The Impact of Preprocedural Platelet Function Testing on Periprocedural Complication Rates Associated With Pipeline Flow Diversion: An International Multicenter Study

BACKGROUND AND OBJECTIVES

Dual antiplatelet therapy (DAPT) is necessary to minimize the risk of periprocedural thromboembolic complications associated with aneurysm embolization using pipeline embolization device (PED). We aimed to assess the impact of platelet function testing (PFT) on reducing periprocedural thromboembolic complications associated with PED flow diversion in patients receiving aspirin and clopidogrel.

METHODS

Patients with unruptured intracranial aneurysms requiring PED flow diversion were identified from 13 centers for retrospective evaluation. Clinical variables including the results of PFT before treatment, periprocedural DAPT regimen, and intracranial complications occurring within 72 h of embolization were identified. Complication rates were compared between PFT and non-PFT groups. Differences between groups were tested for statistical significance using the Wilcoxon rank sum, Fisher exact, or χ 2 tests. A P -value <.05 was statistically significant.

RESULTS

580 patients underwent PED embolization with 262 patients dichotomized to the PFT group and 318 patients to the non-PFT group. 13.7% of PFT group patients were clopidogrel nonresponders requiring changes in their pre-embolization DAPT regimen. Five percentage of PFT group [2.8%, 8.5%] patients experienced thromboembolic complications vs 1.6% of patients in the non-PFT group [0.6%, 3.8%] ( P = .019). Two (15.4%) PFT group patients with thromboembolic complications experienced permanent neurological disability vs 4 (80%) non-PFT group patients. 3.7% of PFT group patients [1.5%, 8.2%] and 3.5% [1.8%, 6.3%] of non-PFT group patients experienced hemorrhagic intracranial complications ( P > .9).

CONCLUSION

Preprocedural PFT before PED treatment of intracranial aneurysms in patients premedicated with an aspirin and clopidogrel DAPT regimen may not be necessary to significantly reduce the risk of procedure-related intracranial complications.

Multicenter US clinical experience with the Scepter Mini balloon catheter

INTRODUCTION

Distal navigability and imprecise delivery of embolic agents are two limitations encountered during liquid embolization of cerebrospinal lesions. The dual-lumen Scepter Mini balloon (SMB) microcatheter was introduced to overcome these conventional microcatheters' limitations with few small single-center reports suggesting favorable results.

METHODS

A series of consecutive patients undergoing SMB-assisted endovascular embolization were extracted from prospectively maintained registries in seven North-American centers (November 2019 to September 2022).

RESULTS

Fifty-four patients undergoing 55 embolization procedures utilizing SMB were included (median age 58.5; 48.1% females). Cranial dural arteriovenous fistula embolization was the most common indication (54.5%) followed by cranial arteriovenous malformation (27.3%). Staged/pre-operative embolization was done in 36.4% of cases; and 83.6% of procedures using Onyx-18. Most procedures utilized a transarterial approach (89.1%), and SMB-induced arterial-flow arrest concurrently with transvenous embolization was used in 10.9% of procedures. Femoral access/triaxial setups were utilized in the majority of procedures (65.5% and 60%, respectively). The median vessel diameter where the balloon was inflated of 1.8 mm, with a median of 1.5 cc of injected embolic material per procedure. Technical failures occurred in 5.5% of cases requiring aborting/replacement with other devices without clinical sequelae in any of the patients, with SMB-related procedural complications of 3.6% without clinical sequelae. Radiographic imaging follow-up was available in 76.9% of the patients (median follow-up 3.8 months), with complete occlusion (100%) or >50% occlusion in 92.5% of the cases, and unplanned retreatments in 1.8%.

CONCLUSION

The SMB microcatheter is a useful new adjunctive device for balloon-assisted embolization of cerebrospinal lesions with a high technical success rate, favorable outcomes, and a reasonable safety profile.

Middle meningeal artery patency after surgical evacuation for chronic subdural hematoma

BACKGROUND

Chronic subdural hematoma (CSDH) often requires surgical evacuation, but recurrence rates remain high. Middle meningeal artery (MMA) embolization (MMAE) has been proposed as an alternative or adjunct treatment. There is concern that prior surgery might limit patency, access, penetration, and efficacy of MMAE, such that some recent trials excluded patients with prior craniotomy. However, the impact of prior open surgery on MMA patency has not been studied.

METHODS

A retrospective analysis was conducted on patients who underwent MMAE for cSDH (2019-2022), after prior surgical evacuation or not. MMA patency was assessed using a six-point grading scale.

RESULTS

Of the 109 MMAEs (84 patients, median age 72 years, 20.2% females), 58.7% were upfront MMAEs, while 41.3% were after prior surgery (20 craniotomies, 25 burr holes). Median hematoma thickness was 14 mm and midline shift 3 mm. Hematoma thickness reduction, surgical rescue, and functional outcome did not differ between MMAE subgroups and were not affected by MMA patency or total area of craniotomy or burr-holes. MMA patency was reduced in the craniotomy group only, specifically in the distal portion of the anterior division (p = 0.005), and correlated with craniotomy area (p < 0.001).

CONCLUSION

MMA remains relatively patent after burr-hole evacuation of cSDH, while craniotomy typically only affects the frontal-distal division. However, MMA patency, evacuation method, and total area do not affect outcomes. These findings support the use of MMAE regardless of prior surgery and may influence future trial inclusion/exclusion criteria. Further studies are needed to optimize the timing and techniques for MMAE in cSDH management.

