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Cappellari M, Pracucci G, Saia V, Mandruzzato N, Valletta F, Sallustio F, Casetta I, Fainardi E, Da Ros V, Diomedi M, Capasso F, Nencini P, Vallone S, Bigliardi G, Tessitore A, La Spina P, Bracco S, Tassi R, Bergui M, Cerrato P, Ruggiero M, Longoni M, Castellan L, Malfatto L, Saletti A, De Vito A, Menozzi R, Scoditti U, Simonetti L, Zini A, Lafe E, Cavallini A, Lazzarotti GA, Giannini N, Boghi A, Naldi A, Romano D, Napoletano R, Comai A, Franchini E, Cavasin N, Critelli A, Giorgianni A, Cariddi LP, Semeraro V, Boero G, Zimatore DS, Petruzzellis M, Biraschi F, Nicolini E, Pedicelli A, Frisullo G, Calzoni A, Tassinari T, Gallesio I, Sepe F, Filauri P, Sacco S, Lozupone E, Rizzo A, Besana M, Giossi A, Pavia M, Invernizzi P, Amistà P, Russo M, Florio F, Inchingolo V, Filizzolo M, Mannino M, Mangiafico S, Toni D. Thrombectomy in ischemic stroke patients with tandem occlusion in the posterior versus anterior circulation. Neurol Sci 2024:10.1007/s10072-024-07638-x. [PMID: 38890169 DOI: 10.1007/s10072-024-07638-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 06/07/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Mechanical thrombectomy (MT) was found to be beneficial in acute ischemic stroke patients with anterior tandem occlusion (a-TO). Instead, little is known about the effectiveness of MT in stroke patients with posterior tandem occlusion (p-TO). We aimed to compare MT within 24 h from last known well time in ischemic stroke patients with p-TO versus a-TO. METHODS We conducted a cohort study on prospectively collected data of patients registered in the Italian Registry of Endovascular Treatment in Acute Stroke (IRETAS) who were treated with MT within 24 h from last known well time for acute ischemic stroke with p-TO (n = 275) or a-TO (n = 1853). RESULTS After adjustment for unbalanced pre-procedure variables (year 2015-2021, age, sex, NIHSS score, ASPECTS, and time strata for puncture groin) and pre-stroke mRS score as pre-defined predictor, p-TO was significantly associated with lower probability of mRS score 0-2 (OR 0.415, 95% CI 0.268-0.644) and with higher risk of death (OR 2.813, 95% CI 2.080-3.805) at 3 months. After adjustment for unbalanced procedural and post-procedure variables (IVT, general anesthesia, TICI 3, and 24-h HT) and pre-stroke mRS score as pre-defined predictor, association between p-TO and lower probability of mRS score 0-2 (OR 0.444, 95% CI 0.304-0.649) and association between p-TO and with higher risk of death (OR 2.971, 95% CI 1.993-4.429) remained significant. CONCLUSIONS MT within 24 h from last known well time in ischemic stroke patients with p-TO versus a-TO was associated with worse outcomes at 3 months.
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D'Alessio A, Strocchi S, Dalmasso F, Cannillo B, Matheoud R, Ponzetti A, Aimonetto S, Cernigliaro M, Azzalin G, Giorgianni A, Natrella M, Carriero A, Guzzardi G, Brambilla M. Effective and organ doses in patient undergoing interventional neuroradiology procedures: A multicentre study. Phys Med 2024; 122:103383. [PMID: 38810393 DOI: 10.1016/j.ejmp.2024.103383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 03/22/2024] [Accepted: 05/21/2024] [Indexed: 05/31/2024] Open
Abstract
PURPOSE Radiation doses to adult patients submitted to cerebral angiography and intracranial aneurysms treatments were assessed by using DICOM Radiation Dose Structured Reports (RDSR) and Monte Carlo simulations. Conversion factors to estimate effective and organ doses from Kerma-Area Product (PKA) values were determined. METHODS 77 cerebral procedures performed with five angiographic equipment installed in three Italian centres were analyzed. Local settings and acquisition protocols were considered. The geometrical, technical and dosimetric data of 16,244 irradiation events (13305 fluoroscopy, 2811 digital subtraction angiography, 128 cone-beam CT) were extracted from RDSRs by local dose monitoring systems and were input in MonteCarlo PCXMC software to calculate effective and organ doses. Finally, conversion factors to determine effective and organ doses from PKA were determined. Differences between centres were assessed through statistical analysis and accuracy of dose calculation method based on conversion factors was assessed through Bland-Altman analysis. RESULTS Large variations in PKA (14-561 Gycm2) and effective dose (1.2-73.5 mSv) were observed due to different degrees of complexity in the procedures and angiographic system technology. The most exposed organs were brain, salivary glands, oral mucosa, thyroid and skeleton. The study highlights the importance of recent technology in reducing patient exposure (about fourfold, even more in DSA). No statistically significant difference was observed in conversion factors between centres, except for some organs. A conversion factor of 0.09 ± 0.02 mSv/Gycm2 was obtained for effective dose. CONCLUSIONS Organ and effective doses were assessed for neuro-interventional procedures. Conversion factors for calculating effective and organ doses from PKA were provided.
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Vinciguerra A, Turri-Zanoni M, Ferrari M, Mattavelli D, Giorgianni A, Fazio E, Pierro FD, Rampinelli V, Gazzini L, Verillaud B, Schreiber A, Calabrese L, Bignami M, Battaglia P, Nicolai P, Castelnuovo P, Herman P. Endovascular coils extrusion after internal carotid artery occlusion: From management to follow-up. Int Forum Allergy Rhinol 2024. [PMID: 38690609 DOI: 10.1002/alr.23357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 04/05/2024] [Accepted: 04/12/2024] [Indexed: 05/02/2024]
Abstract
KEY POINTS ICA coil extrusion (ICA-CE) occurs most frequently in the nasopharyngeal/sinonasal site. Evaluating the ICA coils stability, through an angiography, is of primary importance. ICA-CE management needs to be decided based on the patient's symptoms and general status.
