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Kupcs K, Sproge P, Kupca K, Bhogal P. The Stream Device-A Retrospective Review of 51 Cases. J Clin Med 2023; 12:6384. [PMID: 37835028 PMCID: PMC10573462 DOI: 10.3390/jcm12196384] [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: 07/11/2023] [Revised: 09/17/2023] [Accepted: 10/03/2023] [Indexed: 10/15/2023] Open
Abstract
Mechanical thrombectomy is the gold-standard treatment for patients that have suffered large-vessel occlusion (LVO) stroke. Various different stent-retrievers, aspiration catheters, and techniques have been developed to perform this procedure. We present our initial results regarding the Stream device. MATERIALS AND METHODS We performed a retrospective review of a prospectively maintained database at our high-volume centre to identify all patients treated with the Stream device between February 2021 and January 2023. We recorded baseline demographics, NIHSS, ASPECT scores, eTICI scores, complications, and 90-day mRS. RESULTS We identified 51 patients, 49.0% of whom were male (n = 25), with a median age of 73 (range: 51-89) and a median NIHSS score of 17 (range 4-22), and 68.6% received IV tPA. The median ASPECT score was 10 (range 6-10). Hyperdense clots were seen in 34 cases (66.7%), with a mean clot length of 12 ± 6.2 mm (range 2-26 mm). Clots were located in the anterior circulation in 49 patients. The standard Stream device was used in 78.4% of cases, with Stream 17 being used in 19.6% of cases. The FPE was observed in 25.5% of cases (n = 13), with the mFPE being seen in 31.4% of cases (n = 16). A final eTICI score of ≥2b was achieved in 90.2% of cases (n = 46), and eTICI 2c/3 was seen in 84.3% of cases (n = 43). Furthermore, 24 h CT scans showed that the median ASPECT score was 8 (range 0-10). Good functional outcomes at 90 days (mRS ≤ 2) were achieved in 21.6% of cases (n = 11). CONCLUSIONS The Stream device shows acceptable rates of FPE and mFPE compared to existing devices. Further larger studies are required alongside an understanding of the optimal technique for this device's use.
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Affiliation(s)
- Karlis Kupcs
- Department of Neuroradiology, Pauls Stradins Clinical University Hospital, LV-1002 Riga, Latvia; (K.K.); (P.S.); (K.K.)
- Department of Radiology, Riga Stradins University, LV-1007 Riga, Latvia
| | - Patricija Sproge
- Department of Neuroradiology, Pauls Stradins Clinical University Hospital, LV-1002 Riga, Latvia; (K.K.); (P.S.); (K.K.)
| | - Katrina Kupca
- Department of Neuroradiology, Pauls Stradins Clinical University Hospital, LV-1002 Riga, Latvia; (K.K.); (P.S.); (K.K.)
| | - Pervinder Bhogal
- Department of Interventional Neuroradiology, The Royal London Hospital, Barts NHS Trust, London E1 1BB, UK
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2
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Zaidat OO, Ikeme S, Sheth SA, Yoshimura S, Yang XG, Brinjikji W, Kallmes DF, Brouwer P, Pederson J, Tarchand R, Steffenson A, Kallmes KM, Touchette J, Andersson T. MASTRO I: Meta-Analysis and Systematic Review of thrombectomy stent retriever outcomes: comparing functional, safety and recanalization outcomes between EmboTrap, Solitaire and Trevo in acute ischemic stroke. J Comp Eff Res 2023; 12:e230001. [PMID: 37039285 PMCID: PMC10402757 DOI: 10.57264/cer-2023-0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 03/02/2023] [Indexed: 04/12/2023] Open
Abstract
Aim: Stent-retriever (SR) thrombectomy has demonstrated superior outcomes in patients with acute ischemic stroke compared with medical management alone, but differences among SRs remain unexplored. We conducted a Systematic Review/Meta-Analysis to compare outcomes between three SRs: EmboTrap®, Solitaire™, and Trevo®. Methods: We conducted a PRISMA-compliant Systematic Review among English-language studies published after 2014 in PubMed/MEDLINE that reported SRs in ≥25 patients. Functional and safety outcomes included 90-day modified Rankin scale (mRS 0-2), mortality, symptomatic intracranial hemorrhage (sICH), and embolization to new territory (ENT). Recanalization outcomes included modified thrombolysis in cerebral infarction (mTICI) and first-pass recanalization (FPR). We used a random effects Meta-Analysis to compare outcomes; subgroup and outlier-influencer analysis were performed to explore heterogeneity. Results: Fifty-one articles comprising 9,804 patients were included. EmboTrap had statistically significantly higher rates of mRS 0-2 (57.4%) compared with Trevo (50.0%, p = 0.013) and Solitaire (45.3%, p < 0.001). Compared with Solitaire (20.4%), EmboTrap (11.2%, p < 0.001) and Trevo (14.5%, p = 0.018) had statistically significantly lower mortality. Compared with Solitaire (7.7%), EmboTrap (3.9%, p = 0.028) and Trevo (4.6%, p = 0.049) had statistically significantly lower rates of sICH. There were no significant differences in ENT rates across all three devices (6.0% for EmboTrap, 5.3% for Trevo, and 7.7% for Solitaire, p = 0.518). EmboTrap had numerically higher rates of recanalization; however, no statistically significant differences were found. Conclusion: The results of our Systematic Review/Meta-Analysis suggest that EmboTrap may be associated with significantly improved functional outcomes compared with Solitaire and Trevo. EmboTrap and Trevo may be associated with significantly lower rates of sICH and mortality compared with Solitaire. No significant differences in recanalization and ENT rates were found. These conclusions are tempered by limitations of the analysis including variations in thrombectomy techniques in the field, highlighting the need for multi-arm RCT studies comparing different SR devices to confirm our findings.
