etiologia , Fraturas da Coluna Vertebral/complicações , Fraturas da Coluna Vertebral/epidemiologiaRESUMO
BACKGROUND AND PURPOSE: Intracranial aneurysms treated with coils have been associated with incomplete occlusion, particularly in large or wide-neck aneurysms. This study aimed to validate the accuracy of the rabbit elastase model in predicting aneurysm recurrence in humans treated with platinum coils. MATERIALS AND METHODS: Elastase-induced saccular aneurysms were induced in rabbits and embolized with conventional platinum coils. The recurrence rates of aneurysms were retrospectively analyzed. Morphologic characteristics of aneurysms, angiographic outcomes, and histologic healing were evaluated. RESULTS: A total of 28 (15.3%) of 183 aneurysms recurred. The aneurysm recurrence rate observed in this study (15.3%) is similar to those reported in multiple analyses of aneurysm recurrence rates in humans (7%-27%). The rate of recurrence was higher in aneurysms treated without balloon assistance (19/66, 28.8%) compared with those treated with balloon assistance (9/117, 7.7%). Aneurysms treated with balloon-assisted coiling had a lower recurrence rate (OR = 0.17; 95% CI, 0.05-0.47; P = .001) and higher occlusion rate (OR = 6.88; 95% CI, 2.58-20.37; P < .001) compared with those treated without balloon-assisted coiling. In this rabbit elastase-induced aneurysm model, packing density and aneurysm volume were weak predictors of aneurysm recurrence; however, the packing density was a good predictor of the occlusion rate (OR = 1.05; 95% CI, 1.02-1.10; P = .008). CONCLUSIONS: The rabbit elastase aneurysm model may mimic aneurysm recurrence rates observed in humans after platinum coil embolization. Moreover, balloon assistance and high packing densities were significant predictors of aneurysm recurrence and occlusion.
Assuntos
Embolização Terapêutica , Aneurisma Intracraniano , Animais , Humanos , Aneurisma Intracraniano/induzido quimicamente , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/terapia , Elastase Pancreática , Platina/efeitos adversos , Coelhos , Recidiva , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND AND PURPOSE: Aspiration thrombectomy has become a preferred approach to recanalize large-vessel occlusion in stroke with a growing trend toward using larger-bore catheters and stronger vacuum pumps. However, the mechanical response of the delicate cerebral arteries to aspiration force has not been evaluated. Here, we provide preclinical and clinical evidence of intracranial arterial collapse in aspiration thrombectomy. MATERIALS AND METHODS: We presented a clinical case of arterial collapse with previously implanted flow diverters. We then evaluated the effect of vacuum with conventional aspiration catheters (with and without stent retrievers) in a rabbit model (n = 3) using fluoroscopy and intravascular optical coherence tomography. Then, in a validated human cadaveric brain model, we conducted 168 tests of direct aspiration thrombectomy following an experimental design modifying the catheter inner diameter (0.064 inch, 0.068 inch, and 0.070 inch), cerebral perfusion pressures (mean around 60 and 90 mm Hg), and anterior-versus-posterior circulation. Arterial wall response was recorded and graded via direct transluminal observation. RESULTS: Arterial collapse was observed in both the patient and preclinical experimental models. In the human brain model, arterial collapse was observed in 98% of cases in the M2 and in all the cases with complete proximal flow arrest. A larger bore size of the aspiration catheter, a lower cerebral perfusion pressure, and the posterior circulation in comparison with the anterior circulation were associated with a higher probability of arterial collapse. CONCLUSIONS: Arterial collapse does occur during aspiration thrombectomy and is more likely to happen with larger catheters, lower perfusion pressure, and smaller arteries.
Assuntos
Acidente Vascular Cerebral , Trombectomia , Animais , Encéfalo/diagnóstico por imagem , Encéfalo/cirurgia , Catéteres , Artérias Cerebrais/diagnóstico por imagem , Artérias Cerebrais/cirurgia , Humanos , Coelhos , Stents , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/cirurgia , Trombectomia/métodos , Resultado do TratamentoRESUMO
Endovascular treatment of aneurysms with flow diverters or coiling is sometimes complicated by intraprocedural or postprocedural thrombosis along or within the devices. Thrombus composition and structure associated with such complications may provide insights into mechanisms of thrombus formation and clinical strategies to remove the thrombus. We present a retrospective histopathologic study of 4 patients who underwent mechanical thrombectomy due to acute occlusion of either implanted flow diverter devices or along coils during the treatment of intracranial aneurysm.
