Interventional Neurology

BACKGROUND: Traditionally, patients undergoing acute ischemic strokes were candidates for mechanical thrombectomy if they were within the 6-h window from onset of symptoms. This timeframe would exclude many patient populations, such as wake-up strokes. However, the most recent clinical trials, DAWN and DEFUSE3, have expanded the window of endovascular treatment for acute ischemic stroke patients to within 24 h from symptom onset. This expanded window increases the number of potential candidates for endovascular intervention for emergent large vessel occlusions and raises the question of how to efficiently screen and triage this increase of patients...

Purpose: We assess the impact of retrievable stent (RS) compared to first-generation devices on in-hospital mortality and disability in patients with acute ischemic stroke (AIS). Methods: Using the National Inpatient Sample, data were obtained for patients with a primary diagnosis of AIS who underwent mechanical thrombectomy (MT) and were admitted to US hospitals between 2010 and 2014. Two time periods were compared: 2010-2012 (pre-RS Food and Drug Administration [FDA] approval) and 2013-2014 (post-RS FDA approval)...

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BACKGROUND: Flow-diverting stents (FDS) have revolutionized the endovascular management of unruptured, complex, wide-necked, and giant aneurysms. There is no consensus on management of complications associated with the placement of these devices. This review focuses on the management of complications of FDS for the treatment of intracranial aneurysms. SUMMARY: We performed a systematic, qualitative review using electronic databases MEDLINE and Google Scholar. Complications of FDS placement generally occur during the perioperative period...

BACKGROUND/AIMS: Endovascular treatment improves the outcomes of patients presenting with acute large vessel occlusions. Isolated proximal carotid occlusions presenting with hemodynamic ischemic stroke may probably also benefit from endovascular treatment. We aimed to assess the clinical and radiological data findings on patients who underwent endovascular treatment for acute ischemic stroke related to an isolated cervical carotid artery occlusion. METHODS: Of a consecutive series of 223 patients who were admitted with acute ische-mic stroke and were treated by thrombectomy, we included 9 patients with isolated cervical internal carotid occlusions...

Background: "Remote aspiration," using suction from the proximal internal carotid artery (ICA) to open terminus occlusions, has been reported in small case series. However, it remains unclear whether remote aspiration is feasible for middle cerebral artery occlusions in the setting of potential inflow from communicating arteries. We performed an in vitro study to assess whether suction applied at various locations proximal to an occlusion could successfully aspirate the clot...

Introduction: Tandem vertebral ostial disease with acute intracranial vertebrobasilar occlusion with contralateral vertebral occlusion or hypoplasia presents a unique challenge to the interventionalist. Methods: The authors queried a prospectively maintained institutional endovascular database from August 2013 to June 2018 for cases of endovascularly treated acute tandem vertebrobasilar occlusions in the presence of contralateral vertebral occlusive disease or hypoplasia...

Background: Strict criteria for recombinant tissue plasminogen activator (rtPA) eligibility are stipulated on licences for use in ischaemic stroke; however, practitioners may also add non-standard rtPA criteria. We examined eligibility criteria variation in 3 English-speaking countries including use of non-standard criteria, in relation to rtPA treatment rates. Methods: Surveys were mailed to 566 eligible hospitals in Australia (AUS), the UK, and the USA. Criteria were pre-classified as standard (approved indication and contraindications) or non-standard (approved warning or researcher "decoy")...

OBJECTIVE: The middle cerebral artery (MCA) is the most commonly treated artery in mechanical thrombectomy stroke trials; however, there is no pragmatic agreement about the segmental anatomy and nomenclature utilized. It results in significant clinical-radiological dissociation and introduces bias in research trials. The purpose of the study is to review and compare angiographic anatomy with microsurgical anatomy literature of the MCA with emphasis on the discrepancy. METHODOLOGY: Consecutive cerebral angiograms between January 2011 and March 2014 were retrospectively reviewed by endovascular surgical neuroradiologists...

BACKGROUND: Stent-assisted coiling (SAC) leads to significant changes in the vascular angle altering the bifurcation geometry and the hemodynamics at the bifurcation apex. It is believed that the stent alone exerts this effect, but other possible factors have not been studied. PURPOSE: To study the factors contributing to angular remodeling following SAC of bifurcation aneurysms including the anatomical, stent-related, and coil-related factors. MATERIALS AND METHODS: We reviewed 43 basilar and carotid bifurcation aneurysms treated by SAC using Neuroform EZ ( n = 28), Enterprise ( n = 8), and Lvis Jr...