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Affiliation(s)
| | - Shelly Ikeme
- Cardiovascular & Specialty Solutions Group, CERENOVUS, Irvine, CA 92618, USA
| | - Sunil A Sheth
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX 77030, USA
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Hyogo, 663-8131, Japan
| | - Xin-guang Yang
- Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, 510123, China
| | | | - David F Kallmes
- Department of Radiology, Mayo Clinic, Rochester, MN 55902, USA
| | - Patrick Brouwer
- Cardiovascular & Specialty Solutions Group, CERENOVUS, Irvine, CA 92618, USA
| | | | | | | | - Kevin M Kallmes
- Superior Medical Experts, St. Paul, MN 55117, USA
- Nested Knowledge, Inc., St. Paul, MN 55117, USA
| | | | - Tommy Andersson
- Medical Imaging, AZ Groeninge, 8500, Kortrijk, Belgium
- Neuroradiology, Karolinska University Hospital & Clinical Neuroscience Karolinska Institute, 171 77, Stockholm, Sweden
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3
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Omrani O, Hafezi-Bakhtiari N, DeSouza P, Nikola C, Wong K, Lansley J, Dhillon P, Makalanda L, Chan N, Harrison T, Andrews A, Siow I, Lee KS, Yeo L, Spooner O, Bhogal P. The initial experience with the Embotrap III stent-retriever in a real world setting. Interv Neuroradiol 2022:15910199221142097. [PMID: 36523190 DOI: 10.1177/15910199221142097] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024] Open
Abstract
MATERIALS AND METHODS We performed a retrospective review of our prospectively maintained database to identify all patients treated with the Embotrap 3 stent-retriever between January 2021 and January 2022. We recorded the baseline demographics, NIHSS, ASPECT score and clot characteristics, first pass and final eTICI scores, complications and 90 day mRS. RESULTS One hundred and ten patients met the inclusion criteria, average age 69 ± 14 years, 50% were male (n = 55). The median NIHSS at presentation was 18 (range 3-30) and 58.2% received IV tPA prior to MT. The median ASPECT score on plain CT was 8 with average clot length 20.2 ± 14.8 mm (n = 93). The first pass effect (FPE) was seen in 41.8% of cases with modified FPE seen in 59.1%. A 24-hour CT scan (n = 97) showed median ASPECTs of 7. 43.8% of patients achieve mRS ≤ 2 at 90-day mRS (n = 64). CONCLUSION The Embotrap 3 stent-retriever has a high rate of FPE and final recanalization in this real world cohort of patients.
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Affiliation(s)
- Osama Omrani
- Department of Radiology, 112001The Royal London Hospital, Barts NHS Trust, London, UK
| | - Nema Hafezi-Bakhtiari
- Department of Radiology, 112001The Royal London Hospital, Barts NHS Trust, London, UK
| | - Peter DeSouza
- Department of Diagnostic Neuroradiology, Department of Interventional Neuroradiology, 112001The Royal London Hospital, Barts NHS Trust, London, UK
| | - Christos Nikola
- Department of Stroke Medicine, Department of Interventional Neuroradiology, 112001The Royal London Hospital, Barts NHS Trust, London, UK
| | - Ken Wong
- Department of Interventional Neuroradiology, 112001The Royal London Hospital, Barts NHS Trust, London, UK
| | - Joseph Lansley
- Department of Interventional Neuroradiology, 112001The Royal London Hospital, Barts NHS Trust, London, UK
| | - Permesh Dhillon
- Department of Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Levansri Makalanda
- Department of Interventional Neuroradiology, 112001The Royal London Hospital, Barts NHS Trust, London, UK
| | - Nathan Chan
- Department of Interventional Neuroradiology, 112001The Royal London Hospital, Barts NHS Trust, London, UK
| | - Thomas Harrison
- Department of Stroke Medicine, Department of Interventional Neuroradiology, 112001The Royal London Hospital, Barts NHS Trust, London, UK
| | - Alex Andrews
- Department of Stroke Medicine, Department of Interventional Neuroradiology, 112001The Royal London Hospital, Barts NHS Trust, London, UK
| | - Isabel Siow
- 63751Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Keng Siang Lee
- 152331Bristol Medical School, University of Bristol, Bristol, UK
| | - Leonard Yeo
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Oliver Spooner
- Department of Stroke Medicine, Department of Interventional Neuroradiology, 112001The Royal London Hospital, Barts NHS Trust, London, UK
| | - Pervinder Bhogal
- Department of Interventional Neuroradiology, 112001The Royal London Hospital, Barts NHS Trust, London, UK
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Zhang Y, Liu P, Li Z, Peng Y, Chen W, Zhang L, Chu J, Kuai D, Chen Z, Wu W, Xu Y, Zhang Y, Zhou B, Geng Y, Yin C, Li J, Wang M, Zhai N, Peng X, Ji Z, Xiao Y, Zhu X, Cai X, Zhang L, Hong B, Xing P, Shen H, Zhang Y, Li M, Shang M, Liu J, Yang P. Endovascular treatment of acute ischemic stroke with a fully radiopaque retriever: A randomized controlled trial. Front Neurol 2022; 13:962987. [PMID: 36588884 PMCID: PMC9796564 DOI: 10.3389/fneur.2022.962987] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 10/26/2022] [Indexed: 12/15/2022] Open
Abstract