The Influence of Coagulopathy on Radiographic and Clinical Outcomes in Patients Undergoing Middle Meningeal Artery Embolization as Standalone Treatment for Non-acute Subdural Hematomas

Middle meningeal artery embolization (MMAE) is emerging as a safe and effective standalone intervention for non-acute subdural hematomas (NASHs); however, the risk of hematoma recurrence after MMAE in coagulopathic patients is unclear. To characterize the impact of coagulopathy on treatment outcomes, we analyzed a multi-institutional database of patients who underwent standalone MMAE as treatment for NASH. We classified 537 patients who underwent MMAE as a standalone intervention between 2019 and 2023 by coagulopathy status. Coagulopathy was defined as use of anticoagulation/antiplatelet agents or pre-operative thrombocytopenia (platelets <100,000/μL). Demographics, pre-procedural characteristics, in-hospital course, and patient outcomes were collected. Thrombocytopenia, aspirin use, antiplatelet agent use, and anticoagulant use were assessed using univariate and multivariate analyses to identify any characteristics associated with the need for rescue surgical intervention, mortality, adverse events, and modified Rankin Scale score at 90-day follow-up. Propensity score-matched cohorts by coagulopathy status with matching covariates adjusting for risk factors implicated in surgical recurrence were evaluated by univariate and multivariate analyses. Minimal differences in pre-operative characteristics between patients with and those without coagulopathy were observed. On unmatched and matched analyses, patients with coagulopathy had higher rates of requiring subsequent surgery than those without (unmatched: 9.9% vs. 4.3%; matched: 12.6% vs. 4.6%; both p < 0.05). On matched multivariable analysis, patients with coagulopathy had an increased odds ratio (OR) of requiring surgical rescue (OR 3.95; 95% confidence interval [CI] 1.68-9.30; p < 0.01). Antiplatelet agent use (ticagrelor, prasugrel, or clopidogrel) was also predictive of surgical rescue (OR 4.38; 95% CI 1.51-12.72; p = 0.01), and patients with thrombocytopenia had significantly increased odds of in-hospital mortality (OR 5.16; 95% CI 2.38-11.20; p < 0.01). There were no differences in follow-up radiographic and other clinical outcomes in patients with and those without coagulopathy. Patients with coagulopathy undergoing standalone MMAE for treatment of NASH may have greater risk of requiring surgical rescue (particularly in patients using antiplatelet agents), and in-hospital mortality (in thrombocytopenic patients).

Stent-assisted Woven EndoBridge device for the treatment of intracranial aneurysms: an international multicenter study

OBJECTIVE

The Woven EndoBridge (WEB) device is an intrasaccular flow disruptor designed for wide-necked bifurcation aneurysms. These aneurysms may require the use of a concomitant stent. The objective of this study was to determine the clinical and radiological outcomes of patients undergoing stent-assisted WEB treatment. In addition, the authors also sought to determine the predictors of a concomitant stent in aneurysms treated with the WEB device.

METHODS

The data for this study were taken from the WorldWideWEB Consortium, an international multicenter cohort including patients treated with the WEB device. Aneurysms were classified into two groups based on treatment: stent-assisted WEB and WEB device alone. The authors compared clinical and radiological outcomes of both groups. Univariable and multivariable binary logistic regression analyses were performed to determine factors that predispose to stent use.

RESULTS

The study included 691 intracranial aneurysms (31 with stents and 660 without stents) treated with the WEB device. The adequate occlusion status did not differ between the two groups at the latest follow-up (83.3% vs 85.6%, p = 0.915). Patients who underwent stenting had more thromboembolic (32.3% vs 6.5%, p < 0.001) and procedural (16.1% vs 3.0%, p < 0.001) complications. Aneurysms treated with a concomitant stent had wider necks, greater heights, and lower dome-to-neck ratios. Increasing neck size was the only significant predictor for stent use.

CONCLUSIONS

This study demonstrates that there is no difference in the degree of aneurysm occlusion between the two groups; however, complications were more frequent in the stent group. In addition, a wider aneurysm neck predisposes to stent assistance in WEB-treated aneurysms.

The natural history of aneurysms incompletely occluded by placement of a flow diverter: a multiinstitutional study

OBJECTIVE

Treatment of intracranial aneurysms by flow diversion is safe and effective and is increasingly popular. However, the correct treatment paradigm for aneurysms incompletely treated by initial placement of a flow diverter has not been established, nor have the subsequent natural history and occlusion rates of such aneurysms. The authors sought to outline the natural history of such aneurysms, which to date have been considered partially treated.

METHODS

The authors retrospectively reviewed consecutive cases from 6 high-volume neurointerventional services, including all cases in which the first follow-up imaging after placement of a flow diverter showed incomplete occlusion of the aneurysm, and for which subsequent clinical and/or radiological follow-up was available. All included patients were treated with the Pipeline Flex embolization device or the Pipeline Flex embolization device with Shield Technology. Subsequent radiographic and clinical outcome data were collected and analyzed using the Kaplan-Meier survival function.

RESULTS

A total of 263 patients with persistently patent aneurysms on first follow-up imaging after flow diversion were identified. Of these, 204 had clinical follow-up and 152 had additional imaging follow-up. Of this final cohort, 148 aneurysms were unruptured, and 4 were ruptured. The average aneurysm size by maximum dimension was 10.8 mm. The average recorded follow-up was 27.8 months in the cohort, with some patients followed for as long as 9 years from treatment. Over the course of 403 person-years of follow-up, no delayed aneurysm ruptures were recorded. Both with and without retreatment, aneurysms showed a trend toward progressive occlusion over time. Complications related to device placement were low.

CONCLUSIONS

Aneurysms that have been incompletely treated by flow diversion have a benign natural history with progression toward occlusion over time, with or without retreatment.

Cerebral Cavernous Malformations Patient Perception Analysis via Social Media

BACKGROUND

 The rise of social media has allowed for individuals and patients to connect with each other and influence patient behavior. This study aimed to improve our understanding of the patients' experience with cerebral cavernous malformations (CCM) via social media.

METHODS

 Instagram and Twitter were searched using terms of ("cavernoma," "cavernous malformations," "cavernous angioma," or "cav mal"). Public Instagram posts tagged with "#cavernoma" and "@cavernoma" identified 327 posts that directly included a patient's own experience. Twitter posts that included "#cavernoma" and "@cavernoma" were searched, yielding 75 after eliminating those that did not pertain to the patient's own experience. The posts and tweets were coded for relevant themes related to their experience with the disease.

RESULTS

 Overall, more patients are using Instagram (n  =  327) over Twitter (n  =  84) to share their personal experience with CCM with a trend for male patients to use Twitter more compared to females with a female predominance in Instagram. A total of 277 of 327 (84.7%) Instagram posts and 67 of 84 (89.3%) Twitter posts were made after the patient's surgery. The most common theme on Instagram was focused on the postoperative rehabilitation process and mobility support (52.0 and 24.5%, respectively). Other common themes present on Twitter and Instagram were recounting symptoms and complications and life satisfaction (26.0 and 24.2%, respectively). Cavernoma patients prior to surgery were more likely to discuss on Instagram their symptoms (p  =  0.001), fear of bleeding (p  <  0.001), and mental health (p  =  0.014). Postoperatively, cavernoma patients were more likely to discuss disability than they were preoperatively (p  =  0.001).