BACKGROUND: Recent reports have raised various concerns about the risk of vessel wall injury while withdrawing current laser-cut stent retrievers during active strut apposition to the vessel walls. The development of braided thrombectomy assist devices in conjunction with aspiration systems may be gentler on the fragile brain vessels and more optimized with regard to the radial force (RF) for vessel diameters of proximal (M1) and distal (M2) large vessel occlusions (LVOs). METHODS: Mechanical bench testing of the RF was performed using a radial compression station mounted on a tensile testing machine...

OBJECTIVE: To determine the safety and efficacy of flow reversal following proximal flow arrest as an embolic protection strategy for carotid angioplasty and stenting (CAS) with short-term follow-up. METHOD: We performed a retrospective review of our CAS database for patients who underwent stent-supported carotid revascularization in the setting of acute/subacute stroke or TIA. We reviewed clinical and radiographic data during a 36-month period. Primary outcome was clinical evidence of ipsilateral stroke in the first 30 days...

First pass success (FPS) can be defined as in vitro retrieval of clot in a single pass during mechanical thrombectomy (MT) for acute large vessel occlusion (LVO). Despite advancements in MT technology, retrieval of fibrin-rich clots remains a challenge. Therefore, the effect of stent retriever length on FPS for fibrin-rich clots was investigated by using SolitaireTM 6 × 40 versus 6 × 30 mm devices with a balloon guide catheter (BGC) or distal access catheter (DAC) and sheath, in an in vitro model of anterior circulation neurovascular anatomy...

Objective: To examine outcomes for thrombectomy devices used for treatment of acute ischemic stroke (AIS) with middle cerebral artery (MCA) M2 segment emergent large vessel occlusion (ELVO) as the optimal device for such reperfusion is not clearly defined. Methods: A retrospective cohort study of consecutive AIS patients with MCA M2 ELVO undergoing thrombectomy from 3 academic medical centers was conducted from October 1999 through June 2016. The patients were divided based on the device utilized...

BACKGROUND: Successful reperfusion after endovascular thrombectomy (EVT) correlates with good outcome. However, radiographic reperfusion does not always translate into good clinical outcomes even if the reperfusion occurs early after the stroke onset. Reasons for neurological worsening (NW) are thought to be many, such as progression of the stroke, hemorrhagic conversion post tissue plasminogen activator and/or EVT, and procedural complications such as vessel dissection or perforation, distal emboli, and re-occlusion...

Idiopathic intracranial hypertension (IIH) is a rare, ill-understood disease of significant morbidity. Because the pathophysiology is poorly understood, treatment protocols are not uniform and are directed towards alleviating the most common symptoms: headache and visual loss. In this review, we analyze 25 case series, all of which included IIH patients ( n = 408) who were treated with placement of a venous sinus stent. Among 342 patients who had headache, 240 patients (70.2%) had improvement or resolution of headache after the stent insertion...

Background: Induced hypertension has been used to promote cerebral blood flow under vasospastic conditions although there is no randomised clinical trial to support its use. We sought to mathematically model the effects of vasospasm on the cerebral blood flow and the effects of induced hypertension. Methods: The Anatomically Detailed Arterial Network (ADAN) model is employed as the anatomical substrate in which the cerebral blood flow is simulated as part of the simulation of the whole body arterial circulation...

BACKGROUND AND PURPOSE: Several reports have described lower mortality rates in overweight or obese patients as compared to normal weight ones. In the past decade, several studies have investigated the phenomenon, commonly known as the obesity paradox, with mixed results thus far. We sought to determine whether outcomes differ between patients with large vessel occlusion strokes (LVOS) after endovascular therapy (ET) according to their body mass index (BMI). METHODS: We reviewed our prospectively collected endovascular database at a tertiary care academic institution...

Background: The recently published multicenter randomized DAWN trial confirmed greater outcome benefit of endovascular therapy (ET) for anterior circulation large vessel occlusion ischemic stroke from 6 to 24 h from symptom onset compared to medical management in patients selected by advanced imaging with MRI or perfusion CT to identify mismatch between clinical deficit and infarct volume, which represents salvageable penumbra. The debate of CT over MRI is usually the potentially increase time consumption and the difficulty in establishing an adequate standardized workflow utilizing MRI during the hyperacute phase...

BACKGROUND: Platelet inhibitors are used to prevent thromboembolic complications related to neurovascular stenting (NVS) procedures. Despite substantial inter-individual variability of functional platelet inhibition, the value of platelet function tests (PFT) to assess inhibition remains controversial. OBJECTIVE: This study was conducted to compare differences in thromboembolic complication rates associated with NVS in platelet-inhibited patients with and without PFT...