Objective The Neurohawk retriever is a new fully radiopaque retriever. A randomized controlled non-inferiority trial was conducted to compare the Neurohawk and the Solitaire FR in terms of safety and efficacy. In order to evaluate the efficacy and safety of endovascular treatment in acute ischemic stroke (AIS) caused by intracranial atherosclerotic disease (ICAD) larger vessel occlusion (LVO), a sub-analysis was performed. Methods Acute ischemic stroke patients aged 18-80 years with LVO in the anterior circulation were randomly assigned to undergo thrombectomy with either the Neurohawk or the Solitaire FR. The primary efficacy endpoint was successful reperfusion (mTICI 2b-3) rate by the allocated retriever. A relevant non-inferiority margin was 12.5%. Safety outcomes were symptomatic intracranial hemorrhage (sICH) and all-cause mortality within 90 days. Secondary endpoints included first-pass effect (FPE), modified FPE, and favorable outcomes at 90 days. In subgroup analysis, the patients were divided into the ICAD group and non-ICAD group according to etiology, and baseline characteristics, angiographic, and clinical outcomes were compared. Results A total of 232 patients were involved in this analysis (115 patients in the Neurohawk group and 117 in the Solitaire group). The rates of successful reperfusion with the allocated retriever were 88.70% in the Neurohawk group and 90.60% in the Solitaire group (95%CI of the difference, -9.74% to 5.94%; p = 0.867). There were similar results in FPE and mFPE in both groups. The rate of sICH seemed higher in the Solitaire group (13.16% vs. 7.02%, p = 0.124). All-cause mortality and favorable outcome rates were comparable as well. In subgroup analysis, 58 patients were assigned to the ICAD group and the remaining 174 to the non-ICAD group. The final successful reperfusion and favorable outcome rates showed no statistically significant differences in two groups. Mortality within 90 days was relatively lower in the ICAD group (6.90% vs. 17.24%; p = 0.054). Conclusion The Neurohawk retriever is non-inferior to the Solitaire FR in the mechanical thrombectomy of large vessel occlusion-acute ischemic stroke (LVO-AIS). The sub-analysis suggested that endovascular treatment including thrombectomy with the retriever and essential rescue angioplasty is effective and safe in AIS patients with intracranial atherosclerotic disease-larger vessel occlusion (ICAD-LVO). Clinical trial registration https://clinicaltrials.gov/ct2/show/NCT04995757, number: NCT04995757.
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Affiliation(s)
- Yongxin Zhang
- Neurovascular Center, Changhai Hospital, Naval Military Medical University, Shanghai, China
| | - Pei Liu
- Neurovascular Center, Changhai Hospital, Naval Military Medical University, Shanghai, China
| | - Zifu Li
- Neurovascular Center, Changhai Hospital, Naval Military Medical University, Shanghai, China
| | - Ya Peng
- Department of Neurosurgery, Changzhou First People's Hospital, Changzhou, China
| | - Wenhuo Chen
- Department of Neurology, Zhangzhou Hospital Affiliated to Fujian Medical University, Zhangzhou, China
| | - Liyong Zhang
- Department of Neurosurgery, Liaocheng People's Hospital Brain Hospital, Liaocheng, China
| | - Jianfeng Chu
- Department of Neurology, The First People's Hospital of Jining City, Jining, China
| | - Dong Kuai
- Department of Neurosurgery, Shanxi Provincial Cardiovascular Hospital, Taiyuan, China
| | - Zhen Chen
- Department of Neurointervention, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Wei Wu
- Department of Neurology, Qilu Hospital of Shandong University, Jinan, China
| | - Yun Xu
- Department of Neurology, Nanjing Gulou Hospital, Nanjing, China
| | - Yong Zhang
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Bin Zhou
- Department of Neurointervention, Cerebrovascular Disease Center, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China
| | - Yu Geng
- Department of Neurology, Zhejiang Provincial People's Hospital, Hangzhou, China
| | - Congguo Yin
- Department of Neurology, Hangzhou First People's Hospital, Hangzhou, China
| | - Jiang Li
- Department of Neurosurgery, The Second Affiliated Hospital of Air Force Military Medical University, Xi'an, China
| | - Ming Wang
- Department of Neurointervention, Nanyang Second People's Hospital, Nanyang, China
| | - Naichi Zhai
- Department of Neurosurgery, Zibo Central Hospital, Zibo, China
| | - Xiaoxiang Peng
- Department of Neurology, The Third People's Hospital of Hubei Province, Wuhan, China
| | - Zhong Ji
- Department of Neurology, Nanfang Hospital of Southern Medical University, Guangzhou, China
| | - Yaping Xiao
- Department of Neurology, Shanghai Oriental Hospital, Shanghai, China
| | - Xingen Zhu
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xueli Cai
- Department of Neurology, Lishui Municipal Central Hospital, Lishui, China
| | - Lei Zhang
- Neurovascular Center, Changhai Hospital, Naval Military Medical University, Shanghai, China
| | - Bo Hong
- Neurovascular Center, Shanghai General Hospital, Shanghai, China
| | - Pengfei Xing
- Neurovascular Center, Changhai Hospital, Naval Military Medical University, Shanghai, China
| | - Hongjian Shen
- Neurovascular Center, Changhai Hospital, Naval Military Medical University, Shanghai, China
| | - Yongwei Zhang
- Neurovascular Center, Changhai Hospital, Naval Military Medical University, Shanghai, China
| | - Minghua Li
- Institute of Diagnostic and Interventional Neuroradiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Meixia Shang
- Department of Biostatistics, Peking University First Hospital, Beijing, China
| | - Jianmin Liu
- Neurovascular Center, Changhai Hospital, Naval Military Medical University, Shanghai, China,*Correspondence: Jianmin Liu
| | - Pengfei Yang
- Neurovascular Center, Changhai Hospital, Naval Military Medical University, Shanghai, China,Pengfei Yang
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5