Assuntos
Embolização Terapêutica , Procedimentos Endovasculares , Aneurisma Intracraniano , Trombose , Embolização Terapêutica/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/cirurgia , Estudos Retrospectivos , Stents/efeitos adversos , Trombose/diagnóstico por imagem , Trombose/etiologia , Resultado do TratamentoRESUMO
BACKGROUND AND PURPOSE: The persistent challenges in thrombectomy for large-vessel occlusion, such as suboptimal complete recanalization and first-pass effect imply an insufficient understanding of the artery-clot-device interaction. In this study, we present a thrombectomy model using fresh human brains, which can capture the artery-clot-device interaction through concurrent transmural and angiographic visualizations. MATERIALS AND METHODS: Fresh nonfrozen whole adult human brains were collected and connected to a customized pump system tuned to deliver saline flow at a physiologic flow rate and pressure. Angiography was performed to verify the flow in the anterior-posterior and vertebrobasilar circulations and collaterals. Large-vessel occlusion was simulated by embolizing a radiopaque clot analog. Thrombectomy was tested, and the artery-clot-device interactions were recorded by transmural and angiographic videos. RESULTS: Baseline cerebral angiography revealed excellent penetration of contrast in the anterior-posterior and vertebrobasilar circulations without notable arterial cutoffs and with robust collaterals. Small branches (<0.5 mm) and perforating arteries were consistently opacified with good patency. Three device passes were performed to achieve recanalization, with failure modes including elongation, fragmentation, and distal embolization. CONCLUSIONS: This model enables concurrent transmural and angiographic analysis of artery-clot-device interaction in a human brain and provides critical insights into the action mechanism and failure modes of current and upcoming thrombectomy devices.
Assuntos
Embolização Terapêutica , Acidente Vascular Cerebral , Trombose , Encéfalo/diagnóstico por imagem , Encéfalo/cirurgia , Humanos , Acidente Vascular Cerebral/terapia , Trombectomia , Resultado do TratamentoRESUMO
BACKGROUND AND PURPOSE: Identifying and predicting which aneurysms are likely to quickly occlude and which ones are likely to remain open following treatment with flow-diverting devices is important to develop optimal patient management strategies. The purpose of this study was to evaluate predictions based on computational fluid dynamics models using the elastase rabbit aneurysm model. MATERIALS AND METHODS: A series of 13 aneurysms created in rabbits were treated with flow diverters, and outcomes were angiographically assessed at 8 weeks' follow-up. Computational fluid dynamics models were constructed from pretreatment 3D rotational angiograms and Doppler ultrasound flow velocity measurements. Postimplantation mean aneurysm inflow rate and flow velocity were used to prospectively predict aneurysm occlusion blinded to the actual outcomes. Specifically, if both variables were below their corresponding thresholds, fast occlusion was predicted, while if one of them was above the threshold, slow or incomplete occlusion was predicted. RESULTS: Of the 13 aneurysms included, 8 were incompletely occluded 8 weeks after treatment, and 5 were completely occluded. A total of 10 computational fluid dynamics-based predictions agreed with the angiographic outcome, reaching 77% accuracy, 80% sensitivity, and 75% specificity. Posttreatment mean velocity alone was able to achieve the same predictive power as the combination of inflow rate and velocity. CONCLUSIONS: Subject-specific computational fluid dynamics models of the hemodynamic conditions created immediately after implantation of flow-diverting devices in experimental aneurysms created in rabbits are capable of prospectively predicting, with a reasonable accuracy, which aneurysms will completely occlude and which ones will remain incompletely occluded.