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Cappellari M, Pracucci G, Saia V, Fainardi E, Casetta I, Sallustio F, Ruggiero M, Longoni M, Simonetti L, Zini A, Lazzarotti GA, Giannini N, Da Ros V, Diomedi M, Vallone S, Bigliardi G, Limbucci N, Nencini P, Ajello D, Marcheselli S, Burdi N, Boero G, Bracco S, Tassi R, Boghi A, Naldi A, Biraschi F, Nicolini E, Castellan L, Del Sette M, Allegretti L, Sugo A, Buonomo O, Dell'Aera C, Saletti A, De Vito A, Lafe E, Mazzacane F, Bergui M, Cerrato P, Feraco P, Piffer S, Augelli R, Vit F, Gasparotti R, Magoni M, Comelli S, Melis M, Menozzi R, Scoditti U, Cavasin N, Critelli A, Causin F, Baracchini C, Guzzardi G, Tarletti R, Filauri P, Orlandi B, Giorgianni A, Cariddi LP, Piano M, Motto C, Gallesio I, Sepe FN, Romano G, Grasso MF, Pauciulo A, Rizzo A, Comai A, Franchini E, Sicurella L, Galvano G, Mannino M, Mangiafico S, Toni D, On Behalf Of The Iretas Group. IV thrombolysis plus thrombectomy versus IV thrombolysis alone for minor stroke with anterior circulation large vessel occlusion from the IRETAS and Italian SITS-ISTR cohorts. Neurol Sci 2023; 44:4401-4410. [PMID: 37458843 DOI: 10.1007/s10072-023-06948-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 07/04/2023] [Indexed: 11/14/2023]
Abstract
INTRODUCTION The aim of this study was to compare the outcomes of patients treated with intravenous thrombolysis (IVT) <4.5 h after symptom onset plus mechanical thrombectomy (MT) <6 h with those treated with IVT alone <4.5 h for minor stroke (NIHSS ≤5) with large vessel occlusion (LVO) in the anterior circulation. PATIENTS AND METHODS Patients enrolled in the Italian Registry of Endovascular Treatment in Acute Stroke (IRETAS) and in the Italian centers included in the SITS-ISTR were analyzed. RESULTS Among the patients with complete data on 24-h ICH type, 236 received IVT plus MT and 382 received IVT alone. IVT plus MT was significantly associated with unfavorable shift on 24-h ICH types (from no ICH to PH-2) (OR, 2.130; 95% CI, 1.173-3.868; p=0.013) and higher rate of PH (OR, 4.363; 95% CI, 1.579-12.055; p=0.005), sICH per ECASS II definition (OR, 5.527; 95% CI, 1.378-22.167; p=0.016), and sICH per NINDS definition (OR, 3.805; 95% CI, 1.310-11.046; p=0.014). Among the patients with complete data on 3-month mRS score, 226 received IVT plus MT and 262 received IVT alone. No significant difference was reported between IVT plus MT and IVT alone on mRS score 0-1 (72.1% versus 69.1%), mRS score 0-2 (79.6% versus 79%), and death (6.2% versus 6.1%). CONCLUSIONS Compared with IVT alone, IVT plus MT was associated with unfavorable shift on 24-h ICH types and higher rate of 24-h PH and sICH in patients with minor stroke and LVO in the anterior circulation. However, no difference was reported between the groups on 3-month functional outcome measures.
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Cappellari M, Pracucci G, Saia V, Sallustio F, Casetta I, Fainardi E, Capasso F, Nencini P, Vallone S, Bigliardi G, Saletti A, De Vito A, Ruggiero M, Longoni M, Semeraro V, Boero G, Silvagni U, Stancati F, Lafe E, Mazzacane F, Bracco S, Tassi R, Comelli S, Melis M, Romano D, Napoletano R, Menozzi R, Scoditti U, Chiumarulo L, Petruzzellis M, Vinci SL, Ferraù L, Taglialatela F, Zini A, Sanna A, Tassinari T, Iacobucci M, Nicolini E, Bergui M, Cerrato P, Giorgianni A, Princiotta Cariddi L, Amistà P, Russo M, Gallesio I, Sepe F, Comai A, Franchini E, Filauri P, Orlandi B, Besana M, Giossi A, Lazzarotti GA, Orlandi G, Castellano D, Naldi A, Plebani M, Zivelonghi C, Invernizzi P, Mangiafico S, Toni D. Predictors for hemorrhagic transformation and cerebral edema in stroke patients with first-pass complete recanalization. Int J Stroke 2023; 18:1238-1246. [PMID: 37337362 DOI: 10.1177/17474930231185690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
BACKGROUND Predictors of radiological complications attributable to reperfusion injury remain unknown when baseline setting is optimal for endovascular treatment and procedural setting is the best in stroke patients with large vessel occlusion (LVO). AIMS To identify clinical and radiological/procedural predictors for hemorrhagic transformation (HT) and cerebral edema (CED) at 24 hr in patients obtaining complete recanalization in one pass of thrombectomy for ischemic stroke ⩽ 6 h from symptom onset with intra-cranial anterior circulation LVO and ASPECTS ⩾ 6. METHODS We conducted a cohort study on prospectively collected data from 1400 patients enrolled in the Italian Registry of Endovascular Treatment in Acute Stroke. RESULTS HT was reported in 248 (18%) patients and early CED was reported in 260 (19.2%) patients. In the logistic regression model including predictors from a first model with clinical variables and from a second model with radiological/procedural variables, diabetes mellitus (odds ratio (OR) = 1.832, 95% confidence interval (CI) = 1.201-2.795), higher National Institutes of Health Stroke Scale (NIHSS) (OR = 1.076, 95% CI = 1.044-1.110), lower Alberta Stroke Program Early CT (ASPECTS) (OR = 0.815, 95% CI = 0.694-0.957), and longer onset-to-groin time (OR = 1.005, 95% CI = 1.002-1.007) were predictors of HT, whereas general anesthesia was inversely associated with HT (OR = 0.540, 95% CI = 0.355-0.820). Higher NIHSS (OR = 1.049, 95% CI = 1.021-1.077), lower ASPECTS (OR = 0.700, 95% CI = 0.613-0.801), intravenous thrombolysis (OR = 1.464, 95% CI = 1.061-2.020), longer onset-to-groin time (OR = 1.002, 95% CI = 1.001-1.005), and longer procedure time (OR = 1.009, 95% CI = 1.004-1.015) were predictors of early CED. After repeating a fourth logistic regression model including also good collaterals, the same variables remained predictors for HT and/or early CED, except diabetes mellitus and thrombolysis, while good collaterals were inversely associated with early CED (OR = 0.385, 95% CI = 0.248-0.599). CONCLUSIONS Higher NIHSS, lower ASPECTS, and longer onset-to-groin time were predictors for both HT and early CED. General anesthesia and good collaterals were inversely associated with HT and early CED, respectively. Longer procedure time was predictor of early CED.
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Gentile L, Pracucci G, Saia V, Falcou A, Biraschi F, Zini A, Simonetti L, Riva L, Bigliardi G, Vallone S, Nencini P, Limbucci N, Diomedi M, Da Ros V, Longoni M, Ruggiero M, Tassinari T, Allegretti L, Cerrato P, Rubino E, Bergui M, Cavallo R, Naldi A, Comelli C, Cappellari M, Zivelonghi C, Plebani M, De Vito A, Merli N, Saletti A, Musolino RF, Ferraù L, Vinci SL, Sacco S, Orlandi B, De Santis F, Filauri P, Ruiz L, Sepe FN, Gallesio I, Petruzzellis M, Chiumarulo L, Sangalli D, Salmaggi A, Filizzolo M, Moller J, Melis M, Comelli S, Magoni M, Gilberti N, Gasparotti R, Invernizzi P, Pavia M, Pinto V, Laspada S, Marcheselli S, Ajello D, Viaro F, Baracchini C, Causin F, Giannini N, Caselli MC, Mancuso M, Cosottini M, Scoditti U, Menozzi R, Russo M, Amistá P, Napoletano R, Romano DG, Tassi R, Bracco S, Carimati F, Versino M, Giorgianni A, De Boni A, Fasano A, Barbarini L, Paladini A, Franchini E, Dall'Ora E, Comai A, Giovanni F, Pedicelli A, Sallustio F, Casetta I, Fainardi E, Mangiafico S, Toni D. Mechanical thrombectomy in patients with heart failure: the Italian registry of Endovascular Treatment in Acute Stroke. Neurol Sci 2023; 44:3577-3585. [PMID: 37199875 DOI: 10.1007/s10072-023-06830-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 04/26/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Heart failure (HF) is the second most important cardiac risk factor for stroke after atrial fibrillation (AF). Few data are available on mechanical thrombectomy (MT) in acute ischemic stroke (AIS) patients with HF. METHODS The source of data is the multicentre Italian Registry of Endovascular Treatment in Acute Stroke (IRETAS). All AIS patients ≥ 18 years receiving MT were categorised in two groups: HF and no-HF. Baseline clinical and neuroradiological findings on admission were analysed. RESULTS Of 8924 patients, 642 (7.2%) had HF. Compared to the no-HF group, HF patients had higher prevalence of cardiovascular risk factors. Rate of complete recanalisation (TICI 2b-3) was 76.9% in HF vs 78.1% in no-HF group (p = 0.481). Rate of symptomatic intracerebral haemorrhage at 24-h non-contrast computed tomography (NCCT) was 7.6% in HF vs 8.3% in no-HF patients (p = 0.520). At 3 months, 36.4% of HF patients and 48.2% of no-HF patients (p < 0.001) had mRS 0-2, and mortality was, respectively, 30.7% and 18.5% (p < 0.001). In multivariate logistic regression, HF was independently associated with mortality at 3 months (OR 1.53, 1.24-1.88 95% CI, p < 0.001). In multivariate ordinal regression, HF patients had a probability of transitioning to a higher mRS level of 1.23 (1.05-1.44 95% CI, p = 0.012). The propensity score analysis of two groups matched for age, sex, and NIHSS at admission yielded the same results. CONCLUSION MT is safe and effective in HF patients with AIS. Patients with HF and AIS suffered from higher 3-month mortality and unfavourable outcome regardless of acute treatments.
