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1.
J Neurointerv Surg ; 2019 Aug 23.
Artigo em Inglês | MEDLINE | ID: mdl-31444288

RESUMO

BACKGROUND: Angiographic parametric imaging (API) is an imaging method that uses digital subtraction angiography (DSA) to characterize contrast media dynamics throughout the vasculature. This requires manual placement of a region of interest over a lesion (eg, an aneurysm sac) by an operator. OBJECTIVE: The purpose of our work was to determine if a convolutional neural network (CNN) was able to identify and segment the intracranial aneurysm (IA) sac in a DSA and extract API radiomic features with minimal errors compared with human user results. METHODS: Three hundred and fifty angiographic images of IAs were retrospectively collected. The IAs and surrounding vasculature were manually contoured and the masks put to a CNN tasked with semantic segmentation. The CNN segmentations were assessed for accuracy using the Dice similarity coefficient (DSC) and Jaccard index (JI). Area under the receiver operating characteristic curve (AUROC) was computed. API features based on the CNN segmentation were compared with the human user results. RESULTS: The mean JI was 0.823 (95% CI 0.783 to 0.863) for the IA and 0.737 (95% CI 0.682 to 0.792) for the vasculature. The mean DSC was 0.903 (95% CI 0.867 to 0.937) for the IA and 0.849 (95% CI 0.811 to 0.887) for the vasculature. The mean AUROC was 0.791 (95% CI 0.740 to 0.817) for the IA and 0.715 (95% CI 0.678 to 0.733) for the vasculature. All five API features measured inside the predicted masks were within 18% of those measured inside manually contoured masks. CONCLUSIONS: CNN segmentation of IAs and surrounding vasculature from DSA images is non-inferior to manual contours of aneurysms and can be used in parametric imaging procedures.

2.
J Neurointerv Surg ; 2019 Aug 23.
Artigo em Inglês | MEDLINE | ID: mdl-31444289

RESUMO

INTRODUCTION: Accurate estimation of the incidence of large vessel occlusion (LVO) is critical for planning stroke systems of care and approximating workforce requirements. This systematic review aimed to estimate the prevalence of LVO among patients with acute ischemic stroke (AIS), with emphasis on definitions and methods used by different studies. METHODS: A systematic literature review was performed to search for articles on the prevalence of LVO and AIS. All articles describing the frequency of LVO frequency among AIS patients were included. Studies without consecutive recruitment or confirmation of LVO with CT angiography or MR angiography were excluded. Heterogeneity of the studies was assessed; meta-regression was performed to estimate the effect of LVO definition and study methods on LVO prevalence. RESULTS: 18 articles met the inclusion criteria: 5 studies presented population based estimates; 13 provided single hospital experiences (5 prospective, 8 retrospective). The AIS denominator (number of all AIS) from which LVO rates were generated was variable. Nine different definitions were used, based on occlusion site. Significant heterogeneity existed among the studies (I2=99%, P<0.001). The prevalence of LVO among patients with suspected AIS ranged from 13% to 52%. Overall prevalence was 30.0% (95% CI 25.0% to 35.0%). Pooled prevalence of LVO among suspected AIS patients was 21% (95% CI 19% to 30%). Based on meta-regression, the method of AIS denominator determination significantly influenced heterogeneity (P=0.018). CONCLUSION: The heterogeneity of LVO estimates was remarkably high. The method of AIS denominator determination was the most significant predictor of LVO estimates. Studies with a standardized LVO definition and methods of AIS estimation are necessary to estimate the true prevalence of LVO among patients with AIS.