Assuntos
Aneurisma Intracraniano , Animais , Hemodinâmica , Hidrodinâmica , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/cirurgia , Elastase Pancreática , Prognóstico , Coelhos , Resultado do TratamentoRESUMO
BACKGROUND AND PURPOSE: Hydrophilic polymers and polytetrafluoroethylene liners, commonly used in the construction of endovascular devices, occasionally separate from devices with subsequent embolization. We determined the frequency of such materials in thrombus specimens retrieved by mechanical thrombectomy in patients with stroke. MATERIALS AND METHODS: We retrospectively reviewed H&E-stained thrombus sections for presence and types of foreign materials. We identified 4 types of foreign materials-Type I: material was light green with refraction and had a homogeneous texture; type II: material was light gray and/or dark gray, thin, and loose or attenuated in texture; type III: material was light green with refraction, solitary in texture, irregular in shape, and was often associated with round or oval bubblelike particles and/or diffuse black particles; and type IV: material had homogeneous texture and was light pink or red. In addition, polymer materials from different layers of used mechanical thrombectomy catheters were compared with the foreign materials found in thrombus specimens. RESULTS: A total of 101 thrombi were evaluated. Foreign materials were found in 53 (52.5%) thrombus samples. The most common type was type I (92%), followed by type II (30%). The histopathologic features of the polymer materials from mechanical thrombectomy catheters were similar to the foreign materials found in thrombus specimens. The inner polytetrafluoroethylene liner and coating layer of catheters resembled type I and type II of the foreign materials, respectively. CONCLUSIONS: Foreign polymer materials are present in approximately half of retrieved thrombi, most commonly polytetrafluoroethylene from catheter liners and less from hydrophilic coatings.
Assuntos
Corpos Estranhos , Acidente Vascular Cerebral , Trombectomia , Trombose , Materiais Biocompatíveis , Corpos Estranhos/patologia , Humanos , Doença Iatrogênica , Polímeros , Estudos Retrospectivos , Acidente Vascular Cerebral/cirurgia , Trombectomia/instrumentação , Trombose/patologiaRESUMO
In recent years, there has been substantial progression in the field of stroke clot/thrombus imaging. Thrombus imaging aims to deduce the histologic composition of the clot through evaluation of various imaging characteristics. If the histology of a thrombus can be reliably determined by noninvasive imaging methods, critical information may be extrapolated about its expected response to treatment and about the patient's clinical outcome. Crucially, as we move into an era of stroke therapy individualization, determination of the histologic composition of a clot may be able to guide precise and targeted therapeutic effort. Most radiologists, however, remain largely unfamiliar with the topic of clot imaging. This article will review the current literature regarding clot imaging, including its histologic backdrop, the correlation of images with cellular components and treatment responsiveness, and future expectations.
Assuntos
Trombose Intracraniana , Radiologia , Acidente Vascular Cerebral , Trombose , Humanos , Trombose Intracraniana/diagnóstico por imagem , Radiografia , Acidente Vascular Cerebral/diagnóstico por imagem , Trombose/diagnóstico por imagemRESUMO
BACKGROUND AND PURPOSE: Previous studies have successfully created blood clot analogs for in vitro endovascular device testing using animal blood of various species. Blood components vary greatly among species; therefore, creating clot analogs from human blood is likely a more accurate representation of thrombi formed in the human vasculature. MATERIALS AND METHODS: Following approval from the Mayo Clinic institutional review board, human whole-blood and platelet donations were obtained from the blood transfusion service. Twelve clot analogs were created by combining different ratios of red blood cells + buffy coat, plasma, and platelets. Thrombin and calcium chloride were added to stimulate coagulation. Clot composition was assessed using histologic and immunohistochemical staining. To assess the similarities of mechanical properties to patient clots, 3 types of clot analogs (soft, elastic, and stiff) were selected for in vitro thrombectomy testing. RESULTS: The range of histopathologic compositions produced is representative of clots removed during thrombectomy procedures. The red blood cell composition ranged from 8.9% to 91.4%, and fibrin composition ranged from 3.1% to 53.4%. Platelets (CD42b) and von Willebrand Factor ranged from 0.5% to 47.1% and 1.0% to 63.4%, respectively. The soft clots had the highest first-pass effect and successful revascularization rates followed by the elastic and stiff clots. Distal embolization events were observed when clot ingestion could not be achieved, requiring device pullback. The incidence rate of distal embolization was the highest for the stiff clots due to the weak clot/device integration. CONCLUSIONS: Red blood cell-rich, fibrin-rich, and platelet-rich clot analogs that mimic clots retrieved from patients with acute ischemic stroke were created in vitro. Differing retrieval outcomes were confirmed using in vitro thrombectomy testing in a subset of clots.