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Cappellari M, Saia V, Pracucci G, Casetta I, Fainardi E, Sallustio F, Ruggiero M, Romoli M, Simonetti L, Zini A, Lazzarotti GA, Orlandi G, Vallone S, Bigliardi G, Renieri L, Nencini P, Semeraro V, Boero G, Bracco S, Tassi R, Castellano D, Naldi A, Biraschi F, Nicolini E, Del Sette B, Malfatto L, Allegretti L, Tassinari T, Tessitore A, Ferraù L, Saletti A, De Vito A, Lafe E, Cavallini A, Bergui M, Bosco G, Feraco P, Bignamini V, Mandruzzato N, Vit F, Mardighian D, Magoni M, Comelli S, Melis M, Menozzi R, Scoditti U, Cester G, Viario F, Stecco A, Fleetwood T, Filauri P, Sacco S, Giorgianni A, Cariddi LP, Piano M, Motto C, Gallesio I, Sepe F, Romano G, Grasso MF, Lozupone E, Fasano A, Comai A, Franchini E, Bruni S, Silvestrini M, Chiumarulo L, Petruzzelli M, Pavia M, Invernizzi P, Puglielli E, Casalena A, Pedicelli A, Frisullo G, Amistà P, Russo M, Allegritti M, Caproni S, Mangiafico S, Toni D. Stroke with large vessel occlusion in the posterior circulation: IV thrombolysis plus thrombectomy versus IV thrombolysis alone. J Thromb Thrombolysis 2023; 56:454-462. [PMID: 37378700 DOI: 10.1007/s11239-023-02844-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/03/2023] [Indexed: 06/29/2023]
Abstract
Efficacy and safety of mechanical thrombectomy (MT) for stroke with posterior circulation large vessel occlusion (LVO) is still under debate. We aimed to compare the outcomes of stroke patients with posterior circulation LVO treated with intravenous thrombolysis (IVT) (< 4.5 h after symptom onset) plus MT < 6 h after symptom onset with those treated with IVT alone (< 4.5 h after symptom onset). Patients enrolled in the Italian Registry of Endovascular Treatment in Acute Stroke (IRETAS) and in the Italian centers included in the SITS-ISTR were analysed. We identified 409 IRETAS patients treated with IVT plus MT and 384 SITS-ISTR patients treated with IVT alone. IVT plus MT was significantly associated with higher rate of sICH (ECASS II) compared with IVT alone (3.1 vs 1.9%; OR 3.984, 95% CI 1.014-15.815), while the two treatments did not differ significantly in 3-month mRS score ≤ 3 (64.3 vs 74.1%; OR 0.829, 95% CI 0.524-1.311). In 389 patients with isolated basilar artery (BA) occlusion, IVT plus MT was significantly associated with higher rate of any ICH compared with IVT alone (9.4 vs 7.4%; OR 4.131, 95% CI 1.215-14.040), while two treatments did not differ significantly in 3-month mRS score ≤ 3 and sICH per ECASS II definition. IVT plus MT was significantly associated with higher rate mRS score ≤ 2 (69.1 vs 52.1%; OR 2.692, 95% CI 1.064-6.811) and lower rate of death (13.8 vs 27.1%; OR 0.299, 95% CI 0.095-0.942) in patients with distal-segment BA occlusion, while two treatments did not differ significantly in 3-month mRS score ≤ 3 and sICH per ECASS II definition. IVT plus MT was significantly associated with lower rate of mRS score ≤ 3 (37.1 vs 53.3%; OR 0.137, 0.009-0.987), mRS score ≤ 1 (22.9 vs 53.3%; OR 0.066, 95% CI 0.006-0.764), mRS score ≤ 2 (34.3 vs 53.3%; OR 0.102, 95% CI 0.011-0.935), and higher rate of death (51.4 vs 40%; OR 16.244, 1.395-89.209) in patients with proximal-segment BA occlusion. Compared with IVT alone, IVT plus MT was significantly associated with higher rate of sICH per ECASS II definition in patients with stroke and posterior circulation LVO, while two treatment groups did not differ significantly in 3-month mRS score ≤ 3. IVT plus MT was associated with lower rate of mRS score ≤ 3 compared with IVT alone in patients with proximal-segment BA occlusion, whereas no significant difference was found between the two treatments in primary endpoints in patients isolated BA occlusion and in the other subgroups based on site occlusion.
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D’Alessio A, Cannillo B, Azzalin G, Matheoud R, Guzzardi G, Giorgianni A, Brambilla M, Strocchi S. ESTIMATION OF EFFECTIVE AND ORGAN DOSES IN PATIENT UNDERGOING INTERVENTIONAL NEURORADIOLOGY PROCEDURES: PRELIMINARY RESULTS OF A MULTICENTER STUDY. Phys Med 2022. [DOI: 10.1016/s1120-1797(22)02253-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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Agosti E, Saraceno G, Rampinelli V, Raffetti E, Veiceschi P, Buffoli B, Rezzani R, Giorgianni A, Hirtler L, Alexander AY, Deganello A, Piazza C, Nicolai P, Castelnuovo P, Locatelli D, Peris-Celda M, Fontanella MM, Doglietto F. Quantitative Anatomic Comparison of Endoscopic Transnasal and Microsurgical Transcranial Approaches to the Anterior Cranial Fossa. Oper Neurosurg (Hagerstown) 2022; 23:e256-e266. [PMID: 36106936 DOI: 10.1227/ons.0000000000000312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 04/12/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Several microsurgical transcranial approaches (MTAs) and endoscopic transnasal approaches (EEAs) to the anterior cranial fossa (ACF) have been described. OBJECTIVE To provide a preclinical, quantitative, anatomic, comparative analysis of surgical approaches to the ACF. METHODS Five alcohol-fixed specimens underwent high-resolution computed tomography. The following approaches were performed on each specimen: EEAs (transcribriform, transtuberculum, and transplanum), anterior MTAs (transfrontal sinus interhemispheric, frontobasal interhemispheric, and subfrontal with unilateral and bilateral frontal craniotomy), and anterolateral MTAs (supraorbital, minipterional, pterional, and frontotemporal orbitozygomatic approach). An optic neuronavigation system and dedicated software (ApproachViewer, part of GTx-Eyes II-UHN) were used to quantify the working volume of each approach and extrapolate the exposure of different ACF regions. Mixed linear models with random intercepts were used for statistical analyses. RESULTS EEAs offer a large and direct route to the midline region of ACF, whose most anterior structures (ie, crista galli, cribriform plate, and ethmoidal roof) are also well exposed by anterior MTAs, whereas deeper ones (ie, planum sphenoidale and tuberculum sellae) are also well exposed by anterolateral MTAs. The orbital roof region is exposed by both anterolateral and lateral MTAs. The posterolateral region (ie, sphenoid wing and optic canal) is well exposed by anterolateral MTAs. CONCLUSION Anterior and anterolateral MTAs play a pivotal role in the exposure of most anterior and posterolateral ACF regions, respectively, whereas midline regions are well exposed by EEAs. Furthermore, certain anterolateral approaches may be most useful when involvement of the optic canal and nerves involvement are suspected.