3.
Neurosurgery ; 2019 Aug 21.
Artigo em Inglês | MEDLINE | ID: mdl-31435656

RESUMO

BACKGROUND: Symptomatic intracranial atherosclerotic disease (ICAD) is an important cause of stroke. Although the high periprocedural risk of intracranial stenting from recent randomized studies has dampened enthusiasm for such interventions, submaximal angioplasty without stenting may represent a safer endovascular treatment option. OBJECTIVE: To examine the periprocedural and long-term risks associated with submaximal angioplasty for ICAD based on the available literature. METHODS: All English language studies of intracranial angioplasty for ICAD were screened. Inclusion criteria were as follows: ≥ 5 patients, intervention with submaximal angioplasty alone, and identifiable periprocedural (30-d) outcomes. Analysis was co-nducted to identify the following: 1) periprocedural risk of any stroke (ischemic or hemorrh-agic) or death, and 2) stroke in the territory of the target vessel and fatal stroke beyond 30 d. Mixed effects logistic regression was used to summarize event rates. Funnel plot and rank correlation tests were employed to detect publication bias. The relative risk of periprocedural events from anterior vs posterior circulation disease intervention was also examined. RESULTS: A total of 9 studies with 408 interventions in 395 patients met inclusion criteria. Six of these studies included 113 posterior circulation interventions. The estimated pooled rate for 30-d stroke or death following submaximal angioplasty was 4.9% (95% CI: 3.2%-7.5%), whereas the estimated pooled rate beyond 30 d was 3.7% (95% CI: 2.2%-6.0%). There was no statistical difference in estimated pooled rate for 30-d stroke or death between patients with anterior (4.8%, 95% CI: 2.8%-7.9%) vs posterior (5.3%, 95% CI: 2.4%-11.3%) circulation disease (P > .99). CONCLUSION: Submaximal angioplasty represents a potentially promising intervention for symptomatic ICAD.

4.
J Neuroimaging ; 29(5): 565-572, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31339613

RESUMO

BACKGROUND AND PURPOSE: Visualization of structural details of treatment devices during neurointerventional procedures can be challenging. A new true two-resolution imaging X-ray detector system features a 194 µm pixel conventional flat-panel detector (FPD) mode and a 76 µm pixel high-resolution high-definition (Hi-Def) zoom mode in one detector panel. The Hi-Def zoom mode was developed for use in interventional procedures requiring superior image quality over a small field of view (FOV). We report successful use of this imaging system during intracranial aneurysm treatment in 1 patient with a Pipeline-embolization device and 1 patient with a low-profile visualized intramural support (LVIS Blue) device plus adjunctive coiling. METHODS: A guide catheter was advanced from the femoral artery insertion site to the proximity of each lesion using standard FPD mode. Under magnified small FOV Hi-Def imaging mode, an intermediate catheter and microcatheters were guided to the treatment site, and the PED and LVIS Blue plus coils were deployed. Radiation doses were tracked intraprocedurally. RESULTS: Critical details, including structural changes in the PED and LVIS Blue and position and movement of the microcatheter tip within the coil mass, were more readily apparent in Hi-Def mode. Skin-dose mapping indicated that Hi-Def mode limited radiation exposure to the smaller FOV of the treatment area. CONCLUSIONS: Visualization of device structures was much improved in the high-resolution Hi-Def mode, leading to easier, more controlled deployment of stents and coils than conventional FPD mode.

5.
World Neurosurg ; 129: e831-e837, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31207378

RESUMO

BACKGROUND: Treatment of unruptured intracranial aneurysms (IAs) in elderly patients is associated with a high risk of morbidity and mortality, necessitating a thorough understanding of the potential rupture risk. The aim of this study was to identify morphologic parameters and anatomic locations that could discriminate ruptured IAs in patients ≥70 years old. METHODS: Retrospective analysis was performed of three-dimensional angiograms and medical records of 344 patients with 411 saccular IAs. Patients ≥70 years old were defined as elderly. IAs were subdivided into ruptured and unruptured. Morphologic parameters and anatomic locations were compared in elderly and younger (<70 years old) patients with ruptured and unruptured IAs. RESULTS: The study included 266 patients <70 years old and 78 patients ≥70 years old with 411 aneurysms (102 ruptured and 309 unruptured). In the elderly group, 22 of 95 aneurysms were ruptured (23.15%) compared with 80 of 316 (25.3%) in the younger group. Size ratio and aspect ratio were higher in ruptured IAs, but only in the younger group. Undulation index, indicating IA shape irregularity, was significantly different between ruptured and unruptured IAs in younger and elderly groups. The only variables associated with rupture in the elderly group were undulation index (0.11 ± 0.07 vs. 0.07 ± 0.06, P = 0.02) and location (P = 0.001). CONCLUSIONS: Aneurysm size, size ratio, and aspect ratio may not be reliable discriminants of rupture in elderly patients. Unruptured IAs in elderly patients should be evaluated on the basis of shape irregularity and anatomic location.