Assuntos
AVC Isquêmico , Trombectomia , Trombose , Plaquetas/patologia , Eritrócitos/patologia , Fibrina , Humanos , Técnicas In Vitro , AVC Isquêmico/diagnóstico por imagem , AVC Isquêmico/etiologia , AVC Isquêmico/cirurgia , Modelos Biológicos , Trombectomia/métodos , Trombose/complicações , Trombose/patologiaRESUMO
BACKGROUND: Rupture of brain aneurysms is associated with high fatality and morbidity rates. Through remodeling of the collagen matrix, many aneurysms can remain unruptured for decades, despite an enlarging and evolving geometry. OBJECTIVE: Our objective was to explore this adaptive remodeling for the first time in an elastase induced aneurysm model in rabbits. METHODS: Saccular aneurysms were created in 22 New Zealand white rabbits and remodeling was assessed in tissue harvested 2, 4, 8 and 12 weeks after creation. RESULTS: The intramural principal stress ratio doubled after aneurysm creation due to increased longitudinal loads, triggering a remodeling response. A distinct wall layer with multi-directional collagen fibers developed between the media and adventitia as early as 2 weeks, and in all cases by 4 weeks with an average thickness of 50.6 ± 14.3 µm. Collagen fibers in this layer were multi-directional (AI = 0.56 ± 0.15) with low tortuosity (1.08 ± 0.02) compared with adjacent circumferentially aligned medial fibers (AI = 0.78 ± 0.12) and highly tortuous adventitial fibers (1.22 ± 0.03). A second phase of remodeling replaced circumferentially aligned fibers in the inner media with longitudinal fibers. A structurally motivated constitutive model with both remodeling modes was introduced along with methodology for determining material parameters from mechanical testing and multiphoton imaging. CONCLUSIONS: A new mechanism was identified by which aneurysm walls can rapidly adapt to changes in load, ensuring the structural integrity of the aneurysm until a slower process of medial reorganization occurs. The rabbit model can be used to evaluate therapies to increase aneurysm wall stability.
RESUMO
BACKGROUND AND PURPOSE: Ischemic stroke is the leading cause of long-term disability in adults, but our ability to prognosticate from baseline imaging data is limited. The ASPECTS measures ischemic change in the middle cerebral artery territory on noncontrast CT based on 10 anatomic regions. Here, we investigated whether infarction in particular regions was associated with worse long-term outcome. MATERIALS AND METHODS: We identified consecutive patients receiving mechanical thrombectomy for ICA/MCA occlusion at 2 comprehensive stroke centers. Pretreatment ASPECTS was assessed by 2 blinded reviewers. Clinical data including demographics, baseline NIHSS score, and 90-day mRS were collected. The relationship between individual ASPECTS regions and the mRS score (0-2 versus 3-6) was assessed using multivariable logistic regression. RESULTS: Three hundred fifty-three patients were included (mean age, 70 years; 46% men), of whom 214 had poor outcome (mRS = 3-6). Caudate (OR = 3.26; 95% CI, 1.33-8.82), M4 region (OR = 2.94; 95% CI, 1.09-9.46), and insula (OR = 1.75; 95% CI, 1.08-2.85) infarcts were associated with significantly greater odds of poor outcome, whereas M1 region infarction reduced the odds of poor outcome (OR = 0.38; 95% CI, 0.14-0.99). This finding remained unchanged when restricted to only patients with good recanalization. No significant associations were found by laterality. Similarly, no region was predictive of neurologic improvement during the first 24 hours or of symptomatic intracerebral hemorrhage. CONCLUSIONS: Our results indicate that ASPECTS regions are not equal in their contribution to functional outcome. This finding suggests that patient selection based on total ASPECTS alone might be insufficient, and infarct topography should be considered when deciding eligibility for thrombectomy.