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Sallustio F, Pracucci G, Cappellari M, Saia V, Mascolo AP, Marrama F, Gandini R, Koch G, Diomedi M, D'Agostino F, Rocco A, Da Ros V, Wlderk A, Nezzo M, Argirò R, Morosetti D, Renieri L, Nencini P, Vallone S, Zini A, Bigliardi G, Pitrone A, Grillo F, Bracco S, Tassi R, Bergui M, Naldi A, Carità G, Casetta I, Gasparotti R, Magoni M, Simonetti L, Haznedari N, Paolucci M, Mavilio N, Malfatto L, Menozzi R, Genovese A, Cosottini M, Orlandi G, Comai A, Franchini E, Pedicelli A, Frisullo G, Puglielli E, Casalena A, Cester G, Baracchini C, Castellano D, Di Liberto A, Ricciardi GK, Chiumarulo L, Petruzzellis M, Lafe E, Persico A, Cavasin N, Critelli A, Semeraro V, Tinelli A, Giorgianni A, Carimati F, Auteri W, Rizzuto S, Biraschi F, Nicolini E, Ferrari A, Melis M, Calia S, Tassinari T, Nuzzi NP, Corato M, Sacco S, Squassina G, Invernizzi P, Gallesio I, Ruiz L, Dui G, Carboni N, Amistà P, Russo M, Maiore M, Zanda B, Craparo G, Mannino M, Inzitari D, Toni D, Mangiafico S. Carotid artery stenting during endovascular thrombectomy for acute ischemic stroke with tandem occlusion: the Italian Registry of Endovascular Treatment in Acute Stroke. Acta Neurol Belg 2022; 123:475-485. [PMID: 36056270 DOI: 10.1007/s13760-022-02067-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 08/11/2022] [Indexed: 11/01/2022]
Abstract
PURPOSE The management of tandem extracranial internal carotid artery and intracranial large vessel occlusion during endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) has been under-investigated. We sought to investigate outcomes of AIS patients with tandem occlusion (TO) treated with carotid artery stenting (CAS) compared to those not treated with CAS (no-CAS) during EVT. METHODS We performed a cohort study using data from AIS patients enrolled in the Italian Registry of Endovascular Treatment in Acute Stroke. Outcomes were 3 months' mortality, functional outcome, complete and successful recanalization, any intracranial hemorrhage, parenchymal hematoma and symptomatic intracerebral hemorrhage. RESULTS Among 466 AIS patients with TO, CAS patients were 122 and no-CAS patients were 226 (118 excluded). After adjustment for unbalanced variables, CAS was associated with a lower rate of 3 months' mortality (OR 0.407, 95% CI 0.171-0.969, p = 0.042). After adjustment for pre-defined variables, CAS was associated with a lower rate of 3 months' mortality (aOR 0.430, 95% CI 0.187-0.989, p = 0.047) and a higher rate of complete recanalization (aOR 1.986, 95% CI 1.121-3.518, p = 0.019), successful recanalization (aOR 2.433, 95% CI 1.263-4.686, p = 0.008) and parenchymal hematoma (aOR 2.876, 95% CI 1.173-7.050, p = 0.021). CAS was associated with lower 3 months mortality (OR 0.373, 95% CI 0.141-0.982, p = 0.046) and higher rates of successful recanalization (OR 2.082, 95% CI 1.099-3.942, p = 0.024) after adjustment for variables associated with 3 months' mortality and successful recanalization, respectively. CONCLUSIONS Among AIS patients with TO, CAS during EVT was associated with a higher rate of successful reperfusion and a lower rate of 3 months' mortality.
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Russo R, Boghi A, Giorgianni A, Lazzarotti GA, Bozzi A, Chegai F, Saletti A, Gallizioli G, Gavrilovic V, Michelozzi C, Petralia B, Gatti FL, Gorgatti T, Gallesio I, Cristaudo C, Politi MA, Molinaro S, Bergui M. Silk Vista Baby flow diverter stent for ruptured intracranial aneurysms: a retrospective observational study. Neuroradiology 2022; 64:2031-2037. [PMID: 35773522 DOI: 10.1007/s00234-022-03003-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 06/23/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Flow diversion changed the approach to complex intracranial aneurysms, leading to a widespread use and a rapid technological evolution. Indeed, indications continued to expand, including ruptured intracranial aneurysms in selected cases. Recently, new devices have been designed specifically to target smaller vessels. Therefore, we conducted a multicenter study to evaluate clinical outcome, complications, and occlusion rate of patients with ruptured aneurysms treated with new generation low profile Silk Vista Baby (SVB) flow diverter stent (FD). METHODS We performed a retrospective observational study on consecutive patients who underwent treatment with SVB for ruptured aneurysms at 12 Italian centers. Primary end point was favorable clinical outcome rate, defined as modified ranking score (mRS) of 0-2 at the 3 months. Secondary outcomes were complication rate, aneurysm re-rupture, and complete aneurysm occlusion at last radiological follow-up. RESULTS Twenty-five patients were included; at 3 months' follow-up, 19 patients (79.1%) had favorable clinical outcome (mRS 0-2). Three patients (12.5%) died during follow-up. In-stent thrombosis occurred in two cases (8.3%), managed with glycoprotein IIb/IIIA and intra-stent angioplasty, without clinical consequences. In 18 (85.7%) patients, complete occlusion at 3 months was demonstrated. No rebleeding occurred during follow-up. Presentation with unfavorable World Federation of Neurosurgical Societies grading system (WFNS) and posterior circulation location were both significantly correlated with unfavorable clinical outcome (p = 0.005 and p = 0.02). CONCLUSIONS Our data suggests that low profile FD treatment of ruptured intracranial aneurysms located distally of the circle of Willis is feasible. New generation low profile FD may represent an alternative option in carefully selected cases.