6.
Neurosurgery ; 85(suppl_1): S72, 2019 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-31197333

RESUMO

This video illustrates access to tortuous distal intracranial vasculature and the use of intra-arterial (IA) tissue plasminogen activator (tPA) for the revascularization of small vessel occlusion. IA tPA is a reasonable approach for distal arterial occlusion resistant to intravenous tPA or mechanical thrombectomy. In this video, the patient had a posterior circulation stroke with elevated time-to-peak in the cerebellar hemispheres. He had received intravenous tPA in the emergency room but ataxia and dysarthria symptoms persisted. Cerebral angiography showed right superior cerebellar artery (SCA) occlusion. Although his NIHSS score was low, his symptoms were disabling. While not standard of care, discussion with patients about potential options is crucial; and we believe that mechanical and localized therapies in these circumstances may be beneficial. A Velocity microcatheter (Penumbra, Alameda, California) was initially used to attempt SCA access but was unsuccessful. A second attempt was made with a Headway Duo (MicroVention, Aliso Viejo, California)-a smaller, more pliant microcatheter better suited to the acute turn in the SCA. A 2 mg IA tPA dose was administered at the occlusion site. A direct aspiration first-pass technique (ADAPT) and stent retriever were thought to be too aggressive in a small SCA. The proximal vessel was recanalized, and the microcatheter was advanced to the distal occlusion site before IA administration of another 2 mg of tPA. Post-tPA runs showed excellent SCA revascularization. For occlusion of small intracranial vessels where IV tPA is ineffective and mechanical thrombectomy is unsafe, local administration of IA tPA can be an effective therapy. Consent was obtained from the patient prior to performing the procedure. Institutional review board approval is not required for the report of a single case.

7.
Neurosurgery ; 85(suppl_1): S52-S57, 2019 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-31197334

RESUMO

BACKGROUND: Acute ischemic stroke (AIS) remains a significant source of morbidity and mortality worldwide. Multiple recent randomized clinical trials for AIS patients presenting with large vessel occlusion have demonstrated radical improvement in outcomes with mechanical thrombectomy (MT), which is now recognized as the new standard of care for patients presenting up to 24 hr. OBJECTIVE: To provide a perspective on training and credentialing requirements for practitioners in this field. METHODS: Relevant articles were systematically searched and analyzed. Standards for Reporting Qualitative Research guidelines were utilized. RESULTS: : The Committee for Advanced Subspecialty Training (CAST) brings together the principal specialties of Radiology, Neurology, and Neurosurgery. Their training standards document the most recent consensus on training for neuroendovascular surgery (NES) and include the endovascular treatment of AIS as a part of the field of NES. This unified consensus represents a significant landmark in the evolution of stroke therapy. Presently, training at most centers follows an apprenticeship type model. Simulation methods and objective performance metrics have not been widely incorporated. Maintenance of proficiency has not been conclusively addressed reflecting the overall developing nature of the field. CONCLUSION: The evolution of the standard of care interventional therapy for large vessel AIS utilizing MT raises concerns regarding work force needs, training standards, competency, and credentialing requirements for practitioners. The CAST framework represents the most modern and flexible approach for both individuals and training programs. Methods based on objective performance metrics utilizing simulation as primary vehicle may be the logical next steps in the evolution of NES.