CONCLUSION

 Social media platforms offer a communication tool for patients with CCM patients to share their experience with other patients and the general public and portrays their personal experience with CCM. These platforms allow for physicians to better understand the patient experience following cavernoma surgery.

General Versus Nongeneral Anesthesia for Middle Meningeal Artery Embolization for Chronic Subdural Hematomas: Multicenter Propensity Score Matched Study

BACKGROUND AND OBJECTIVES

The choice of anesthesia type (general anesthesia [GA] vs nongeneral anesthesia [non-GA]) in middle meningeal artery embolization (MMAE) procedures for chronic subdural hematomas (cSDH) differs between institutions and left to care team discretion given lack of standard guidelines. We compare the outcomes of GA vs non-GA in MMAE.

METHODS

Consecutive patients receiving MMAE for cSDH at 14 North American centers (2018-2023) were included. Clinical, cSDH characteristics, and technical/clinical outcomes were compared between the GA/non-GA groups. Using propensity score matching (PSM), patients were matched controlling for age, baseline modified Rankin Scale, concurrent/prior surgery, hematoma thickness/midline shift, and baseline antiplatelet/anticoagulation. The primary end points included surgical rescue and radiographic success rates (≥50% reduction in maximum hematoma thickness with minimum 2 weeks of imaging). Secondary end points included technical feasibility, procedural complications, and functional outcomes.

RESULTS

Seven hundred seventy-eight patients (median age 73 years, 73.2% male patients) underwent 956 MMAE procedures, 667 (70.4%) were non-GA and 280 were GA (29.6%). After running 1:3 PSM algorithm, this resulted in 153 and 296 in the GA and non-GA groups, respectively. There were no baseline/procedural differences between the groups except radial access more significantly used in the non-GA group (P = .001). There was no difference between the groups in procedural technical feasibility, complications rate, length of stay, surgical rescue rates, or favorable functional outcome at the last follow-up. Subsequent 1:1 sensitivity PSM retained the same results. Bilateral MMAE procedures were more performed under non-GA group (75.8% vs 67.2%; P = .01); no differences were noted in clinical/radiographic outcomes between bilateral vs unilateral MMAE, except for longer procedure duration in the bilateral group (median 73 minutes [IQR 48.3-100] vs 54 minutes [39-75]; P < .0001). Another PSM analysis comparing GA vs non-GA in patients undergoing stand-alone MMAE retained similar associations.

CONCLUSION

We found no significant differences in radiological improvement/clinical outcomes between GA and non-GA for MMAE.

Readability of cerebrovascular diseases online educational material from major cerebrovascular organizations

INTRODUCTION

The internet is an essential resource for patients and their loved ones to understand their medical conditions, and professional medical organizations have taken great strides to develop educational material targeting patients. The average American reads at a seventh to eighth grade reading level, hence it is important to understand the readability of this medical information to ensure patients comprehend what is being presented.

METHODS

In January 2023, online patient education material was downloaded from major cerebrovascular healthcare organizations and assessed using eight assessments, including Bormuth Cloze Mean, Bormuth Grade Placement, Coleman-Liau (grade levels), Coleman-Liau (predictive cloze scores), Flesch Reading Ease (FRE), and Fry.

RESULTS

A total of 32 files were extracted from six organizations and analyzed across 15 readability measures. None of the organizations met the federal government guidelines for grade-level readability. This held constant across all measured tests. Two organizations had above a postgraduate level. The FRE graphs do not identify any organizations with material below a ninth grade reading level, while the American Association of Neurological Surgeons (AANS) and the Society of Interventional Radiology (SIR) have a postgraduate readability level. The Fry graphs show similar results, with AANS/CNS Cerebrovascular Section, Society of NeuroInterventional Surgery (SNIS), SIR, and AANS having college-level readability. The lowest readability across all measures is only at an early seventh grade reading level.

CONCLUSIONS

Current health literacy content for cerebrovascular patients is far above the recommended readability level. We provide straightforward suggestions for how major professional organizations should improve their informational material on cerebrovascular diseases to improve patient understanding.

Utilization and reimbursement of diagnostic cerebral angiograms: A Medicare trends analysis from 2013 to 2020

INTRODUCTION

Increasing life expectancy has caused growing concern about maintaining viable neurointerventional practices due to altered Medicare payment structures. This study analyzes the financial trends of three common diagnostic tests for cerebrovascular disease: cerebral digital subtraction angiography (DSA), computed tomography angiography (CTA), and magnetic resonance angiography (MRA).

METHODS

Medicare Part B National Summary Data files from 2013 to 2020 were queried by Current Procedural Terminology (CPT) codes for DSA (36221-36228), CTA (70496, 70498), and MRA (70544-70547, 70549). Inflation-adjusted charges and reimbursement were calculated using the U.S. City Average Consumer Price Index for Medical Services. Regression analysis was performed on charges, reimbursement, and volume.

RESULTS

A total of 1,519,245 diagnostic procedures were conducted between 2013 and 2020 (782,370 angiograms, 246,603 CTAs, and 490,272 MRAs). A total of $41.005 million was reimbursed by Medicare in 2020 for these diagnostic procedures. The annual percent change in volume for all procedures was -2.90%. From 2013 to 2020, inflation-adjusted: Medicare total physician reimbursement decreased for cerebral angiograms (-4.12%, p = 0.007), CTAs (-2.77%, p = 0.458), and MRAs (-9.06%, p < 0.001). Procedural volume billed to Medicare decreased for cerebral angiograms (-4.63%, p = 0.007) and MRAs (-2.94%, p = 0.0.81) and increased for CTAs (+3.15%, p = 0.004). The greatest increase in Medicare reimbursement (+66.75%) came from CPT code 36224, "place catheter carotid artery", and the greatest decrease in Medicare reimbursement (-8.66%) came from CPT code 36226, "place catheter vertebral artery."

CONCLUSIONS

This study provides an analysis of Medicare reimbursement trends for routine cerebrovascular angiogram techniques. The findings highlight a decline in Medicare reimbursements for neurointerventionalists.