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Bai X, Fu Z, Sun Z, Xu R, Guo X, Tian Q, Dmytriw AA, Zhao H, Wang W, Wang X, Patel AB, Yang B, Jiao L. Thrombectomy Using the EmboTrap Clot-Retrieving Device for the Treatment of Acute Ischemic Stroke: A Glimpse of Clinical Evidence. AJNR Am J Neuroradiol 2022; 43:1736-1742. [PMID: 36456081 DOI: 10.3174/ajnr.a7708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 10/11/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND The EmboTrap Recanalization Device is a novel stent retriever for thrombectomy in the setting of acute ischemic stroke due to large-vessel occlusion. PURPOSE Our aim was to summarize the safety and efficacy of the EmboTrap Recanalization Device in acute ischemic stroke-large-vessel occlusion through a systematic review and meta-analysis. DATA SOURCES Medline, EMBASE, the Cochrane Library, Web of Science, and Google Scholar were searched up to April 2022. STUDY SELECTION Nine observational studies using the EmboTrap Recanalization Device were selected. DATA ANALYSIS We adapted effect size with 95% CIs for dichotomous data. P value <.05 was statistically significant. DATA SYNTHESIS The estimated rate of successful recanalization (modified TICI 2b-3) was 90% (95% CI, 86%-95%; I 2 = 82.4%); 90-day favorable outcome (mRS 0-2), 53% (95% CI, 42%-63%; I 2 = 88.6%); modified first-pass effect, 43% (95% CI, 35%-51%; I 2 = 63.7%); and first-pass effect, 36% (95% CI, 29%-46%; I 2 = 10.7%). The rate of any intracerebral hemorrhage was 19% (95% CI, 16%-22%; I 2 = 0.0%); symptomatic intracerebral hemorrhage, 5% (95% CI, 1%-8%; I 2 = 84.6%); and 90-day mortality, 14% (95% CI, 9%-19%; I 2 = 79.3%). Subgroup analysis showed higher rates of complete recanalization for EmboTrap II than for the EmboTrap System. LIMITATIONS The included studies are single-arm without direct comparison with other stent retrievers. Some of the studies recruited had a small sample size and were limited by the retrospective study design. In addition, the uncertain heterogeneity among studies was high. CONCLUSIONS The EmboTrap Recanalization Device is safe and efficient in treating acute ischemic stroke due to large-vessel occlusion.
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Affiliation(s)
- X Bai
- From the Departments of Neurosurgery (X.B., Z.F., Z.S., R.X., H.Z., B.Y., L.J.).,China International Neuroscience Institute (X.B., Z.F., Z.S., R.X., H.Z., B.Y., L.J.), Beijing, China
| | - Z Fu
- From the Departments of Neurosurgery (X.B., Z.F., Z.S., R.X., H.Z., B.Y., L.J.).,China International Neuroscience Institute (X.B., Z.F., Z.S., R.X., H.Z., B.Y., L.J.), Beijing, China
| | - Z Sun
- From the Departments of Neurosurgery (X.B., Z.F., Z.S., R.X., H.Z., B.Y., L.J.).,China International Neuroscience Institute (X.B., Z.F., Z.S., R.X., H.Z., B.Y., L.J.), Beijing, China
| | - R Xu
- From the Departments of Neurosurgery (X.B., Z.F., Z.S., R.X., H.Z., B.Y., L.J.).,China International Neuroscience Institute (X.B., Z.F., Z.S., R.X., H.Z., B.Y., L.J.), Beijing, China
| | - X Guo
- Department of Neurology (X.G.), Loma Linda University Health, Loma Linda, California
| | - Q Tian
- Beijing Key Laboratory of Clinical Epidemiology (Q.T.), School of Public Health, Capital Medical University, Beijing, China
| | - A A Dmytriw
- Neuroendovascular Program (A.A.D.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - H Zhao
- From the Departments of Neurosurgery (X.B., Z.F., Z.S., R.X., H.Z., B.Y., L.J.).,China International Neuroscience Institute (X.B., Z.F., Z.S., R.X., H.Z., B.Y., L.J.), Beijing, China
| | - W Wang
- Library (W.W., X.W., A.B.P.)
| | - X Wang
- Library (W.W., X.W., A.B.P.)
| | | | - B Yang
- From the Departments of Neurosurgery (X.B., Z.F., Z.S., R.X., H.Z., B.Y., L.J.).,China International Neuroscience Institute (X.B., Z.F., Z.S., R.X., H.Z., B.Y., L.J.), Beijing, China
| | - L Jiao
- From the Departments of Neurosurgery (X.B., Z.F., Z.S., R.X., H.Z., B.Y., L.J.) .,Interventional Neuroradiology (L.J.), Xuanwu Hospital, Capital Medical University, Xicheng District, Beijing, China.,China International Neuroscience Institute (X.B., Z.F., Z.S., R.X., H.Z., B.Y., L.J.), Beijing, China
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6
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Goertz L, Weiss D, Abdullayev N, Moenninghoff C, Borggrefe J, Phung TH, Haage P, Schlamann M, Dorn F, Kaschner M, Kabbasch C, Nordmeyer H. Safety and Efficacy of the Novel Low-Profile APERIO Hybrid 17 for a Treatment of Proximal and Distal Vessel Occlusion in Acute Ischemic Stroke: A Multi-Center Experience. World Neurosurg 2022; 167:e386-e396. [PMID: 35963612 DOI: 10.1016/j.wneu.2022.08.023] [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: 05/26/2022] [Revised: 08/04/2022] [Accepted: 08/05/2022] [Indexed: 10/31/2022]
Abstract
OBJECTIVE To report our initial experience with the novel low-profile APERIO Hybrid17 Thrombectomy Device (AP17) for proximal and distal vessel occlusions in acute ischemic stroke. METHODS A multicentric retrospective analysis of patients treated with the AP17 was performed. The primary effectiveness endpoint was first-pass TICI ≥2b (Thrombolysis in cerebral infarction scale). The primary safety endpoint was the occurrence of hemorrhagic complications. Further outcome measures were number of passes, device-related complications, and 3-month functional outcome. RESULTS The AP17 was used in 71 patients (mean age: 73 years) with a median baseline National Institutes of Health Stroke Scale score of 9. Treated vessels were the carotid-T in 8 cases (11%), the M1-segment in 16 (23%), the M2-segment in 29 (41%), the anterior cerebral artery in 3 (4%), and basilar/posterior cerebral arteries in 15 (21%). The rates of first-pass and final TICI ≥2b were 75.6% and 92.7%, retrospectively, with a mean number of passes of 3 ± 2. Final TICI ≥2b rates were comparable between large and medium vessel occlusions. Symptomatic intracranial hemorrhages were recorded in 2 cases (2.8%). At 3-month clinical follow-up, a modified Rankin scale score ≤2 was achieved in 69.0% (29/42). The all-cause mortality at discharge was 17.4%. CONCLUSIONS The AP17 was associated with a reasonable safety and efficacy profile for both proximal and distal vessel occlusions. These results may contribute to establish mechanical thrombectomy for distal occlusions.