Assuntos
Isquemia Encefálica , AVC Isquêmico , Idoso , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/cirurgia , Feminino , Humanos , Masculino , Estudos Retrospectivos , Trombectomia , Resultado do TratamentoRESUMO
BACKGROUND AND PURPOSE: While WEB devices have been shown to be safe and effective for aneurysm treatment, WEB-shape modification compression has been associated with incomplete aneurysm occlusion. We explored the relationship between occlusion rates and WEB-shape modification in different WEB device types in an experimental aneurysm model. MATERIALS AND METHODS: Elastase-induced aneurysms were created in rabbits and treated with dual-layer (n = 12), single-layer (n = 12), or single-layer sphere (n = 12) WEB devices. Aneurysms were followed up either at 3 or 12 months. Angiographic occlusion was graded using the WEB Occlusion Scale: grade I, complete; grade II, complete but recess filling; grade III, residual neck; or grade IV, residual aneurysm. WEB-shape modification and histologic features were also analyzed. RESULTS: Grade I or II occlusion was seen in 16 (44%) aneurysms, and grade I, II, or III ("adequate") occlusion was observed in 22 (61.1%) aneurysms at follow-up. WEB-shape modification was observed in 22 (61.1%) aneurysms. WEB-shape modification was higher in single-layer (9/12) and dual-layer (10/12) devices compared with single-layer sphere devices (3/12). Aneurysms with WEB-shape modification had a higher level of thrombus organization in the dome compared with those without WEB-shape modification (68% [15/22] versus 50% [7/14]). WEB-shape modification was not correlated with angiographic or histologic outcomes but was significantly correlated with levels of fibrosis and smooth muscle cells in the aneurysm. CONCLUSIONS: WEB-shape modification is not associated with incomplete aneurysm occlusion of WEB devices in the rabbit model but may be related to connective tissue formation and the healing response to WEB device implantation.
Assuntos
Prótese Vascular , Embolização Terapêutica/instrumentação , Procedimentos Endovasculares/instrumentação , Aneurisma Intracraniano , Animais , Aneurisma Intracraniano/induzido quimicamente , Aneurisma Intracraniano/terapia , Elastase Pancreática/toxicidade , Coelhos , Resultado do TratamentoRESUMO
BACKGROUND: Weighting neuroimaging findings based on eloquence can improve the predictive value of ASPECTS, possibly aiding in informed treatment decisions for acute ischemic stroke. PURPOSE: Our aim was to study the contribution of region-specific ASPECTS infarction to acute ischemic stroke outcomes. DATA SOURCES: We searched MEDLINE and EMBASE for reports on ASPECTS in patients with acute ischemic stroke from 2000 to March 2019. STUDY SELECTION: Two investigators independently reviewed articles and extracted data. Three-month poor functional outcome defined as mRS >2 was the primary end point. DATA ANALYSIS: A random-effects meta-analysis was performed to compare the association between infarct and mRS >2 among ASPECTS regions. Subanalyses included the following: laterality of stroke (left/right), imaging technique (NCCT or advanced imaging with DWI, CTP, or CTA), and interventional technique (IV-tPA/conservative management or mechanical thrombectomy). DATA SYNTHESIS: M6 infarct was most associated with poor functional outcome (OR = 3.26; 95% CI, 2.21-4.80; P < .001). Pair-wise comparisons of ASPECTS regions regarding the association between infarct and mRS >2 were not significant, with the exception of M6 versus lentiform (P = .009). However, pair-wise comparisons among ASPECTS regions were not significant among subgroup analyses. LIMITATIONS: Limitations were the heterogeneity of time points, neuroimaging modalities, and interventional techniques; limited studies for inclusion; publication bias among some comparisons; and the retrospective nature of included studies. CONCLUSIONS: Our study indicated an unequal impact of some ASPECTS subregions in predicting outcomes of patients with acute ischemic stroke. Stroke laterality, imaging technique, and interventional technique subgroup analyses showed no differences among ASPECTS regions in predicting outcome. Investigation in larger cohorts is required to assess the association of ASPECTS with acute ischemic stroke outcome.