Global Outcomes for Microsurgical Clipping of Unruptured Intracranial Aneurysms: A Benchmark Analysis of 2245 Cases

BACKGROUND AND OBJECTIVES

Benchmarks represent the best possible outcome and help to improve outcomes for surgical procedures. However, global thresholds mirroring an optimal and reachable outcome for microsurgical clipping of unruptured intracranial aneurysms (UIA) are not available. This study aimed to define standardized outcome benchmarks in patients who underwent clipping of UIA.

METHODS

A total of 2245 microsurgically treated UIA from 15 centers were analyzed. Patients were categorized into low- ("benchmark") and high-risk ("nonbenchmark") patients based on known factors affecting outcome. The benchmark was defined as the 75th percentile of all centers' median scores for a given outcome. Benchmark outcomes included intraoperative (eg, duration of surgery, blood transfusion), postoperative (eg, reoperation, neurological status), and aneurysm-related factors (eg, aneurysm occlusion). Benchmark cutoffs for aneurysms of the anterior communicating/anterior cerebral artery, middle cerebral artery, and posterior communicating artery were determined separately.

RESULTS

Of the 2245 cases, 852 (37.9%) patients formed the benchmark cohort. Most operations were performed for middle cerebral artery aneurysms (53.6%), followed by anterior communicating and anterior cerebral artery aneurysms (25.2%). Based on the results of the benchmark cohort, the following benchmark cutoffs were established: favorable neurological outcome (modified Rankin scale ≤2) ≥95.9%, postoperative complication rate ≤20.7%, length of postoperative stay ≤7.7 days, asymptomatic stroke ≤3.6%, surgical site infection ≤2.7%, cerebral vasospasm ≤2.5%, new motor deficit ≤5.9%, aneurysm closure rate ≥97.1%, and at 1-year follow-up: aneurysm closure rate ≥98.0%. At 24 months, benchmark patients had a better score on the modified Rankin scale than nonbenchmark patients.

CONCLUSION

This study presents internationally applicable benchmarks for clinically relevant outcomes after microsurgical clipping of UIA. These benchmark cutoffs can serve as reference values for other centers, patient registries, and for comparing the benefit of other interventions or novel surgical techniques.

Comaneci-assisted coiling of a right posterior communicating artery aneurysm: an unusual case of coil retention

Although endovascular embolization has become the main treatment option for intracranial aneurysms,1 2 wide-necked intracranial aneurysms remain difficult to coil.3 Both stent- and balloon-assisted coiling are used for wide-necked aneurysms because they provide a scaffold that protects the parent vessel during coiling.4 5 However, stent-assisted coiling requires dual antiplatelet therapy, which increases the risk of bleeding, whereas balloon-assisted coiling temporarily obstructs blood flow.4 6 7 The Comaneci device (Rapid Medical, Yokneam, Israel) has recently received US Food and Drug Administration approval as a 'temporary coil embolization assist device'.5 It temporarily covers the aneurysm neck and allows safe coiling, avoiding the disadvantages mentioned above.6-8 A potential complication of Comaneci-assisted coiling is coil retention when it adheres to the device on recapture; this complication should be promptly recognized and managed.5 9 10 In this video, we present an unusual case of coil retention with the Comaneci device (Video 1). neurintsurg;15/12/1286/V1F1V1Video 1 .

Radiographic and clinical outcomes with particle or liquid embolic agents for middle meningeal artery embolization of nonacute subdural hematomas

BACKGROUND

Middle meningeal artery (MMA) embolization is an apparently efficacious minimally invasive treatment for nonacute subdural hematomas (NASHs), but how different embolisates affect outcomes remains unclear. Our objective was to compare radiographic and clinical outcomes after particle or liquid MMA embolization.

METHODS

Patients who had MMA embolization for NASH were retrospectively identified from a multi-institution database. The primary radiographic and clinical outcomes-50% NASH thickness reduction and need for surgical retreatment within 90 days, respectively-were compared for liquid and particle embolizations in patients treated 1) without surgical intervention (upfront), 2) after recurrence, or 3) with concomitant surgery (prophylactic).

RESULTS

The upfront, recurrent, and prophylactic subgroups included 133, 59, and 16 patients, respectively. The primary radiographic outcome was observed in 61.8%, 61%, and 72.7% of particle-embolized patients and 61.3%, 55.6%, and 20% of liquid-embolized patients, respectively (p = 0.457, 0.819, 0.755). Hazard ratios comparing time to reach radiographic outcome in the particle and liquid groups or upfront, recurrent, andprophylactic timing were 1.31 (95% CI 0.78-2.18; p = 0.310), 1.09 (95% CI 0.52-2.27; p = 0.822), and 1.5 (95% CI 0.14-16.54; p = 0.74), respectively. The primary clinical outcome occurred in 8.0%, 2.4%, and 0% of patients who underwent particle embolization in the upfront, recurrent, and prophylactic groups, respectively, compared with 0%, 5.6%, and 0% who underwent liquid embolization (p = 0.197, 0.521, 1.00).

CONCLUSIONS

MMA embolization with particle and liquid embolisates appears to be equally effective in treatment of NASHs as determined by the percentage who reach, and the time to reach, 50% NASH thickness reduction and the incidence of surgical reintervention within 90 days.

Anterior circulation location-specific results for stent-assisted coiling - carotid versus distal aneurysms: 1-year outcomes from the Neuroform Atlas Stent Pivotal Trial

BACKGROUND

The Neuroform Atlas Stent System is an established treatment modality for unruptured anterior and posterior circulation intracranial aneurysms. Location-specific results are needed to guide treatment decision-making. However, it is unclear whether there are differences in safety and efficacy outcomes between carotid and more distal anterior circulation aneurysms.

METHODS

The ATLAS IDE trial was a prospective, multicenter, single-arm, open-label interventional study that evaluated the safety and efficacy of the Neuroform Atlas Stent System. We compared differences in efficacy and safety outcomes of proximal internal carotid artery (ICA) versus distal and bifurcation anterior circulation aneurysms.