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Casetta I, Fainardi E, Pracucci G, Saia V, Sallustio F, da Ros V, Nappini S, Nencini P, Bigliardi G, Vinci S, Grillo F, Bracco S, Tassi R, Bergui M, Cerrato P, Saletti A, De Vito A, Gasparotti R, Magoni M, Simonetti L, Zini A, Ruggiero M, Longoni M, Castellan L, Malfatto L, Castellini P, Cosottini M, Comai A, Franchini E, Lozupone E, Della Marca G, Puglielli E, Casalena A, Baracchini C, Savio D, Duc E, Ricciardi G, Cappellari M, Chiumarulo L, Petruzzellis M, Cavallini A, Cavasin N, Critelli A, Burdi N, Boero G, Giorgianni A, Versino M, Biraschi F, Nicolini E, Comelli S, Melis M, Padolecchia R, Tassinari T, Paolo Nuzzi N, Marcheselli S, Sacco S, Invernizzi P, Gallesio I, Ferrandi D, Fancello M, Valeria Saddi M, Russo M, Pischedda A, Baule A, Mannino M, Florio F, Inchingolo V, Elena Flacco M, Romano D, Silvagni U, Inzitari D, Mangiafico S, Toni D. Sex differences in outcome after thrombectomy for acute ischemic stroke. A propensity score-matched study. Eur Stroke J 2022; 7:151-157. [PMID: 35647312 PMCID: PMC9134778 DOI: 10.1177/23969873221091648] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 03/14/2022] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND AND PURPOSE We sought to investigate whether there are gender differences in clinical outcome after stroke due to large vessel occlusion (LVO) after mechanical thrombectomy (EVT) in a large population of real-world patients. METHODS From the Italian Registry of Endovascular Thrombectomy, we extracted clinical and outcome data of patients treated for stroke due to large vessel occlusion. We compared clinical and safety outcomes in men and women who underwent EVT alone or in combination with intravenous thrombolysis (IVT) in the total population and in a Propensity Score matched set. RESULTS Among 3422 patients included in the study, 1801 (52.6%) were women. Despite older age at onset (mean 72.4 vs 68.7; p < 0.001), and higher rate of atrial fibrillation (41.7% vs 28.6%; p < 0.001), women had higher probability of 3-month functional independence (adjusted odds ratio-adjOR 1.19; 95% CI 1.02-1.38), of complete recanalization (adjOR 1.25; 95% CI 1.09-1.44) and lower probability of death (adjOR 0.75; 95% CI 0.62-0.90). After propensity-score matching, a well-balanced cohort comprising 1150 men and 1150 women was analyzed, confirming the same results regarding functional outcome (3-month functional independence: OR 1.25; 95% CI 1.04-1.51), and complete recanalization (OR 1.29; 95% CI 1.09-1.53). CONCLUSIONS Subject to the limitations of a non-randomized comparison, women with stroke due to LVO treated with mechanical thrombectomy had a better chance to achieve complete recanalization, and 3-month functional independence than men. The results could be driven by women who underwent combined treatment.
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Giorgianni A, Agosti E, Molinaro S, Terrana AV, Vizzari FA, Nativo L, Garg K, Craparo G, Conti V, Locatelli D, Baruzzi F, Valvassori L, Lanzino G. Flow diversion for acutely ruptured intracranial aneurysms treatment: A retrospective study and literature review. J Stroke Cerebrovasc Dis 2022; 31:106284. [PMID: 35007933 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 12/19/2021] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVE Flow diversion is becoming an increasingly established practice for the treatment of acutely ruptured intracranial aneurysms. In this study the authors present a literature review and meta-analysis, adding a retrospective review of institutional registry on emergency treatment of aRIA with flow diverter stent. MATERIALS AND METHODS A systematic search of PubMed, SCOPUS, Ovid MEDLINE, and Ovid EMBASE was performed on April 20th, 2021, extrapolating 35 articles. R language 'meta' and 'metafor' packages were used for data pooling. The DerSimonian-Laird model was used to calculate the pooled effect. The I2 value and Q statistic evaluated study heterogeneity. Additionally, the authors retrospectively reviewed their institutional database for the treatment and outcomes of all patients with acutely ruptured intracranial aneurysms treated with flow diverter stent placement from May 2010 to November 2020 was performed. RESULTS From the systematic literature review and meta-analysis, the pooled proportion of complete aneurysm occlusion was 78%, with a pooled rate of 79%, 71%, 80%, and 50% for dissecting, saccular, fusiform, and mycotic aneurysms, respectively. The pooled proportion of aneurysm rebleeding and intrastent stenosis was 12% and 15% respectively, for a total of 27% rate. The analysis of authors retrospective register showed an overall mortality rate of 16.7% (3/18), with a low but not negligible postprocedural rebleeding and intrastent thrombosis rates (5.6% and 11.1% respectively). CONCLUSION Although increasingly utilized in the management of selected patients with acutely ruptured intracranial aneurysms, flow diversion for acutely ruptured intracranial aneurysms treatment presents rebleeding and intrastent stenosis rates not negligible.
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Cappellari M, Saia V, Pracucci G, Enrico F, Consoli A, Nappini S, Castellan L, Bracco S, Bergui M, Cosottini M, Vangosa AB, Vinci S, Ruggiero M, Puglielli E, Chiumarulo L, Cester G, Comelli C, Silvagni U, Morosetti D, Caldiera V, Cavasin N, Ledda V, Sanfilippo G, Saletti A, Filauri P, Gallesio I, Nuzzi NP, Amistá P, Zivelonghi C, Plebani M, Pavia M, Romano D, Biraschi F, Menozzi R, Gasparotti R, Giorgianni A, Zini A, Inzitari D, Toni D, Mangiafico S. Association of the Careggi Collateral Score with 3-month modified Rankin Scale score after thrombectomy for stroke with occlusion of the middle cerebral artery. J Neurol 2021; 269:1013-1023. [PMID: 34797435 DOI: 10.1007/s00415-021-10898-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 11/07/2021] [Accepted: 11/08/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The Careggi Collateral Score (CCS) (qualitative-quantitative evaluation) was developed from a single-centre cohort as an angiographic score to describe both the extension and effectiveness of the pial collateral circulation in stroke patients with occlusion of the anterior circulation. We aimed to examine the association between CCS (quantitative evaluation) and 3-month modified Rankin Scale (mRS) score in a large multi-center cohort of patients receiving thrombectomy for stroke with occlusion of middle cerebral artery (MCA). METHODS We conducted a study on prospectively collected data from 1284 patients enrolled in the Italian Registry of Endovascular Treatment in Acute Stroke. According to the extension of the retrograde reperfusion in the cortical anterior cerebral artery (ACA)-MCA territories, CCS ranges from 0 (absence of retrograde filling) to 4 (visualization of collaterals until the alar segment of the MCA). RESULTS Using CCS of 4 as reference, CCS grades were associated in the direction of unfavourable outcome on 3-month mRS shift (0 to 6); significant difference was found between CCS of 0 and CCS of 1 and between CCS of 3 and CCS of 4. CCS ≥ 3 was the optimal cut-off for predicting 3-month excellent outcome, while CCS ≥ 1 was the optimal cut-off for predicting 3-month survival. CCS of 0 and CCS < 3 were associated in the direction of unfavourable recanalization on TICI shift (0 to 3) compared with CCS ≥ 1 and CCS ≥ 3, respectively. Compared with CCS ≥ 3 as reference, CCS of 0 and CCS 1 to 2 were associated in the direction of unfavourable recanalization on TICI shift. There was no evidence of heterogeneity of effects of successful recanalization and procedure time ≤ 60 min on 3-month mRS shift across CCS categories. CONCLUSION The CCS could provide a future advantage for improving the prognosis in patients receiving thrombectomy for stroke with M1 or M1-M2 segment of the MCA occlusion.
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Casetta I, Fainardi E, Pracucci G, Saia V, Vallone S, Zini A, Bergui M, Cerrato P, Nappini S, Nencini P, Gasparotti R, Saletti A, Causin F, Romano D, Burdi N, Giorgianni A, Mangiafico S, Toni D. Endovascular treatment beyond 24 hours from the onset of acute ischemic stroke: the Italian Registry of Endovascular Thrombectomy in Acute Stroke (IRETAS). J Neurointerv Surg 2021; 14:1186-1188. [PMID: 34732532 DOI: 10.1136/neurintsurg-2021-018045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 10/24/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Clinical trials and observational studies have demonstrated the benefit of thrombectomy up to 16 or 24 hours after the patient was last known to be well. This study aimed to evaluate the outcome of stroke patients treated beyond 24 hours from onset. METHODS We analyzed the outcome of 34 stroke patients (mean age 70.7±12.3 years; median National Institutes of Health Stroke Scale (NIHSS) score 13) treated with endovascular thrombectomy beyond 24 hours from onset who were recruited in the Italian Registry of Endovascular Thrombectomy in Acute Stroke. Selection criteria for patients were: pre-stroke modified Rankin scale (mRS) score of ≤2, non-contrast CT Alberta Stroke Program Early CT score of ≥6, good collaterals on single phase CT angiography (CTA) or multiphase CTA, and CT perfusion mismatch with an infarct core size ≤50% of the total hypoperfusion extent or involving less than one-third of the extent of the middle cerebral artery territory evaluated by visual inspection. The primary outcome measure was functional independence assessed by the mRS at 90 days after onset. Safety outcomes were 90 day mortality and the occurrence of symptomatic intracranial hemorrhage (sICH). RESULTS Successful recanalization (Thrombolysis in Cerebral Infarction score of 2b or 3) was present in 76.5% of patients. Three month functional independence (mRS score 0-2) was observed in 41.1% of patients. The case fatality rate was 26.5%. and the incidence of sICH was 8.8%. CONCLUSIONS These findings suggest that, in a real world setting, very late endovascular therapy is feasible in appropriately selected patients.