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Affiliation(s)
- Lukas Goertz
- Department of Neuroradiology, Medical Faculty and University Hospital, University of Cologne, Cologne, Germany.
| | - Daniel Weiss
- Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Düsseldorf, Germany
| | - Nuran Abdullayev
- Department of Neuroradiology, Medical Faculty and University Hospital, University of Cologne, Cologne, Germany
| | - Christoph Moenninghoff
- University Institute for Radiology, Neuroradiology and Nuclear Medicine, Johannes Wesling Klinikum Minden, Minden, Germany
| | - Jan Borggrefe
- University Institute for Radiology, Neuroradiology and Nuclear Medicine, Johannes Wesling Klinikum Minden, Minden, Germany
| | - Timo Huan Phung
- Institute for interventional Radiology and Neuroradiology, Neurozentrum Solingen, Radprax St. Lukas Hospital, Solingen, Germany
| | - Patrick Haage
- Department of Diagnostic and Interventional Radiology, Helios University Hospital, Wuppertal, Germany; School of Medicine, Department of Health, Witten/Herdecke University, Witten, Germany
| | - Marc Schlamann
- Department of Neuroradiology, Medical Faculty and University Hospital, University of Cologne, Cologne, Germany
| | - Franziska Dorn
- Department of Neuroradiology, Medical Faculty and University Hospital, University of Bonn, Bonn, Germany
| | - Marius Kaschner
- Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Düsseldorf, Germany
| | - Christoph Kabbasch
- Department of Neuroradiology, Medical Faculty and University Hospital, University of Cologne, Cologne, Germany
| | - Hannes Nordmeyer
- Institute for interventional Radiology and Neuroradiology, Neurozentrum Solingen, Radprax St. Lukas Hospital, Solingen, Germany; School of Medicine, Department of Health, Witten/Herdecke University, Witten, Germany
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7
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Weiss D, Kabbasch C, Lichtenstein T, Turowski B, Kaschner M. A fully radiopaque hybrid stent retriever versus a precursor device: Outcome, efficacy, and safety in large vessel stroke. J Neuroimaging 2022; 32:947-955. [PMID: 35415956 DOI: 10.1111/jon.12999] [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: 01/28/2022] [Revised: 03/17/2022] [Accepted: 03/20/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND AND PURPOSE The aim of this multicenter study was to compare the clinical outcome, safety, and efficacy of the full-length radiopaque Aperio Hybrid stent retriever (APH) with the precursor Aperio thrombectomy device (AP). METHODS Multicentric retrospective analysis of patients with stroke, treated with the APH and AP due to an acute ischemic stroke by large vessel occlusions in the anterior or posterior circulation, was performed. We focused on the comparison of favorable clinical outcome (modified Rankin Scale, 0-2) after 3 months, favorable reperfusion rates (thrombolysis in cerebral infarction scale ≥ 2b), and the complication rate. RESULTS A total of 51 patients (female: n = 33, 64.7%, mean age 73 ± 16 years) with a median baseline National Institutes of Health Stroke Scale: 15 were treated with the APH or AP. Favorable outcome in patients treated with APH was excellent (44.0%) and comparable to the AP (36.8%). The rate of final favorable reperfusion for both devices was outstanding (APH 31/31 and AP 20/20). The overall complication rate for the APH was slightly higher compared to the AP (32.3%/15.0%). Symptomatic intracranial hemorrhage was recorded in 0 of 51 cases. The all-cause mortality rate at 90 days was 20.0% for the APH and comparable for the AP (21.1%). CONCLUSIONS Comparable clinical outcome, efficacy, and safety of the AP and the recently introduced APH were demonstrated. Both devices appeared feasible, efficient, and safe with regard to endovascular treatment in large vessel occlusion.