RESULTS

Of 182 cases, there were 70 aneurysms in the ICA and 112 in the distal anterior circulation (including ICA terminus/bifurcation). There were no significant differences in the primary efficacy endpoint (85.5% vs 83.9%, p=0.78) and complete aneurysm occlusion rates (88.7% vs 87.9%, p=0.78) between proximal ICA aneurysms and distal aneurysms, respectively. Complications were more often encountered in distal and bifurcation aneurysms, but the overall rate of major safety events was low and comparable between the two groups (1.4% vs 6.3%, p=0.14). Recanalization and retreatment rates were also similar between the groups.

CONCLUSION

The results of this study suggest that the Neuroform Atlas Stent System is a safe and efficacious treatment modality for unruptured anterior circulation intracranial aneurysms, regardless of aneurysm location.

TRIAL REGISTRATION NUMBER

NCT02340585.

Postoperative de novo epilepsy after resection of brain arteriovenous malformations: A national database study of 536 patients

OBJECTIVE

We aimed to assess the incidence and risk factors for de novo epilepsy after arteriovenous malformation (AVM) resection and compare them with a nonresection cohort after propensity score matching, utilizing a national database.

METHODS

Utilizing the TriNetX Research Network, we queried cases from January 1, 2004 to March 1, 2022. We included patients of all ages who underwent supratentorial AVM resection, presenting without seizures on or before surgery and without being on antiseizure medications at least 1 day before surgery. The primary outcome was seizures manifesting at least 6 weeks after surgery. Patient characteristics and outcomes were compared between the cohorts with and without postoperative epilepsy. Further cohorts were created to compare cohorts with and without embolization or rupture. After propensity score matching, we compared an additional cohort of patients with an AVM diagnosis who did not undergo resection.

RESULTS

Of the 536 patients (mean age = 38.9 ± 19.6, 52% females) presenting without seizure who underwent AVM resection, 99 (18.5%) developed de novo epilepsy, with a 1-year cumulative incidence of 13.8%. Patients with epilepsy had higher rates of intracerebral hemorrhage, and intracerebral hemorrhage was less common in the embolization cohort. Patients in the ruptured cohort were older and more often males. After propensity score matching with 18 588 patients with AVM diagnosis but no resection, each group consisted of 529 patients, and de novo epilepsy at 1 year was significantly higher in the AVM resection cohort compared to the nonresection cohort (11.5% vs. 3.4%, p < .001).

SIGNIFICANCE

This analysis of 536 patients provides evidence that de novo epilepsy after brain AVM resection occurs at a 1-year cumulative incidence of 13.8%, with a total of 19.4% developing de novo epilepsy. Intracerebral hemorrhage was inconsistently associated with postoperative de novo epilepsy. De novo epilepsy was significantly less frequent after AVM diagnosis without resection.

Effect of Chronic Anticoagulation on Outcomes of Endovascular Treatment for Unruptured Intracranial Aneurysms-A Propensity-Matched Multicenter Study

BACKGROUND AND OBJECTIVES

Endovascular treatment of unruptured intracranial aneurysms (UIAs) in patients receiving anticoagulant medications has not been well studied. Whether long-term anticoagulation (AC) use affects aneurysmal obliteration rates and treatment-related complications is unclear.

METHODS

Patients with endovascular treatment for UIA from 4 academic centers were identified and divided into AC and non-AC groups. Periprocedural complications, radiographic and clinical outcomes, and retreatment rates were compared between the 2 groups before and after propensity score matching.

RESULTS

The initial cohort consisted of 70 patients in the AC group and 355 in the non-AC group. After one-to-one nearest neighbor propensity matching, 38 pairs of patients were compared for periprocedural complications. The total number of complications were higher in the AC group yet not significant (18.4% vs 5.3%, P = .15). After adding imaging follow-up duration to matched variables, 36 pairs were obtained. There was no significant difference in Raymond-Roy occlusion rate between the 2 groups ( P = .74). However, retreatment rate trended higher in the AC group compared with the non-AC group (22.2% vs 5.6%, P = .09). When clinical follow-up duration was added among matched variables, 26 pairs of cases were obtained for long-term clinical outcomes. There was no significant difference in modified Rankin Scale score between the 2 groups ( P = .61). One-to-many nearest neighbor propensities matched analysis with bigger sample sizes yielded similar results.

CONCLUSION

The use of anticoagulants does not affect occlusion rates or long-term outcomes in endovascular treatment of UIAs. Retreatment rates were higher in the AC group; however, this was not statistically significant.

Intraoperative angiography in neurosurgery: temporal trend, access site, and operative indication considerations from a 6-year institutional experience

BACKGROUND

Historically, the transfemoral approach (TFA) has been the most common access site for cerebral intraoperative angiography (IOA). However, in line with trends in cardiac interventional vascular access preferences, the transradial approach (TRA) and transulnar approach (TUA) have been gaining popularity owing to favorable safety and patient satisfaction outcomes.

OBJECTIVE

To compare the efficacy and safety of TRA/TUA and TFA for cerebral and spinal IOA at an institutional level over a 6-year period.

METHODS

Between July 2016 and December 2022, 317 angiograms were included in our analysis, comprising 60 TRA, 10 TUA, 243 TFA, and 4 transpopliteal approach cases. Fluoroscopy time, contrast dose, reference air kerma, and dose-area products per target vessel catheterized were primary endpoints. Multivariate regression analyses were conducted to evaluate predictors of elevated contrast dose and radiation exposure and to assess time trends in access site selection.

RESULTS

Contrast dose and radiation exposure metrics per vessel catheterized were not significantly different between access site groups when controlling for patient position, operative region, 3D rotational angiography use, and different operators. Access site was not a significant independent predictor of elevated radiation exposure or contrast dose. There was a significant relationship between case number and operative indication over the study period (P<0.001), with a decrease in the proportion of cases for aneurysm treatment offset by increases in total cases for the management of arteriovenous malformation, AVF, and moyamoya disease.

CONCLUSIONS

TRA and TUA are safe and effective access site options for neurointerventional procedures that are increasingly used for IOA.

Comparative analysis of long term effectiveness of Neuroform Atlas stent versus low profile visualized intraluminal stent/Woven EndoBridge devices in treatment of wide necked intracranial aneurysms

BACKGROUND

We compared the outcomes of wide necked aneurysms (WNA) treated with the Neuroform Atlas with those treated with the low profile visualized intraluminal stent (LVIS) or the Woven EndoBridge (WEB).