Assuntos
AVC Isquêmico/diagnóstico por imagem , AVC Isquêmico/patologia , Neuroimagem/métodos , Idoso , Feminino , Humanos , AVC Isquêmico/cirurgia , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Prognóstico , Estudos Retrospectivos , Tomografia Computadorizada por Raios X/métodos , Resultado do TratamentoRESUMO
BACKGROUND AND PURPOSE: There are only few data and lack of consensus regarding antiplatelet management for carotid stent placement in the setting of endovascular stroke treatment. We aimed to develop a consensus-based algorithm for antiplatelet management in acute ischemic stroke patients undergoing endovascular treatment and simultaneous emergent carotid stent placement. MATERIALS AND METHODS: We performed a literature search and a modified Delphi approach used Web-based questionnaires that were sent in several iterations to an international multidisciplinary panel of 19 neurointerventionalists from 7 countries. The first round included open-ended questions and formed the basis for subsequent rounds, in which closed-ended questions were used. Participants continuously received feedback on the results from previous rounds. Consensus was defined as agreement of ≥70% for binary questions and agreement of ≥50% for questions with >2 answer options. The results of the Delphi process were then summarized in a draft manuscript that was circulated among the panel members for feedback. RESULTS: A total of 5 Delphi rounds were performed. Panel members preferred a single intravenous aspirin bolus or, in jurisdictions in which intravenous aspirin is not available, a glycoprotein IIb/IIIa receptor inhibitor as intraprocedural antiplatelet regimen and a combination therapy of oral aspirin and a P2Y12 inhibitor in the postprocedural period. There was no consensus on the role of platelet function testing in the postprocedural period. CONCLUSIONS: More and better data on antiplatelet management for carotid stent placement in the setting of endovascular treatment are urgently needed. Panel members preferred intravenous aspirin or, alternatively, a glycoprotein IIb/IIIa receptor inhibitor as an intraprocedural antiplatelet agent, followed by a dual oral regimen of aspirin and a P2Y12 inhibitor in the postprocedural period.
Assuntos
Hemorragia Cerebral/prevenção & controle , AVC Isquêmico/terapia , Inibidores da Agregação Plaquetária/uso terapêutico , Stents , Acidente Vascular Cerebral/cirurgia , Consenso , Técnica Delphi , Procedimentos Endovasculares/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Trombectomia/métodosRESUMO
BACKGROUND AND PURPOSE: There is a paucity of data regarding antiplatelet management strategies in the setting of stent-assisted coiling/flow diversion for ruptured intracranial aneurysms. This study aimed to identify current challenges in antiplatelet management during stent-assisted coiling/flow diversion for ruptured intracranial aneurysms and to outline possible antiplatelet management strategies. MATERIALS AND METHODS: The modified DELPHI approach with an on-line questionnaire was sent in several iterations to an international, multidisciplinary panel of 15 neurointerventionalists. The first round consisted of open-ended questions, followed by closed-ended questions in the subsequent rounds. Responses were analyzed in an anonymous fashion and summarized in the final manuscript draft. The statement received endorsement from the World Federation of Interventional and Therapeutic Neuroradiology, the Japanese Society for Neuroendovascular Therapy, and the Chinese Neurosurgical Society. RESULTS: Data were collected from December 9, 2019, to March 13, 2020. Panel members achieved consensus that platelet function testing may not be necessary and that antiplatelet management for stent-assisted coiling and flow diversion of ruptured intracranial aneurysms can follow the same principles. Preprocedural placement of a ventricular drain was thought to be beneficial in cases with a high risk of hydrocephalus. A periprocedural dual, intravenous, antiplatelet regimen with aspirin and a glycoprotein IIb/IIIa inhibitor was preferred as a standard approach. The panel agreed that intravenous medication can be converted to oral aspirin and an oral P2Y12 inhibitor within 24 hours after the procedure. CONCLUSIONS: More and better data on antiplatelet management of patients with ruptured intracranial aneurysms undergoing stent-assisted coiling or flow diversion are urgently needed. Panel members in this DELPHI consensus study preferred a periprocedural dual-antiplatelet regimen with aspirin and a glycoprotein IIb/IIIa inhibitor.