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Affiliation(s)
- Daniel Weiss
- Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Düsseldorf, 40225, Germany
| | - Christoph Kabbasch
- Department of Diagnostic and Interventional Radiology, University Cologne, Medical Faculty, Cologne, 50937, Germany
| | - Thorsten Lichtenstein
- Department of Diagnostic and Interventional Radiology, University Cologne, Medical Faculty, Cologne, 50937, Germany
| | - Bernd Turowski
- Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Düsseldorf, 40225, Germany
| | - Marius Kaschner
- Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Düsseldorf, 40225, Germany
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8
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Ahmed SU, Chen X, Peeling L, Kelly ME. Stentrievers : An engineering review. Interv Neuroradiol 2022; 29:125-133. [PMID: 35253526 PMCID: PMC10152824 DOI: 10.1177/15910199221081243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The advent of endovascular therapy for acute large vessel occlusion has revolutionized stroke treatment. Timely access to endovascular therapy, and the ability to restore intracranial flow in a safe, efficient, and efficacious manner has been critical to the success of the thrombectomy procedure. The stentriever has been a mainstay of endovascular stroke therapy, and current guidelines recommend the usage of stentrievers in the treatment of large vessel occlusion stroke. Despite the success of existing stentrievers, there continues to be significant development in the field, with newer stentrievers attempting to improve on each of the three key aspects of the thrombectomy procedure. Here, we elucidate the technical requirements that a stentriever must fulfill. We then review the basic variables of stent design, including the raw material and its form, fabrication method, geometric configuration, and further additions. Lastly, a selection of stentrievers from successive generations are reviewed using these engineering parameters, and clinical data is presented. Further avenues of stentriever development and testing are also presented.
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Affiliation(s)
- Syed Uzair Ahmed
- Division of Neurosurgery, Department of Surgery, 7235University of Saskatchewan, Saskatoon, SK, Canada
| | - Xiongbiao Chen
- Division of Biomedical Engineering, College of Engineering, 7235University of Saskatchewan, Saskatoon, SK, Canada
| | - Lissa Peeling
- Division of Neurosurgery, Department of Surgery, 7235University of Saskatchewan, Saskatoon, SK, Canada
| | - Michael E Kelly
- Division of Neurosurgery, Department of Surgery, 7235University of Saskatchewan, Saskatoon, SK, Canada.,Division of Biomedical Engineering, College of Engineering, 7235University of Saskatchewan, Saskatoon, SK, Canada
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9
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Brinjikji W, Ikeme S, Kottenmeier E, Khaled A, M S, Khanna R. Real-world outcomes associated with the use of the EmboTrap revascularization device for ischemic stroke in the United States. J Neurointerv Surg 2021; 14:1068-1072. [PMID: 34750107 DOI: 10.1136/neurintsurg-2021-018175] [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: 08/23/2021] [Accepted: 10/20/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Mechanical thrombectomy (MT) has become the standard of care for the treatment of acute ischemic stroke (AIS). The EmboTrap revascularization device (CERENOVUS, Johnson & Johnson Medical Devices, Irvine, California, USA) has an innovative, dual layer feature designed to facilitate thrombus retrieval. OBJECTIVE To investigate the real-world clinical and economic outcomes among patients with AIS undergoing MT using the EmboTrap device in the United States (US). METHODS Adult patients (≥18 years) who underwent MT for AIS using the EmboTrap device between July 2018 and December 2020 were identified from the Premier Healthcare Database. Patient outcomes included discharge status (including in-hospital mortality), mean length of stay (LOS), intracranial hemorrhage (ICH), mean hospital costs, and 30-day readmissions (all-cause, cardiovascular (CV)-related, and AIS-related). RESULTS A total of 318 patients (mean age 68.5±14.6 years) with AIS treated with the EmboTrap device as the only stent retriever used were identified. Approximately 25% of patients were discharged to home/home health organization, and the in-hospital mortality rate was 10.7%. The rate of ICH was 16.7%. Mean hospital LOS was 9.9±11.3 days, and the mean hospital costs were US$47 367±30 297. The 30-day readmission rate was 9.6% for all-causes, 5.9% for CV-related causes, and 2.6% for AIS-related causes. CONCLUSIONS This is the first study in the US to report real-world outcomes sourced by retrospective database analysis among patients with AIS undergoing MT using the EmboTrap device. Further research is needed to better understand performance of the EmboTrap device in real-world settings.
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Affiliation(s)
| | - Shelly Ikeme
- Franchise Health Economics and Market Access, Johnson and Johnson, Irvine, California, USA
| | - Emilie Kottenmeier
- Franchise Health Economics and Market Access, Johnson and Johnson, Irvine, California, USA
| | - Alia Khaled
- Franchise Health Economics and Market Access, Johnson and Johnson, Irvine, California, USA
| | - Sidharth M
- Mu Sigma, Inc, Bangalore, Karnataka, India
| | - Rahul Khanna
- Medical Device Epidemiology and Real-World Data Sciences, Johnson and Johnson, New Brunswick, New Jersey, USA
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10
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Bala F, Ferrigno M, Personnic T, Estrade L, Karam A, Henon H, Bricout N. Thrombectomy Using the EmboTrap II Device in Late Treatment Patients in the Real-World Setting. World Neurosurg 2021; 151:e387-e394. [PMID: 33878468 DOI: 10.1016/j.wneu.2021.04.040] [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: 02/21/2021] [Accepted: 04/11/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We aimed to evaluate the safety and efficacy of endovascular thrombectomy (EVT) using the EmboTrap Revascularization Device (EmboTrap) in patients with ischemic stroke treated >6-24 hours after stroke onset. METHODS We performed a retrospective analysis of data from a prospective registry of consecutive patients with stroke with anterior circulation large vessel occlusion treated by stent-retriever thrombectomy with EmboTrap II in a single stroke center in France from 2016 to 2017. Patients were divided into late treatment window (>6-24 hours after stroke onset) or early treatment window (≤6 hours) groups. Baseline clinical and imaging characteristics, rates of successful recanalization (modified Thrombolysis in Cerebral Infarction score ≥2b), complications, 3 months good functional outcome (modified Rankin Scale score 0-2), and mortality were analyzed. RESULTS Of the 225 patients (mean age, 71.5 ± 14.5 years; 55.6% [125/225] female) included in the study, 54 were treated in the late treatment window, with a mean time from last known well to treatment of 651 ± 223 minutes. Compared with the early treatment window group, there were no significant differences in baseline characteristics, successful recanalization (83.3% [45/54] vs. 81.3% [139/171]; P = 0.734), 3 months good functional outcome (37.0% [20/54] vs. 37.4% [64/171]; P = 0.959), or mortality (24.1% [13/54] vs. 27.5% [47/171]; P = 0.621). CONCLUSIONS This real-world study provides evidence that EVT using EmboTrap is safe and effective in the late treatment window in patients with large vessel occlusion.