METHODS

Objective, prospectively collected, core laboratory adjudicated data from published trials for the Neuroform Atlas, LVIS, and WEB devices were reviewed. ATLAS (Safety and Effectiveness of the Treatment of Wide Neck, Saccular Intracranial Aneurysms With the Neuroform Atlas Stent System) study patients were included if they met other studies' inclusion criteria. Outcomes included (1) primary effectiveness (complete aneurysmal occlusion without retreatment/>50% parent vessel stenosis), (2) primary safety, (3) complete aneurysmal occlusion, and (4) retreatment rates (outcomes evaluated at the 12 month follow-up). Matching adjusted indirect comparison analysis was used to compare outcomes.

RESULTS

Analytical samples included 141 ATLAS subjects meeting WEB-IT (Woven EndoBridge Intrasaccular Therapy Study) criteria (ATLAS/WEB-IT) and 241 meeting LVIS (Pivotal Study of the Low Profile Visualized Intraluminal Support) criteria (ATLAS/LVIS). ATLAS/WEB-IT exhibited significantly higher rates of primary effectiveness and complete occlusion versus WEB (86.6% vs 53.9 %, P<0.0001, and 90.3% vs 53.9%, P<0.0001, respectively). For LVIS, there was no significant differences in primary effectiveness rates between ATLAS and LVIS (84.2% vs 77.7%, respectively, P=0.12). However, ATLAS/LVIS had a significantly higher proportion of patients achieving complete occlusion than LVIS (88.1 vs 79.1, P=0.03). Retreatment rates and primary safety outcomes were not significantly different (P>0.05) for the Atlas versus other devices except for a lower retreatment rate for ATLAS/WEB-IT versus WEB-IT (2.4% vs 9.8%, P=0.01).

CONCLUSION

The Neuroform Atlas provided higher occlusion rates and similar retreatment rates in comparable datasets compared with LVIS and WEB devices when treating WNA.

Intrasaccular flow disruption for ruptured aneurysms: an international multicenter study

BACKGROUND

The Woven EndoBridge (WEB) device is a novel intrasaccular flow disruptor tailored for bifurcation aneurysms. We aim to describe the degree of aneurysm occlusion at the latest follow-up, and the rate of complications of aneurysms treated with the WEB device stratified according to rupture status.

METHODS

Our data were taken from the WorldWideWeb Consortium, an international multicenter cohort including patients treated with the WEB device. Aneurysms were classified into two groups: ruptured and unruptured. We compared clinical and radiologic outcomes of both groups. Propensity score matching (PSM) was done to match according to age, gender, bifurcation, location, prior treatment, neck, height, dome width, daughter sac, incorporated branch, pretreatment antiplatelets, and last imaging follow-up.

RESULTS

The study included 676 patients with 691 intracranial aneurysms (529 unruptured and 162 ruptured) treated with the WEB device. The PSM analysis had 55 pairs. In both the unmatched (85.8% vs 84.3%, p=0.692) and matched (94.4% vs 83.3%, p=0.066) cohorts there was no significant difference in the adequate occlusion rate at the last follow-up. Likewise, there were no significant differences in both ischemic and hemorrhagic complications between the two groups. There was no documented aneurysm rebleeding after WEB device implantation.

CONCLUSION

There was no significant difference in both the radiologic outcomes and complications between unruptured and ruptured aneurysms. Our findings support the feasibility of treatment of ruptured aneurysms with the WEB device.

COManeci MechANical Dilation for vasospasm (COMMAND): multicenter experience

BACKGROUND

We report the largest multicenter experience to date of utilizing the Comaneci device for endovascular treatment of refractory intracranial vasospasm.

METHODS

Consecutive patients undergoing Comaneci mechanical dilatation for vasospasm were extracted from prospectively maintained registries in 11 North American centers (2020-2022). Intra-arterial vasodilators (IAV) were allowed, with the Comaneci device utilized after absence of vessel dilation post-infusion. Pre- and post-vasospasm treatment scores were recorded for each segment, with primary radiological outcome of score improvement post-treatment. Primary clinical outcome was safety/device-related complications, with secondary endpoints of functional outcomes at last follow-up.

RESULTS

A total of 129 vessels in 40 patients (median age 52 years; 67.5% females) received mechanical dilation, 109 of which (84.5%) exhibited pre-treatment severe-to-critical vasospasm (ie, score 3/4). Aneurysmal subarachnoid hemorrhage was the most common etiology of vasospasm (85%), with 65% of procedures utilizing Comaneci-17 (92.5% of patients received IAV). The most treated segments were anterior cerebral artery (34.9%) and middle cerebral artery (31%). Significant vasospasm drop (pre-treatment score (3-4) to post-treatment (0-2)) was achieved in 89.9% of vessels (96.1% of vessels experienced ≥1-point drop in score post-treatment). There were no major procedural/post-procedural device-related complications. Primary failure (ie, vessel unresponsive) was encountered in one vessel (1 patient) (1/129; 0.8%) while secondary failure (ie, recurrence in previously treated segment requiring retreatment in another procedure) occurred in 16 vessels (7 patients) (16/129; 12.4%), with median time-to-retreatment of 2 days. Favorable clinical outcome (modified Rankin Scale 0-2) was noted in 51.5% of patients (median follow-up 6 months).

CONCLUSIONS

The Comaneci device provides a complementary strategy for treatment of refractory vasospasm with reasonable efficacy/favorable safety. Future prospective trials are warranted.

Feasibility and safety of transradial intraoperative angiography for neurosurgery: An institutional experience

BACKGROUND

Transradial approach for neuroangiography is becoming increasingly popular because of the advantages demonstrated by interventional cardiology. Many advantages of radial access could be applied to intraoperative angiography.

OBJECTIVE

To report our institutional experience with transradial and transulnar intraoperative angiography, and evaluate its safety and feasibility.

METHODS

Intraoperative angiography through upper extremity vessels was attempted in 70 consecutive patients between April 2019 and December 2022. Data on patient characteristics and surgical indications, procedural variables, and complications were collected.