8.
Neurosurgery ; 85(suppl_1): S38-S46, 2019 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-31197342

RESUMO

Early recognition and differentiation of acute ischemic stroke from intracranial hemorrhage and stroke mimics and the identification of large vessel occlusion (LVO) are critical to the appropriate management of stroke patients. In this review, we discuss the current evidence and practices surrounding safe and efficient triage in the emergency room. As the indications of stroke intervention are evolving to further improve stroke care, focus has begun to revolve around recognition of LVO and provision of endovascular thrombectomy with or without the administration of tissue plasminogen activator. Systems of stroke care are being organized to achieve this goal without delay. Clinical history is important in determining time of onset or last known well time, but, alone or along with an examination, it cannot reliably predict an LVO or exclude intracranial hemorrhage and stroke mimics. The choice of imaging is influenced mainly by the duration of symptoms. On the basis of recent trials, patients presenting after the 6-h therapeutic window can be considered for endovascular thrombectomy if the computed tomographic or magnetic resonance perfusion imaging shows favorable findings. The Society of NeuroInterventional Surgery has established time metrics for each step of triage and initial management. Hospitals are required to develop multidisciplinary stroke teams and emergency protocols to meet these goals. There also needs to be coordination of the emergency medical services with the emergency facility of an appropriate stroke center (a primary stroke center, comprehensive stroke care center, or a thrombectomy-capable stroke center).

10.
Cardiovasc Intervent Radiol ; 42(8): 1160-1167, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31152229

RESUMO

BACKGROUND AND PURPOSE: Data on safety and efficacy of periprocedural use of heparin are limited during treatment of acute ischemic stroke patients with anterior circulation tandem occlusion. This study aimed to investigate the impact of heparin use during endovascular therapy of anterior circulation tandem occlusions on the functional and safety outcomes. METHODS: A retrospective analysis of the multicenter observational TITAN registry was performed. Patients with anterior circulation tandem occlusion and treated with endovascular therapy (EVT) were included, with or without extracranial carotid intervention. We divided patients into two groups based on periprocedural heparin use (heparin vs. non-heparin). The dose of intravenous unfractionated heparin ranged from 1500 to 2500 I.U. Primary study endpoint was 90-day Modified Rankin Scale (mRS). Secondary study endpoint included angiographic and safety endpoints such as hemorrhagic complications. A propensity-score-matched analysis was performed. RESULTS: Among 369 patients, heparin was used in 68 patients (18.4%). In the propensity-score-matched cohort, favorable outcome (mRS 0-2) occurred in 51.3% in heparin group and 58.0% in non-heparin group (matched OR, 0.76; 95% CI, 0.32-1.78; P = 0.52). Similar result was found in propensity-score-adjusted cohort (adjusted OR, 0.72; 95%CI, 0.39-1.32; P = 0.28). Likewise, there was no difference in the rate of successful reperfusion (mTICI 2b-3) (propensity-score-adjusted OR, 1.03; 95%CI, 0.50-2.09; P = 0.93) neither in safety endpoints between the two groups. CONCLUSIONS: Periprocedural heparin use during EVT of anterior circulation tandem occlusions was not associated with better functional, angiographic or safety outcomes. These findings are applicable for low doses of heparin, and further studies are warranted.

11.
J Neurointerv Surg ; 2019 Jun 25.
Artigo em Inglês | MEDLINE | ID: mdl-31239328

RESUMO

BACKGROUND: Thrombectomy is an efficacious treatment for acute ischemic stroke (AIS). However, relatively few studies to date have specifically examined the impact and clinical implications of age on outcomes for thrombectomy in anterior AIS. OBJECTIVE: To provide a snapshot of patient metrics and outcomes with respect to age following thrombectomy for anterior AIS to supplement the current body of data for predictors of clinical outcomes in a real-world setting. METHODS: Data were collected for 20 consecutive patients with AIS treated with thrombectomy at 15 high-volume stroke centers across North America between 2015 and 2016. Patients with anterior occlusions were dichotomized based on whether they were older or younger than 80 years. Ordinal logistic regression analyzed how clinical variables impacted disability using 90-day modified Rankin Scale (mRS) scores. RESULTS: Adequate revascularization (TICI ≥2B) was achieved in 92.3% of patients aged <80 years with an average 1.7±0.1 passes taken with the primary technique and in 88.0% of patients aged ≥80 years with an average 1.7±0.2 passes. Despite similar baseline characteristics, mRS scores were significantly higher in older patients postoperatively and at 90 days after intervention. Age was a significant predictor of 90-day mRS across the study population. CONCLUSION: This analysis affirms age is a significant determinant of 90-day mRS scores following thrombectomy for large vessel anterior AIS. Further investigation into risks faced by elderly patients during thrombectomy may provide actionable information to help refine patient selection and improve outcomes.