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Affiliation(s)
- Fouzi Bala
- Department of Interventional Neuroradiology, CHU Lille, Lille, France
| | - Marc Ferrigno
- Department of Vascular Neurology-Stroke Unit, CHU Lille, Lille, France; Inserm U1171-Degenerative and Vascular Cognitive Disorders, Lille, France
| | - Thomas Personnic
- Department of Interventional Neuroradiology, CHU Lille, Lille, France
| | - Laurent Estrade
- Department of Interventional Neuroradiology, CHU Lille, Lille, France
| | - Arnaud Karam
- Department of Interventional Neuroradiology, CHU Lille, Lille, France; Department of Vascular Neurology-Stroke Unit, CHU Lille, Lille, France
| | - Hilde Henon
- Department of Vascular Neurology-Stroke Unit, CHU Lille, Lille, France; Inserm U1171-Degenerative and Vascular Cognitive Disorders, Lille, France
| | - Nicolas Bricout
- Department of Interventional Neuroradiology, CHU Lille, Lille, France.
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11
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Kaschner M, Lichtenstein T, Weiss D, Turowski B, Goertz L, Kluner C, Schlamann M, Mathys C, Kabbasch C. The New Fully Radiopaque Aperio Hybrid Stent Retriever: Efficient and Safe? An Early Multicenter Experience. World Neurosurg 2020; 141:e278-e288. [DOI: 10.1016/j.wneu.2020.05.104] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 05/11/2020] [Accepted: 05/12/2020] [Indexed: 11/16/2022]
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12
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Kaschner MG, Weiss D, Rubbert C, Lee JI, Gliem M, Jander S, Ivan V, Kraus B, Turowski B, Caspers J. One-year single-center experience with the Aperio thrombectomy device in large vessel occlusion in the anterior circulation: safety, efficacy, and clinical outcome. Neurol Sci 2019; 40:1443-1451. [PMID: 30949780 DOI: 10.1007/s10072-019-03861-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 03/20/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE The Aperio thrombectomy device (Aperio) is a stent retriever designed to achieve rapid and substantial flow restoration in acute ischemic stroke due to large-vessel occlusions (LVOs). We evaluated the safety and efficacy of the Aperio device and compared it with published data of established stent retrievers. METHODS We retrospectively analyzed institutional data of consecutive stroke procedures in patients with LVO in the anterior circulation that were treated between January 2017 and December 2017 with the Aperio. Reperfusion rate regarding to the extended thrombolysis in cerebral infarction scale (eTICI), procedural times, early clinical outcome, and complications were documented. RESULTS Eighty-two patients were treated by using the Aperio in LVO in the anterior circulation. Median age was 77 (± 12) years (w = 59.8%). Median Baseline National Institutes of Health Stroke Scale (NIHSS) score was 14. Fifty-three (64.6%) patients received intravenous thrombolysis. Successful recanalization (eTICI≥2b) was achieved in 85.3%. Mean time from groin puncture to final recanalization was 52.3 ± 34.8 min. Embolization to new territories occurred in one case. Symptomatic intracranial hemorrhage within 24 h was observed in six patients (7.3%). Twenty-eight (41.2%) out of 68 patients available for assessment of functional outcome at 3 months achieved favorable outcome (mRS 0-2). CONCLUSION The Aperio stent retriever mechanical thrombectomy device demonstrated high rates of successful reperfusion and a good safety profile in patients with acute ischemic stroke due to LVO in the anterior circulation.
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Affiliation(s)
- Marius Georg Kaschner
- Medical Faculty, Department of Diagnostic and Interventional Radiology, University Duesseldorf, Moorenstr.5, 40225, Duesseldorf, Germany
| | - Daniel Weiss
- Medical Faculty, Department of Diagnostic and Interventional Radiology, University Duesseldorf, Moorenstr.5, 40225, Duesseldorf, Germany.