Assuntos
Aneurisma Roto/terapia , Procedimentos Endovasculares , Aneurisma Intracraniano/terapia , Trombose Intracraniana/prevenção & controle , Inibidores da Agregação Plaquetária/uso terapêutico , Adulto , Consenso , Técnica Delphi , Embolização Terapêutica/efeitos adversos , Embolização Terapêutica/instrumentação , Embolização Terapêutica/métodos , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/métodos , Feminino , Humanos , Trombose Intracraniana/etiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , StentsRESUMO
BACKGROUND AND PURPOSE: Impairment of macrophage polarization from a proinflammatory macrophage type 1 (M1) population to an anti-inflammatory macrophage type 2 (M2) population is a hallmark of poor wound healing. In this study, we aimed to evaluate the distribution of M1 and M2 macrophages and to analyze their association with healing in aneurysms embolized by endovascular coiling. MATERIALS AND METHODS: Elastase-induced aneurysms were created in female rabbits and subsequently embolized with platinum coils. Aneurysm occlusions were evaluated with angiographic imaging at 1 (n = 6), 3 (n = 5), or 6 (n = 6) months. Aneurysm tissues were harvested for histologic analysis, quantification of M1 and M2 macrophages by immunofluorescence, and collagen deposition determined by Masson trichrome staining. Histologic grading of aneurysm healing was also performed. Untreated aneurysms were used as controls (n = 6). RESULTS: The M1 macrophage population was highest at 1 month posttreatment, progressively decreasing at 3 and 6 months. The M2 macrophage population progressively increased at 3 and 6 months posttreatment. The highest collagen deposition was at 6 months posttreatment. We found a moderate-to-weak direct correlation between the percentage of M2 macrophages and collagen deposition, as well as total histologic scores overall, and a strongly positive direct correlation between the percentage of M2 macrophages and total histologic scores at 6 months posttreatment. CONCLUSIONS: Our data support the direct correlation between M2 macrophage polarization and healing in aneurysm tissues. Our results show a positive relationship between M2 macrophage populations and total histologic scores at later stages of healing after endovascular coiling. We conclude that interventions aimed at stimulating M2 macrophage expression locally may improve aneurysm healing after coil embolization.
Assuntos
Embolização Terapêutica/métodos , Aneurisma Intracraniano , Macrófagos , Cicatrização/fisiologia , Animais , Prótese Vascular , Embolização Terapêutica/instrumentação , Feminino , Aneurisma Intracraniano/terapia , Platina , CoelhosRESUMO
BACKGROUND: Surveillance imaging of previously unruptured, coiled aneurysms remains routine even though reports of rupture of these aneurysms are extremely rare. PURPOSE: We performed meta-analysis to examine long-term rupture risk over ≥1-year follow-up duration in patients with unruptured intracranial aneurysm who underwent endovascular therapy. DATA SOURCES: Multiple databases were searched for relevant publications between 1995 and 2018. STUDY SELECTION: Studies reporting outcome of long-term rupture risk over ≥1-year follow-up in treated patients with unruptured intracranial aneurysms were included. DATA ANALYSIS: Random effects meta-analysis was used, and results were expressed as long-term rupture rate per 100 patient-year with respective 95% CIs. For ruptured aneurysms during follow-up, data were collected on size and completeness of initial Treatment. DATA SYNTHESIS: Twenty-four studies were identified. Among 4842 patients with a mean follow-up duration of 3.2 years, a total of 12 patients (0.25%) experienced rupture of previous unruptured intracranial aneurysms after endovascular treatment. Nine of these 12 patients harbored aneurysms that were large, incompletely treated, or both. A total of 2 anterior circulation, small, completely coiled aneurysms subsequently ruptured. The long-term rupture rate per 100 patient-year for unruptured intracranial aneurysms treated with endovascular therapy was 0.48 (95% CI, 0.45-0.51). Retreatment was carried out in 236 (4.9%) of these 4842 patients. LIMITATIONS: A limitation of the study is that a lack of systematic nature of follow-up and mean follow-up duration of 3.2 years are not sufficient to make general recommendations about aneurysm followup paradigms. CONCLUSIONS: Given a 5% retreatment rate, postcoil embolization spontaneous rupture of previously unruptured, small- and medium-sized, well-treated aneurysms is exceedingly rare.