12.
World Neurosurg ; 2019 May 13.
Artigo em Inglês | MEDLINE | ID: mdl-31096030

RESUMO

BACKGROUND: Concerns exist that neurosurgery might fail to lead the field of endovascular surgical neuroradiology (ESN), as other specialties are allowed to train and practice ESN. This study aimed to assess the current breakdown of specialties and their relative academic productivity in accredited ESN fellowship programs. METHODS: A list of fellowship programs was obtained from the Accreditation Council for Graduate Medical Education and Committee on Advanced Subspecialty Training directories. Primary specialty (i.e., residency) training for each faculty member in these programs was determined using information provided by the programs. A bibliometric search was performed for each member using Web of Science (Clarivate Analytics, Philadelphia, Pennsylvania, USA). Cumulative and ESN-specific h indices were calculated; h indices were compared between each specialty group and between international medical graduates and US medical graduates, regardless of specialty training. RESULTS: Thirty-one ESN fellowship programs with 88 faculty members were included. Neurosurgeons constituted 61.4% (n = 54) of the total ESN faculty, followed by radiologists with 30.7% (n = 27), and neurologists with 7.9% (n = 7). The mean ESN-specific h index for neurosurgery-trained ESN faculty was 16.2 ± 14.6 compared with 14.4 ± 10.9 for radiologists and 13.0 ± 12.6 for neurologists (P = 0.76). There were 12 IMGs and 76 USMGs. The mean ESN-specific h index was greater for IMGs than USMGs, 24.7 ± 14.3 versus 14.0 ± 12.7 (P = 0.008), respectively. CONCLUSIONS: Neurosurgery is leading the ESN field in numbers; however, the h index is not significantly different among ESN faculty based on primary training. The number of IMGs is relatively small, yet IMGs have significantly higher mean h indices.

13.
World Neurosurg ; 2019 Apr 30.
Artigo em Inglês | MEDLINE | ID: mdl-31048049

RESUMO

BACKGROUND: Various studies have suggested that age ≥80 years is associated with a higher rate of complications after carotid artery stenting (CAS). The Buffalo Risk Assessment Scale (BRASS) predicts complications in symptomatic patients undergoing CAS. Application of the BRASS has shown the ability to improve patient selection. We used the BRASS system to evaluate whether the higher rate of complications associated with CAS in the elderly is related to vascular anatomy. METHODS: A retrospective review of CAS was performed at our institution over 7 years. Demographic information, anatomic characteristics, BRASS categorization, and outcome measures were compared between elderly (≥80 years) and younger patients (<80 years). RESULTS: The study included 447 patients: 335 patients (75%) <80 years and 112 patients (25%) ≥80 years. There were significantly more elderly patients in the high-risk BRASS category (P < 0.01), and more young patients in the low-risk BRASS category (P = 0.04). The complication rates in the 2 groups were similar. Older patients were more likely to harbor complex vascular anatomy: they had significantly higher rates of types II and III aortic arches (P = 0.01 and P < 0.01, respectively), higher percentage of tortuous carotid vessels (P < 0.01), and higher rates of hostile anatomy for deployment of distal embolic protection devices (P = 0.02). CONCLUSIONS: Complex vascular anatomy, rather than age, is the key factor behind the higher CAS-associated complication rate in the elderly. Complications can be avoided through proper patient selection and stratifying patients based on anatomic characteristics, which can be achieved through the BRASS scoring system.