| | - Christian Rubbert
- Medical Faculty, Department of Diagnostic and Interventional Radiology, University Duesseldorf, Moorenstr.5, 40225, Duesseldorf, Germany
| | - John-Ih Lee
- Medical Faculty, Department of Neurology, University Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Michael Gliem
- Medical Faculty, Department of Neurology, University Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Sebastian Jander
- Medical Faculty, Department of Neurology, University Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Vivien Ivan
- Medical Faculty, Department of Diagnostic and Interventional Radiology, University Duesseldorf, Moorenstr.5, 40225, Duesseldorf, Germany
| | - Bastian Kraus
- Medical Faculty, Department of Diagnostic and Interventional Radiology, University Duesseldorf, Moorenstr.5, 40225, Duesseldorf, Germany
| | - Bernd Turowski
- Medical Faculty, Department of Diagnostic and Interventional Radiology, University Duesseldorf, Moorenstr.5, 40225, Duesseldorf, Germany
| | - Julian Caspers
- Medical Faculty, Department of Diagnostic and Interventional Radiology, University Duesseldorf, Moorenstr.5, 40225, Duesseldorf, Germany
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Boulanger M, Lapergue B, Turjman F, Touzé E, Anxionnat R, Bracard S, Piotin M, Gory B. First-line contact aspiration vs stent-retriever thrombectomy in acute ischemic stroke patients with large-artery occlusion in the anterior circulation: Systematic review and meta-analysis. Interv Neuroradiol 2019; 25:244-253. [PMID: 30864466 DOI: 10.1177/1591019918821074] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND In acute ischemic stroke patients with large-artery occlusion, uncertainties remain about whether clinically important outcomes are comparable between first-line contact aspiration and stent-retriever thrombectomy, although two trials have investigated whether one strategy should be preferred over another. PURPOSE The purpose of this article is to compare the efficacy and safety of first-line contact aspiration and stent-retriever thrombectomy in stroke patients with anterior circulation large-artery occlusion. METHODS We undertook a systematic review of studies of patients treated for large-artery occlusion, with the latest devices of either strategy, within six hours of stroke onset. We determined rates of final complete reperfusion (defined as modified Thrombolysis In Cerebral Infarction score = 3), periprocedural complications and 90-day functional independence (defined as modified Rankin Scale (mRS) score 0-2), and excellent outcome (defined as mRS score 0-1) after contact aspiration and after stent-retriever thrombectomy using random-effects meta-analyses. Any differential effects in rates between the two strategies were assessed using random-effects meta-regressions. RESULTS Fifteen studies (1817 patients) were included. There was no difference in rates of final complete reperfusion at the end of all endovascular procedures between contact aspiration and stent retrievers (51.1%, 95% confidence interval (CI) 39.3-62.9; vs 38.3%, 95% CI 28.6-48.0; pint = 0.14), 90-day functional independence (45.0%, 40.7-49.2; vs 52.4%, 47.7-57.1; pint = 0.45) and excellent outcome (32.1%, 25.7-38.5; vs 34.1%, 21.2-46.9; pint = 0.94). Rates of periprocedural complications did not differ between the two strategies. CONCLUSIONS Current data suggest no difference in efficacy and safety between first-line contact aspiration and stent-retriever thrombectomy in stroke patients with large-artery occlusion.
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Affiliation(s)
- Marion Boulanger
- 1 Normandie University, UNICAEN, Inserm U1237, CHU Caen, Stroke Unit, Caen, France
| | - Bertrand Lapergue
- 2 Department of Neurology, Foch Hospital, University Versailles Saint-Quentin en Yvelines, Suresnes, France
| | - Francis Turjman
- 3 Department of Interventional Neuroradiology, Hospices Civils de Lyon, Lyon, France
| | - Emmanuel Touzé
- 1 Normandie University, UNICAEN, Inserm U1237, CHU Caen, Stroke Unit, Caen, France
| | - René Anxionnat
- 4 Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nancy, Nancy, France.,5 University of Lorraine, INSERM U1254, IADI, F-54000, Nancy, France
| | - Serge Bracard
- 4 Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nancy, Nancy, France.,5 University of Lorraine, INSERM U1254, IADI, F-54000, Nancy, France
| | - Michel Piotin
- 6 Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France
| | - Benjamin Gory
- 4 Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nancy, Nancy, France.,5 University of Lorraine, INSERM U1254, IADI, F-54000, Nancy, France
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14
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Valente I, Nappini S, Renieri L, Pedicelli A, Lozupone E, Colosimo C, Mangiafico S, Limbucci N. Initial experience with the novel EmboTrap II clot-retrieving device for the treatment of ischaemic stroke. Interv Neuroradiol 2019; 25:271-276. [PMID: 30714502 DOI: 10.1177/1591019918819709] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION We report our experience with the novel stent-type clot-retrieval device EmboTrap II for the revascularization of large artery occlusions in acute ischaemic stroke. MATERIALS AND METHODS Twenty-nine patients with acute ischaemic stroke due to large artery occlusion underwent mechanical thrombectomy with the new EmboTrap II in two Italian centres. Clinical, procedural and radiological data were collected. Angiographic results and neurological outcomes were analysed. RESULTS Only large vessel occlusions were included. Intravenous thrombolysis was administered in 72% of patients. Successful reperfusion (TICI 2b-3) was obtained in 76% of patients treated exclusively with EmboTrap II. No device-related permanent complications occurred. CONCLUSION In our experience, mechanical thrombectomy with EmboTrap II is safe and effective. Reperfusion rate was comparable to that obtained with other stent retrievers.
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Affiliation(s)
- Iacopo Valente
- 1 UOC Radiologia e Neuroradiologia, Dipartimento di diagnostica per immagini, radioterapia oncologia ed ematologia, Fondazione Policlinico Universitario A.Gemelli IRCCS, Roma, Italy
| | - Sergio Nappini
- 2 Interventional Neurovascular Unit, Careggi University Hospital, Firenze, Italy
| | - Leonardo Renieri
- 2 Interventional Neurovascular Unit, Careggi University Hospital, Firenze, Italy
| | - Alessandro Pedicelli
- 1 UOC Radiologia e Neuroradiologia, Dipartimento di diagnostica per immagini, radioterapia oncologia ed ematologia, Fondazione Policlinico Universitario A.Gemelli IRCCS, Roma, Italy
| | - Emilio Lozupone
- 1 UOC Radiologia e Neuroradiologia, Dipartimento di diagnostica per immagini, radioterapia oncologia ed ematologia, Fondazione Policlinico Universitario A.Gemelli IRCCS, Roma, Italy
| | - Cesare Colosimo
- 1 UOC Radiologia e Neuroradiologia, Dipartimento di diagnostica per immagini, radioterapia oncologia ed ematologia, Fondazione Policlinico Universitario A.Gemelli IRCCS, Roma, Italy.,3 Istituto di Radiologia, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Salvatore Mangiafico
- 2 Interventional Neurovascular Unit, Careggi University Hospital, Firenze, Italy
| | - Nicola Limbucci
- 2 Interventional Neurovascular Unit, Careggi University Hospital, Firenze, Italy
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