RESULTS

Of the 70 patients who underwent intraoperative angiography, 58.6% were female, and the mean age was 52.9 ± 14.0 years. The reason for surgery was aneurysm clipping in 42 (60.0%) cases. In total, 55 patients (78.6%) were positioned supine, 13 (18.6%) prone, and two (2.9%) were positioned three-quarters prone. Access was attempted via the radial artery in 60 (85.7%) patients and the ulnar artery in 10 (14.3%) patients. The procedure was successful in 69 of 70 cases (98.6%), as one required conversion to transfemoral approach due to significant spasm in the proximal right radial artery. The median fluoroscopy time was 8 min. No procedure was aborted, and no patient experienced access-site or angiography-related complications. Intraoperative angiography altered the surgical management in 3 (4.3%) cases. Re-access for follow-up angiography was unsuccessful in three (13.6%) of 22 due to radial artery occlusion.

CONCLUSIONS

Our institutional experience supports that transradial and transulnar intraoperative angiography is safe and feasible during neurovascular procedures for various indications and positions.

The impact of Verapamil for radial access in diagnostic cerebrovascular angiograms: A retrospective case-control study

INTRODUCTION

Different combinations of medications are utilized during wrist access for radial artery (RA) or ulnar artery (UA) catheterization in neuroendovascular procedures to preclude vasospasm. These "cocktails" commonly include the calcium channel blocker Verapamil, without established benefit. We analyze outcomes in patients with and without Verapamil in their "cocktail" by using a case-control cohort of our single-center experience.

METHODS

A prospective log of consecutive patients who underwent diagnostic cerebral angiograms using RA/UA access was retrospectively reviewed, and patients were grouped into Verapamil and non-Verapamil cohorts. The primary outcomes assessed were the presence of forearm skin rashes (hives) and RA/UA spasms. Our initial management included Verapamil (5 mg) in the cocktail, but Verapamil was removed after we noticed the development of hives in multiple patients immediately following its injection.

RESULTS

A total of 221 patients underwent 241 RA/UA diagnostic cerebral angiograms and were included in our analysis. One hundred and forty-nine patients (61.8%) underwent catheterization with Verapamil and 92 (38.2%) were catheterized without it. Four of the 149 patients in the Verapamil group (2.7%) developed hives during the procedure and were treated with Benadryl (25 mg). Of the 92 patients who did not receive Verapamil, there were zero (0%) cases of hives and one (1.1%) case of vasospasm.

CONCLUSION

Verapamil in the "cocktail" for wrist access diagnostic cerebral angiograms was associated with periprocedural hives, but not associated with a significant reduction in spasm compared to the non-Verapamil group. Our findings suggest that the administration of prophylactic Verapamil for these procedures may not be necessary.

Dexamethasone and Statins in Patients Undergoing Primary Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: A Propensity-Matched Study in the TriNetX Research Network

OBJECTIVE

Middle meningeal artery embolization (MMAE) is an effective minimally invasive option for chronic subdural hematoma (cSDH). Dexamethasone and statins have been reported to improve the resolution of cSDH and reduce its recurrence. However, only 1 study has investigated the role of statins in patients treated with MMAE, and there is no such study on dexamethasone. Thus, we used the TriNetX research network to determine whether adding dexamethasone or statin along with primary MMAE is associated with a benefit in outcomes.

METHODS

We queried all primary MMAE cases for cSDH between January 1st, 2012, and July 1st, 2022, in the TriNetX research network. We included patients greater than or equal to 18 years old and separated them regarding statin and dexamethasone use around the time of MMAE. Outcomes were evaluated within 6 months and 3 years after MMAE, and analyses were performed before and after propensity score matching.

RESULTS

The study included 372 patients with chronic subdural hematoma who underwent MMAE and were on dexamethasone, 339 not on dexamethasone, 391 on statins, and 278 not on statins. After propensity score matching, the dexamethasone cohorts included 250 patients each and only headache remained more prevalent in the dexamethasone cohort at both 6 months (21.2% vs. 10.0%, P = 0.001) and 3 years (23.6% vs. 12.4%, P = 0.001). After propensity score matching, the statin cohorts included 150 patients each and no differences in outcomes were found at both 6 months and 3 months after MMAE.

CONCLUSIONS

Patients treated with primary MMAE and were on dexamethasone or statins had no differences in mortality and functional/provider dependence compared to those who were not on dexamethasone or statins. Patients on dexamethasone had a higher prevalence of headaches.

Liquid embolic agents for middle meningeal artery embolization in chronic subdural hematoma: Institutional experience with systematic review and meta-analysis

INTRODUCTION

Chronic subdural hematoma (CSDH) is associated with high recurrence rates. Middle meningeal artery embolization (MMAE) has emerged as a promising treatment option. In this systematic review and meta-analysis, we aimed to assess the safety and efficacy of MMAE for CSDH using liquid embolic agents and compare them with particles.

METHODS

We systematically reviewed all studies describing MMAE for CSDH with liquid embolic agents, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Additionally, we included a cohort of patients from our institution using liquid and particle embolic agents. Data were analyzed using random-effects proportions and comparisons meta-analysis, and statistical heterogeneity was assessed.

RESULTS

A total of 18 studies with 507 cases of MMAE with liquid embolic agents (including our institutional experience) were included in the analysis. The success rate was 99% (95% confidence interval [CI]: 98-⁠100%), all complications rate was 1% (95% CI: 0-⁠5%), major complications rate was 0% (95% CI: 0-⁠0%), and mortality rate was 1% (95% CI: 0-⁠6%). The rate of hematoma size reduction was 97% (95% CI: 73-⁠100%), complete resolution 64% (95% CI: 33-⁠87%), radiographic recurrence 3% (95% CI: 1-⁠7%), and reoperation 3% (95% CI: 1-⁠7%). No significant differences in outcomes were found between liquid and particle embolic agents. Sensitivity analyses revealed that liquid embolic agents were associated with lower reoperation rates in upfront MMAE (risk ratio 0.13, 95% CI: 0.02-⁠0.95).

CONCLUSION

MMAE with liquid embolic agents is safe and effective for the treatment of CSDH. Outcomes are comparable to particles, but liquids were associated with a decreased risk of reoperation in upfront MMAE. However, further studies are needed to support our findings.