14.
J Neurointerv Surg ; 11(10): 957-963, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30975738

RESUMO

BACKGROUND: Thrombectomy for anterior large vessel occlusion less than 24 hours since last known well is now standard of care. Certain aspects of clinical trials may limit generalizability to 'real-world' practice. OBJECTIVE: To compare revascularization rates and outcomes for direct aspiration (ADAPT) and stent retriever thrombectomy following anterior acute ischemic stroke (AIS) in a real-life setting. METHODS: Data from the most recent 20 consecutive patients with AIS treated with mechanical thrombectomy between 2015 and 2016 were collected from 15 high-volume stroke centers across North America for a total of 300 cases. Patients with proximal anterior large vessel occlusions were dichotomized by primary treatment technique. Ordinal logistic regression assessed the effects of clinical variables on patient disability using 90-day modified Rankin Scale (mRS) scores. RESULTS: Adequate revascularization (Thrombolysis in Cerebral Infarction ≥2b) was ultimately achieved in 91.2% of first-line direct aspiration (ADAPT) cases with an average of 1.9±1.9 passes and in 87.5% of stent retriever cases with an average of 1.7±1.0 passes. Time from groin puncture to revascularization was shorter for ADAPT cases. The mean 90-day mRS score for both groups was 3.0±2.4. Number of passes using primary technique, and postintervention intracranial hemorrhage, were significant predictors of 90-day mRS scores after ADAPT, while age and preprocedure mRS score were predictive of outcomes following first-line stent retriever. CONCLUSIONS: Our data show similar adequate revascularization rates and 90-day functional outcomes for first-line direct aspiration and stent retrievers for anterior large vessel occlusion in a real-world setting. These results support the findings of other prospective trials evaluating the two techniques.

15.
J Neurointerv Surg ; 11(10): 970-974, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30842304

RESUMO

INTRODUCTION: Endovascular treatment (EVT) for tandem occlusion (TO) of the anterior circulation is complex but effective. The effect of extracranial internal carotid artery (EICA) lesion severity on the outcomes of EVT is unknown. In this study we investigated the effect of EICA lesion severity on the outcomes of tandem occlusion EVT. METHODS: A multicenter retrospective TITAN (Thrombectomy In TANdem lesions) study that included 18 international endovascular capable centers was performed. Patients who received EVT for atherosclerotic TO with or without EICA lesion intervention were included. Patients were divided into two groups based on the EICA lesion severity (high-grade stenosis (≥90% North American Symptomatic Carotid Endarterectomy Trial) vs complete occlusion). Outcome measures included the 90-day clinical outcome (modified Rankin Scale score (mRS)), angiographic reperfusion (modified Thrombolysis In Cerebral Ischemia (mTICI) at the end of the procedure), procedural complications, and intracranial hemorrhage at 24 hours follow-up. RESULTS: A total of 305 patients were included in the study, of whom 135 had complete EICA occlusion and 170 had severe EICA stenosis. The EICA occlusion group had shorter mean onset-to-groin time (259±120 min vs 305±202 min; p=0.037), more patients with diabetes, and fewer with hyperlipidemia. With respect to the outcome, mTICI 2b-3 reperfusion was lower in the EICA occlusion group (70% vs 81%; p=0.03). The favorable outcome (90-day mRS 0-2), intracerebral hemorrhage and procedural complications were similar in both groups. CONCLUSION: Atherosclerotic occlusion of the EICA in acute tandem strokes was associated with a lower rate of mTICI 2b-3 reperfusion but similar functional and safety outcomes when compared with high-grade EICA stenosis.

16.
J Neurointerv Surg ; 11(7): 729-732, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30842301

RESUMO

BACKGROUND: Pediatric acute ischemic stroke with underlying large vessel occlusion is a rare disease with significant morbidity and mortality. There is a paucity of data about the safety and outcomes of endovascular thrombectomy in these cases, especially with modern devices. METHODS: We conducted a retrospective review of all pediatric stroke patients who underwent endovascular thrombectomy in nine US tertiary centers between 2008 and 2017. RESULTS: Nineteen patients (63.2% male) with a mean (SD) age of 10.9(6) years and weight 44.6 (30.8) kg were included. Mean (SD) NIH Stroke Scale (NIHSS) score at presentation was 13.9 (5.7). CT-based assessment was obtained in 88.2% of the patients and 58.8% of the patients had perfusion-based assessment. All procedures were performed via the transfemoral approach. The first-pass device was stentriever in 52.6% of cases and aspiration in 36.8%. Successful revascularization was achieved in 89.5% of the patients after a mean (SD) of 2.2 (1.5) passes, with a mean (SD) groin puncture to recanalization time of 48.7 (37.3) min (median 41.5). The mean (SD) reduction in NIHSS from admission to discharge was 10.2 (6.2). A good neurological outcome was achieved in 89.5% of the patients. One patient had post-revascularization seizure, but no other procedural complications or mortality occurred. CONCLUSIONS: Endovascular thrombectomy is safe and feasible in selected pediatric patients. Technical and neurological outcomes were comparable to adult literature with no safety concerns with the use of standard adult devices in patients as young as 18 months. This large series adds to the growing literature but further studies are warranted.