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Giorgianni A, Molinaro S, Agosti E, Terrana AV, Vizzari FA, Arosio AD, Pietrobon G, Volpi L, Turri-Zanoni M, Craparo G, Piacentino F, Castelnuovo P, Baruzzi FM, Bignami M. Twenty Years of Experience in Juvenile Nasopharyngeal Angiofibroma (JNA) Preoperative Endovascular Embolization: An Effective Procedure with a Low Complications Rate. J Clin Med 2021; 10:jcm10173926. [PMID: 34501374 PMCID: PMC8432214 DOI: 10.3390/jcm10173926] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 08/20/2021] [Accepted: 08/23/2021] [Indexed: 11/16/2022] Open
Abstract
Juvenile nasopharyngeal angiofibroma (JNA) is a benign tumor of the nasal cavity that predominantly affects young boys. Surgical removal remains the gold standard for the management of this disease. Preoperative intra-arterial embolization (PIAE) is useful for reductions in intraoperative blood loss and surgical complications. In our series of 79 patients who underwent preoperative embolization from 1999 to 2020, demographics, procedural aspects, surgical management and follow-up outcome were analyzed. Embolization was performed in a similar fashion for all patients, with a superselective microcatheterization of external carotid artery (ECA) feeders and an injection of polyvinyl alcohol (PVA) particles, followed, in some cases, by the deployment of coils . Procedural success was reached in 100% of cases, with no complications such as bleeding or thromboembolic occlusion, and surgical intraoperative blood loss was significantly decreased. In conclusion, PIAE is a safe and effective technique in JNA treatment, minimizing intraoperative bleeding.
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Bignami M, Pietrobon G, Arosio AD, Fazio E, Nocchi Cardim L, Strocchi S, Molinaro S, Agosti E, Karligkiotis A, Battaglia P, Castelnuovo P, Giorgianni A. Juvenile Angiofibroma: What Is on Stage? Laryngoscope 2021; 132:1160-1165. [PMID: 34374999 DOI: 10.1002/lary.29801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 07/09/2021] [Accepted: 07/26/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVES/HYPOTHESIS The aim of the present study is to validate and compare four of the most widely used staging systems for juvenile angiofibroma on a homogeneous cohort of patients. STUDY DESIGN Retrospective case series. METHODS A retrospective review of patients treated with endoscopic or endoscopic-assisted surgical resection between 1999 and 2020 was carried out. Each case was classified according to the following staging systems: Andrews-Fisch (1989), Radkowski (1996), University of Pittsburgh Medical Center (2010), and Janakiram (2017). Spearman's rank correlation test and areas under the curve of receiver operator curves were used to assess the correlation between outcomes of interests (blood loss, surgical time, need for transfusion, and persistence of disease) and stage of disease. RESULTS Seventy-nine patients were included, with a median follow-up time of 25 months (range 12-127 months). Median surgical time was 217 minutes (range 52-625). Median blood loss was 500 mL (range 40-5200) and 27 patients (34.2%) required blood transfusions. Seven patients (8.9%) showed persistence of disease. All classification systems showed a similar association with blood loss, surgical time, persistence of disease, and need for transfusion. CONCLUSIONS Involvement of the infratemporal fossa and intracranial extension was identified as red flags for surgical planning and preoperative counseling, as associated with increased risk for transfusion and persistent/recurrent disease, respectively. No classification system was found to be better than the others in predicting the most important outcomes. Therefore, the simplest and most easily applicable system would be the preferred one to be used in clinical practice. LEVEL OF EVIDENCE Level 4 case series Laryngoscope, 2021.
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Giorgianni A, Agosti E, Terrana A, Pozzi F, Sileo G, Nativo L, Balbi S, Motta A, Castelnuovo P, Locatelli D, Turri-Zanoni M. Emergency endovascular treatment of cavernous internal carotid artery acute bleeding with flow diverter stent: a single-center experience. Acta Neurochir (Wien) 2021; 163:2055-2061. [PMID: 32808087 PMCID: PMC8195932 DOI: 10.1007/s00701-020-04517-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/30/2020] [Indexed: 11/05/2022]
Abstract
Background and objective To describe our single-center experience in the treatment of cavernous internal carotid artery (ICA) acute bleeding with flow diverter stent (FDS), as a single endovascular procedure or combined with an endoscopic endonasal approach. Methods We analyze a case series of 5 patients with cavernous ICA acute bleeding, i.e., 3 iatrogenic, 1 post-traumatic, and 1 erosive neoplastic. After an immediate nasal packing to temporarily bleeding control, patients underwent digital subtraction angiography (DSA) to identify the site of the ICA injury. A concomitant balloon occlusion test (BOT) was performed, to exclude post-occlusive ischemic neurological damage. An FDS was placed with parallel intravenous infusion of abciximab in 3 cases and tirofiban in 2 cases. In two patients, an innovative “sandwich technique” combining the endovascular reconstruction with an extracranial intrasphenoidal cavernous ICA resurfacing with autologous flaps or grafts by endoscopic endonasal approach was performed. Results No patient had periprocedural ischemic-hemorrhagic complications. All patients had a regular clinical evolution, without general complications or new onset of focal neurological deficits. No further bleeding occurred in 3 patients, while 2 cases experienced a mild rebleeding in a period ranging from 5 to 15 days after the endovascular procedure. In these two cases, we proceeded with an endoscopic endonasal procedure to resurface the exposed ICA wall in the sphenoid sinus. Conclusions Although the treatment of choice for cavernous ICA acute bleeding remains the occlusion of the injured vessel, in cases of poor hemodynamic compensation at the BTO, the endovascular FDS emergency placement can be effective. A combined endoscopic endonasal technique to support the extracranial side of the vessel using autologous flaps or grafts can be performed to prevent the risk of rebleeding.