Assuntos
Transtornos Cerebrovasculares/diagnóstico por imagem , Transtornos Cerebrovasculares/cirurgia , Procedimentos Endovasculares/métodos , Trombectomia/métodos , Adolescente , Criança , Feminino , Humanos , Masculino , Estudos Retrospectivos , Resultado do Tratamento
17.
Neurosurgery ; 2019 Mar 12.
Artigo em Inglês | MEDLINE | ID: mdl-30860254

RESUMO

BACKGROUND: The Pipeline Embolization Device (PED; Medtronic, Dublin, Ireland) has become an important tool for the treatment of cerebral aneurysms. Since FDA approval, there are ongoing efforts to increase aneurysm occlusion rates and reduce the incidence of complications. OBJECTIVE: To assess aneurysm occlusion and complication rates over time. METHODS: Retrospective analysis of consecutive anterior circulation aneurysms treated with a single PED between 2011 and 2016 at 3 academic institutions in the US was performed. Factors contributing to changes in aneurysm occlusion and complication rates over time were identified and evaluated. RESULTS: A total of 284 procedures were performed on 321 anterior circulation aneurysms in 284 patients. At a median follow-up of 13 mo (mean 18 mo), complete or near complete occlusion (>90%) was achieved in 85.9% of aneurysms. There was no significant change in aneurysm occlusion rate or procedure length over time. Thromboembolic complication occurred in 8.1% of procedures, and there was a trend toward decreased incidence from 16.3% in 2011/2012 to 3.3% in 2016 (P = .14). Hemorrhagic complications significantly decreased from 8.2% in 2011/2012 to 0 to 1.0% in 2014-2016 (P = .1). CONCLUSION: We report a notable drop in the rate of hemorrhagic and to a lesser extent thromboembolic complications with increased experience with PED in a multicenter cohort. Multiple factors are believed to contribute to this drop, including the evolved interpretation of platelet function testing, the switching of clopidogrel nonresponders to ticagrelor, and the reduced use of adjunctive coiling.

18.
World Neurosurg ; 2019 Mar 13.
Artigo em Inglês | MEDLINE | ID: mdl-30878752

RESUMO

INTRODUCTION: Embolization of the middle meningeal artery has emerged as a minimally invasive means of managing subdural hematoma. The purpose of this study was to systematically review the literature on the safety and effectiveness of this treatment and to share our clinical experience. METHODS: This review was registered with the International prospective register of systematic reviews (PROSPERO). Public/Publisher Medline (PubMed), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Excerpta Medica dataBASE (EMBASE) and the Cochrane Library were searched using Medical Subject Headings (MeSH) terms for MMA embolization and CSDH from January 2000 through November 2018. All articles in the English language literature describing MMA embolization for CSDH were included, irrespective of study design. Consecutive patients who underwent MMA embolization at our hospital from January 2017 through June 2018 comprised our clinical experience. RESULTS: Fifteen studies with 193 procedures were included in the review. Ninety-five (49.2%) cases involved primary MMA embolization; 88(45.6%) embolization for recurrent CSDH, and 10(5.2%) were performed for prophylaxis after surgical evacuation. Recurrence after MMA embolization requiring further treatment occurred in 7(3.6%) cases. All other patients had symptomatic relief with no further recurrence. No procedure-related complications were reported. Polyvinyl alcohol was the most commonly used material. Our series included 8 patients treated with Onyx (Medtronic). All had symptom relief and significant reduction in hematoma size; no recurrences or procedure-related complications were observed. CONCLUSION: MMA embolization of CSDH is safe and effective for CSDH treatment based on a documented recurrence rate of 3.6% and lack of reported complications.