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Giorgianni A, Vinacci G, Agosti E, Molinaro S, Terrana AV, Casagrande F, Vizzari FA, Baruzzi F, Locatelli D. Ruptured Proximal Anterior Cerebral Artery Aneurysm Treated with Flow Diverter. Turk Neurosurg 2021; 32:160-165. [PMID: 34859825 DOI: 10.5137/1019-5149.jtn.33423-20.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AIM This study aimed to discuss the use of flow modulation in treating ruptured aneurysms of the proximal segment of the anterior cerebral artery (A1 aneurysms). A1 aneurysms are rare, constituting approximately 1% of all intracranial aneurysms. MATERIAL AND METHODS We report a left A1 aneurysm with a wide neck and small sac (3 × 1.8 mm). In order to treat the lesion, a flow diverter (4 × 12-18 mm, FRED, Microvention) was placed from M1 to the proximal end of the paraophthalmic internal carotid artery, without directly covering the neck of the aneurysm. No procedural bleeding occurred. During stent deployment, abciximab was infused. A day after the procedure, double antiplatelet therapy was initiated for 1 month, followed by single antiplatelet therapy for another 3 months. RESULTS Due to the aneurysm morphology, we opted for a competitive flow diversion, covering the parent artery origin and leaving the A1A neck uncovered. A decreased flow into the aneurysmal parent artery gradually promoted aneurysm sac thrombosis. Both digital subtraction angiography at a 12-month follow-up and computed tomography angiography 24-month follow-up confirmed the regular patency of the stent and resolution of the aneurysm. In addition, the competitive modulation of flow in the ipsilateral anterior cerebral artery results in the narrowing of the vessel. CONCLUSION A1 aneurysm endovascular treatment is often challenging. Coiling or assisted coiling is the most frequently employed. Although flow diverter stent (FDS) is a consolidated technique for treating ruptured intracranial blister-like and dissecting aneurysms, its role in treating intracranial saccular ruptured aneurysms has to be elucidated. However, more number of case studies is needed to confirm the efficacy and safety of an FDS in treating ruptured A1 aneurysms.
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Piano M, Lozupone E, Sgoifo A, Nuzzi NP, Asteggiano F, Pero G, Quilici L, Iannucci G, Cerini P, Comelli C, Peschillo S, Princiotta C, Pedicelli A, Limbucci N, Ganci G, Trasimeni G, Ciceri E, Faragò G, Giorgianni A, DE Nicola M, Remida P, Lafe E, Mardighian D, Ruggiero M, Lazzarotti GA, Cavasin N, Castellan L, Chiumarulo L, Burdi N, Paolucci A, Briganti F, Natrella M, Florio FP, Pavia M, Gallesio I, Lucente G, Gozzoli L, Caputo N, Vagnarelli S, Boccardi E, Valvassori L. Long-term follow-up of the Derivo® Embolization Device (DED®) for intracranial aneurysms: the Italian Multicentric Registry. J Neurosurg Sci 2021; 65:361-368. [PMID: 33879762 DOI: 10.23736/s0390-5616.21.05300-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The flow-diverter devices (FDDs) safety and effectiveness have been demonstrated by large series and meta-analyses. Due to the high occlusion rates and the acceptable morbidity rates of FDDs, the indications for their use are continuously expanding. We presented our Italian multicentric experience using the second generation of DERIVO® Embolization Device (DED®; Acandis, Pforzheim, Germany) to cure cerebral aneurysms, evaluating both middle and long-term safety and efficacy of this device. METHODS Between July 2016 and September 2017 we collected 109 consecutive aneurysms in 108 patients treated using DED® during 109 endovascular procedures in 34 Italian centers (100/109 aneurysms were unruptured, 9/109 were ruptured). The collected data included patient demographics, aneurysm location and characteristics, baseline angiography, adverse event and serious adverse event information, morbidity and mortality rates, and pre- and post-treatment modified Rankin Scale scores. Midterm and long-term clinical, angiographic and cross-sectional CT/MR follow-up were recorded and collected until December 2018. RESULTS In 2/109 cases, DED® placement was classified as technical failures. The overall mortality and morbidity rates were respectively 6.5% and 5.5%. Overall DERIVO® related mortality and morbidity rates were respectively 0% and 4.6% (5 out of 108 patients). Midterm neuroimaging follow-up showed the complete or nearly complete occlusion of the aneurysm in 90% cases, which became 93% at long-term follow-up. Aneurysmal sac shrinking was observed in 65% of assessable aneurysms. CONCLUSIONS Our multicentric experience using DED® for endovascular treatment of unruptured and ruptured aneurysms showed a high safety and efficacy profile, substantially equivalent or better compared to the other FDDs.
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Agosti E, Giorgianni A, D'Amore F, Vinacci G, Balbi S, Locatelli D. Is Guillain-Barrè syndrome triggered by SARS-CoV-2? Case report and literature review. Neurol Sci 2021; 42:607-612. [PMID: 32643136 PMCID: PMC7343406 DOI: 10.1007/s10072-020-04553-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 07/02/2020] [Indexed: 01/27/2023]
Abstract
BACKGROUND Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the infectious agent responsible for coronavirus disease 2019 (COVID-19). Respiratory and gastrointestinal manifestations of SARS-CoV-2 are well described, less defined is the clinical neurological spectrum of COVID-19. We reported a case of COVID-19 patient with acute monophasic Guillain-Barré syndrome (GBS), and a literature review on the SARS-CoV-2 and GBS etiological correlation. CASE DESCRIPTION A 68 years-old man presented to the emergency department with symptoms of acute progressive symmetric ascending flaccid tetraparesis. Oropharyngeal swab for SARS-CoV-2 tested positive. Neurological examination showed bifacial nerve palsy and distal muscular weakness of lower limbs. The cerebrospinal fluid assessment showed an albuminocytologic dissociation. Electrophysiological studies showed delayed distal latencies and absent F waves in early course. A diagnosis of Acute Inflammatory Demyelinating Polyradiculoneuropathy (AIDP) subtype of GBS was then made. CONCLUSIONS Neurological manifestations of COVID-19 are still under study. The case we described of GBS in COVID-19 patient adds to those already reported in the literature, in support of SARS-CoV-2 triggers GBS. COVID-19 associated neurological clinic should probably be seen not as a corollary of classic respiratory and gastrointestinal symptoms, but as SARS-CoV-2-related standalone clinical entities. To date, it is essential for all Specialists, clinicians and surgeons, to direct attention towards the study of this virus, to better clarify the spectrum of its neurological manifestations.
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Colombo A, Martinelli Boneschi F, Beretta S, Bresolin N, Versino M, Lorusso L, Spagnoli D, Nastasi G, Vallauri D, Rota S, Repaci M, Ferrarini M, Pozzato M, Princiotta Cariddi L, Tabaee Damavandi P, Carimati F, Banfi P, Clemenzi A, Marelli M, Giorgianni A, Vinacci G, Mauri M, Melzi P, Di Stefano M, Tetto A, Canesi M, Salmaggi A. Posterior reversible encephalopathy syndrome and COVID-19: A series of 6 cases from Lombardy, Italy. eNeurologicalSci 2020; 22:100306. [PMID: 33490654 PMCID: PMC7806512 DOI: 10.1016/j.ensci.2020.100306] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 12/03/2020] [Accepted: 12/19/2020] [Indexed: 12/21/2022] Open
Abstract
Posterior reversible encephalopathy cases are increasingly being reported in patients affected by COVID-19, but the largest series so far only includes 4 patients. We present a series of 6 patients diagnosed with PRES during COVID-19 hospitalized in 5 Centers in Lombardia, Italy. 5 out of the 6 patients required intensive care assistence and seizures developed at weaning from assisted ventilation. 3 out of 6 patients underwent cerebrospinal fluid analysis which was normal in all cases, with negative PCR for Sars-CoV-2 genome search. PRES occurrence may be less rare than supposed in COVID-19 patients and a high suspicion index is warranted for prompt diagnosis and treatment.
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Salsano G, Pracucci G, Mavilio N, Saia V, Bandettini di Poggio M, Malfatto L, Sallustio F, Wlderk A, Limbucci N, Nencini P, Vallone S, Zini A, Bigliardi G, Velo M, Francalanza I, Gennari P, Tassi R, Bergui M, Cerrato P, Carità G, Azzini C, Gasparotti R, Magoni M, Isceri S, Commodaro C, Cordici F, Menozzi R, Latte L, Cosottini M, Mancuso M, Comai A, Franchini E, Alexandre A, Marca GD, Puglielli E, Casalena A, Causin F, Baracchini C, Di Maggio L, Naldi A, Grazioli A, Forlivesi S, Chiumarulo L, Petruzzellis M, Sanfilippo G, Toscano G, Cavasin N, Adriana C, Ganimede MP, Prontera MP, Giorgianni A, Mauri M, Auteri W, Petrone A, Cirelli C, Falcou A, Corraine S, Piras V, Ganci G, Tassinari T, Nuzzi NP, Corato M, Sacco S, Squassina G, Invernizzi P, Gallesio I, Ferrandi D, Dui G, Deiana G, Amistà P, Russo M, Pintus F, Baule A, Craparo G, Mannino M, Castellan L, Toni D, Mangiafico S. Complications of mechanical thrombectomy for acute ischemic stroke: Incidence, risk factors, and clinical relevance in the Italian Registry of Endovascular Treatment in acute stroke. Int J Stroke 2020; 16:818-827. [PMID: 33283685 DOI: 10.1177/1747493020976681] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND There are limited data concerning procedure-related complications of endovascular thrombectomy for large vessel occlusion strokes. AIMS We evaluated the cumulative incidence, the clinical relevance in terms of increased disability and mortality, and risk factors for complications. METHODS From January 2011 to December 2017, 4799 patients were enrolled by 36 centers in the Italian Registry of Endovascular Stroke Treatment. Data on demographic and procedural characteristics, complications, and clinical outcome at three months were prospectively collected. RESULTS The complications cumulative incidence was 201 per 1000 patients undergoing endovascular thrombectomy. Ongoing antiplatelet therapy (p < 0.01; OR 1.82, 95% CI: 1.21-2.73) and large vessel occlusion site (carotid-T, p < 0.03; OR 3.05, 95% CI: 1.13-8.19; M2-segment-MCA, p < 0.01; OR 4.54, 95% CI: 1.66-12.44) were associated with a higher risk of subarachnoid hemorrhage/arterial perforation. Thrombectomy alone (p < 0.01; OR 0.50, 95% CI: 0.31-0.83) and younger age (p < 0.04; OR 0.98, 95% CI: 0.97-0.99) revealed a lower risk of developing dissection. M2-segment-MCA occlusion (p < 0.01; OR 0.35, 95% CI: 0.19-0.64) and hypertension (p < 0.04; OR 0.77, 95% CI: 0.6-0.98) were less related to clot embolization. Higher NIHSS at onset (p < 0.01; OR 1.04, 95% CI: 1.02-1.06), longer groin-to-reperfusion time (p < 0.01; OR 1.05, 95% CI: 1.02-1.07), diabetes (p < 0.01; OR 1.67, 95% CI: 1.25-2.23), and LVO site (carotid-T, p < 0.01; OR 1.96, 95% CI: 1.26-3.05; M2-segment-MCA, p < 0.02; OR 1.62, 95% CI: 1.08-2.42) were associated with a higher risk of developing symptomatic intracerebral hemorrhage compared to no/asymptomatic intracerebral hemorrhage. The subgroup of patients treated with thrombectomy alone presented a lower risk of symptomatic intracerebral hemorrhage (p < 0.01; OR 0.70; 95% CI: 0.55-0.90). Subarachnoid hemorrhage/arterial perforation and symptomatic intracerebral hemorrhage after endovascular thrombectomy worsen both functional independence and mortality at three-month follow-up (p < 0.01). Distal embolization is associated with neurological deterioration (p < 0.01), while arterial dissection did not affect clinical outcome at follow-up. CONCLUSIONS Complications globally considered are not uncommon and may result in poor clinical outcome. Early recognition of risk factors might help to prevent complications and manage them appropriately in order to maximize endovascular thrombectomy benefits.
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Cabrini L, Ageno W, Balbi S, Baruzzi F, Candeloro E, Capra C, Carimati F, Castiglioni B, Conti V, DE Ponti R, Franchi D, Gini G, Giorgianni A, Sartorelli M, Landoni G, Locatelli D, Maffioli L, Pradella R, Severgnini P, Tozzi M, Versino M, Zocchi G, Zoli A. Caring for acute coronary syndrome and other time-sensitive medical emergencies during the coronavirus disease 2019 pandemic in Northern Italy: report from a hub center. Minerva Cardiol Angiol 2020; 70:303-309. [PMID: 33258565 DOI: 10.23736/s2724-5683.20.05384-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The Lombardy region, in Northern Italy, suffered a major outbreak of Coronavirus disease 2019 (COVID-19) at the end of February 2020. The health system was rapidly overwhelmed by the pandemic. It became evident that patients suffering from time-sensitive medical emergencies like stroke, cerebral hemorrhage, trauma and acute myocardial infarction required timely, effective and safe pathways to be treated. The problem was addressed by a regional decree that created a hub-and-spoke system for time-sensitive medical emergencies. METHODS We report the re-organizational changes adopted at a hub hospital (despite having already destined to COVID-19 patients most resources), and the number of emergent procedures for medical emergencies on the first 30-day of activity. These data were compared with the hospital activity in the same period of the previous year. RESULTS Organizational changes were implemented in few hours. Dedicated pathways for non-COVID-19 patients affected by a medical emergency were set up in the emergency department, in the labs and in the operating theater. Ten intensive beds were implemented from a high-dependency unit; two operating rooms were reserved 24 h/day to neurosurgical or trauma emergencies. The number of emergent procedures was not different from that of the previous year, no admission refusal, no treatment delay and no viral transmission to the treated patients were recorded. No viral transmission to health care workers was observed. CONCLUSIONS Re-organization of a hospital in order to adopt a hub-and-spoke model resulted feasible and allowed to face acute coronary syndrome and other time-sensitive medical emergencies timely and safely.
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Cabrini L, Ageno W, Balbi S, Baruzzi F, Candeloro E, Capra C, Carimati F, Castiglioni B, Conti V, De Ponti R, Franchi D, Gini G, Giorgianni A, Sartorelli M, Landoni G, Locatelli D, Maffioli L, Pradella R, Severgnini P, Tozzi M, Versino M, Zocchi G, Zoli A. Caring for acute coronary syndrome and other time-sensitive medical emergencies during the coronavirus disease 2019 pandemic in Northern Italy: report from a hub centre. Minerva Cardioangiol 2020. [PMID: 33258565 DOI: 10.23736/s0026-4725.20.05384-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The Lombardy region, in Northern Italy, suffered a major outbreak of Coronavirus disease 2019 (COVID-19) at the end of February 2020. The health system was rapidly overwhelmed by the pandemic. It became evident that patients suffering from timesensitive medical emergencies like stroke, cerebral hemorrhage, trauma and acute myocardial infarction required timely, effective and safe pathways to be treated. The problem was addressed by a regional decree that created a hub-and-spoke system for time-sensitive medical emergencies. METHODS We report the re-organizational changes adopted at a hub hospital (despite having already destined to COVID-19 patients most resources), and the number of emergent procedures for medical emergencies on the first 30-day of activity. These data were compared with the hospital activity in the same period of the previous year. RESULTS Organizational changes were implemented in few hours. Dedicated pathways for non-COVID-19 patients affected by a medical emergency were set up in the emergency department, in the labs and in the operating theater. Ten intensive beds were implemented from a high-dependency unit; two operating rooms were reserved 24h/day to neurosurgical or trauma emergencies. The number of emergent procedures was not different from that of the previous year, no admission refusal, no treatment delay and no viral transmission to the treated patients were recorded. No viral transmission to health care workers was observed. CONCLUSIONS Re-organization of a hospital in order to adopt a hub-and-spoke model resulted feasible and allowed to face acute coronary syndrome and other time-sensitive medical emergencies timely and safely.
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