19.
J Neurointerv Surg ; 11(9): 884-890, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30760625

RESUMO

INTRODUCTION: Stent retriever combined with aspiration, or the 'Solumbra technique', has recently emerged as one of the popular methods of mechanical thrombectomy (MT). However, the variations in understanding and implementation of the Solumbra technique have not been reported. METHODS: An 18 part anonymous survey questionnaire was designed to extract information regarding technical variations of MT with a focus on the Solumbra technique. The survey link was posted on the Society of Neurointerventional Surgery (SNIS) website in 'SNIS connect'. RESULTS: 80 responses were obtained over 4 weeks that were included in the final analysis. Direct aspiration without a balloon guide catheter (BGC) was the most favored technique among respondents (41.12%) followed by the Solumbra technique without a BGC (32.4%). Among those using the Solumbra technique, 77.6% reported that they wait between 2 and 5 min to allow clot engagement, 55.2% always remove the microcatheter before aspiration, and 69.1% commence aspiration through the intermediate catheter only when retrieving the stent retriever. Operators who infrequently used or did not use BGCs reported a higher incidence of >80% Thrombolysis in Cerebral Infarction 2b/3 annual recanalization rates (OR 8.85, 95% CI 2.03 to 38.55, P=0.004) compared with those who consistently used BGCs. CONCLUSION: Our study documents the variations in MT techniques, and more specifically, attempts to quantify variations in the Solumbra technique. The impact of these variations on recanalization rates and eventually patient outcomes are unclear, especially given the self-reported outcomes contained in this study.

20.
J Stroke Cerebrovasc Dis ; 28(5): 1329-1337, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30772159

RESUMO

BACKGROUND: The two most common approaches to thrombectomy of emergent large vessel occlusion (direct aspiration and primary stent retriever thrombectomy) have been extensively studied; however, the detailed benefit and risk comparison is largely unknown. OBJECTIVE: To conduct a systematic review and meta-analysis to compare radiographic and clinical outcomes between the use of primary stent retrievers and direct aspiration in management of acute ischemic stroke. METHODS: PubMed database was searched for studies between September 1, 2012 and December 31, 2017 with acute ischemic stroke patients. RESULTS: We identified 64 studies with 6875 patients in the primary stent retriever group and 25 studies with 2252 patients in the aspiration group. Primary aspiration alone, without the need of rescue stent retriever devices within the aspiration cohort, was performed in 65% of 2252 patients. There was no difference in the distribution of emergent large vessel occlusion based on occlusion site, age, baseline National Institutes of Health Stroke Scale, or the use of intravenous tPA (P = .19, .051, .23, and .093, respectively). Successful recanalization rates, defined as thrombolysis in cerebral Infarction 2b/3, were significantly higher in the aspiration group than the primary stent retriever group (89% versus 80%, P < .0001). No significant difference in good clinical outcome, defined as modified Rankin scale 0-2 (aspiration 52% versus stent 48%, P = .13), symptomatic intracerebral hemorrhage (aspiration 5.6% versus stent 7.2%, P = .07), and mortality at 3 months (aspiration 15% versus stent 19%, P = .10). CONCLUSIONS: Both aspiration-first (including the subsequent use of stent retriever) and primary stent retriever thrombectomy approaches are equally effective in achieving good clinical outcomes. Our study suggests that direct aspiration with or without subsequent use of stent retriever is a safe and effective alternative to primary stent retriever in acute ischemic stroke.


Assuntos
Procedimentos Endovasculares , Acidente Vascular Cerebral/terapia , Trombectomia/métodos , Idoso , Avaliação da Deficiência , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Recuperação de Função Fisiológica , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/fisiopatologia , Sucção , Trombectomia/efeitos adversos , Trombectomia/instrumentação , Trombectomia/mortalidade , Fatores de Tempo , Resultado do Tratamento
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