Safety and efficacy of the p48 MW and p64 flow modulation devices: a systematic review and meta-analysis

OBJECTIVE

Flow diverters (FDs) have demonstrated increasing safety and efficacy in treating various types of intracranial aneurysms. Although the underlying mechanism of action of all FDs is similar, differences are noted in their intrinsic characteristics, materials, and deployment techniques. The p64 flow modulation device (p64) and the newer p48 movable wire flow modulation device (p48 MW) are not yet available in the US but have been increasingly used mainly in Europe, demonstrating optimistic results. The authors performed a systematic review and meta-analysis of the literature to evaluate the safety and efficacy of the p64 and p48 MW FDs.

METHODS

A literature review (between January 1960 and November 2022) of the PubMed, Scopus, Embase, Web of Science, and Cochrane Central Register of Controlled Trials databases was conducted. The primary efficacy outcome was the proportion of complete angiographic occlusion at last follow-up. Complete occlusion was defined as Raymond-Roy class 1 and O'Kelly-Marotta grade D. The primary safety outcomes were the composite safety rate of ischemic and hemorrhagic events (intra- and postprocedure) and the all-cause mortality rate. Data were analyzed using a random-effects proportions meta-analysis, and statistical heterogeneity was assessed.

RESULTS

Twenty studies with 1781 patients harboring 1957 aneurysms were included in the analysis. Seventeen studies were conducted in Europe. Sixteen studies evaluated the performance of the p64 (MW). Patient ages ranged between 20 and 89 years, and most were female (78.7%). Aneurysm size ranged between 1 and 50 mm. Most aneurysms were unruptured (92.8%) and in the anterior circulation (93.1%). Single antiplatelet therapy pre- and postprocedure was used in 2 studies. Follow-up ranged from 2 to 14.5 months. For the p64 and p48 MW, complete angiographic occlusion rates were 77% (95% CI 68%-85%) and 67% (95% CI 49%-81%), adjunctive coil usage rates were 7% (95% CI 4%-12%) and 4% (95% CI 0%-24%), primary safety composite rates were 2% (95% CI 1%-4%) and 3% (95% CI 1%-11%), and mortality rates were 0.49% (95% CI 0%-1%) and 2% (95% CI 1%-6%), respectively.

CONCLUSIONS

The p64 and p48 MW have primarily been used in Europe thus far. This analysis found that both devices have an acceptable efficacy and favorable safety profile. However, further studies are needed to evaluate the efficacy and safety of prescribing a single antiplatelet regimen after implantation of the newer-generation FDs with antithrombotic coating surface modification.

Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: Predictors of Clinical and Radiographic Failure from 636 Embolizations

Background Knowledge regarding predictors of clinical and radiographic failures of middle meningeal artery (MMA) embolization (MMAE) treatment for chronic subdural hematoma (CSDH) is limited. Purpose To identify predictors of MMAE treatment failure for CSDH. Materials and Methods In this retrospective study, consecutive patients who underwent MMAE for CSDH from February 2018 to April 2022 at 13 U.S. centers were included. Clinical failure was defined as hematoma reaccumulation and/or neurologic deterioration requiring rescue surgery. Radiographic failure was defined as a maximal hematoma thickness reduction less than 50% at last imaging (minimum 2 weeks of head CT follow-up). Multivariable logistic regression models were constructed to identify independent failure predictors, controlling for age, sex, concurrent surgical evacuation, midline shift, hematoma thickness, and pretreatment baseline antiplatelet and anticoagulation therapy. Results Overall, 530 patients (mean age, 71.9 years ± 12.8 [SD]; 386 men; 106 with bilateral lesions) underwent 636 MMAE procedures. At presentation, the median CSDH thickness was 15 mm and 31.3% (166 of 530) and 21.7% (115 of 530) of patients were receiving antiplatelet and anticoagulation medications, respectively. Clinical failure occurred in 36 of 530 patients (6.8%, over a median follow-up of 4.1 months) and radiographic failure occurred in 26.3% (137 of 522) of procedures. At multivariable analysis, independent predictors of clinical failure were pretreatment anticoagulation therapy (odds ratio [OR], 3.23; P = .007) and an MMA diameter less than 1.5 mm (OR, 2.52; P = .027), while liquid embolic agents were associated with nonfailure (OR, 0.32; P = .011). For radiographic failure, female sex (OR, 0.36; P = .001), concurrent surgical evacuation (OR, 0.43; P = .009), and a longer imaging follow-up time were associated with nonfailure. Conversely, MMA diameter less than 1.5 mm (OR, 1.7; P = .044), midline shift (OR, 1.1; P = .02), and superselective MMA catheterization (without targeting the main MMA trunk) (OR, 2; P = .029) were associated with radiographic failure. Sensitivity analyses retained these associations. Conclusion Multiple independent predictors of failure of MMAE treatment for chronic subdural hematomas were identified, with small diameter (<1.5 mm) being the only factor independently associated with both clinical and radiographic failures. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Chaudhary and Gemmete in this issue.

Intraoperative angiography during neurosurgical procedures on patients in prone, three-quarters prone, and park-bench positions: tertiary single-center experience with systematic review and meta-analysis

BACKGROUND

There is limited evidence about the role and effectiveness of intraoperative angiography (IOA) during neurosurgical procedures with patients in prone, three-quarters prone, and park-bench positions.

OBJECTIVE

To carry out a systematic review and meta-analysis of the literature to evaluate the safety and efficacy of IOA during neurosurgical procedures.

METHODS

We reviewed (between January 1960 and July 2022) all studies in which IOAs were performed during neurosurgical procedures with patients in either prone, three-quarters prone, or park-bench positions. Additionally, a cohort of patients from our institutional experience was included. Efficacy outcomes were the rate of successful angiography and the rate of surgical adjustment/revision after IOA. Safety outcomes were the rate of angiography-related complications and mortality. Data were analyzed using a random-effects meta-analysis of proportions, and statistical heterogeneity was assessed.

RESULTS

A total of 26 studies with 142 patients plus 32 subjects from our institution were included in the analysis. The rate of successful intraoperative angiography was 98% (95% CI 94% to 99%; I²=0%). The rate of surgical adjustment/revision was 18% (95% CI 12% to 28%; I²=0%). The rate of complications related to the angiography was 1% (95% CI 0% to 5%; I²=0%). There were no deaths associated with IOA.

CONCLUSION

We found that IOA performed with patients in prone, three-quarters prone, and park-bench positions is feasible and safe with a non-negligible rate of intraoperative post-angiographical surgical adjustment/revision. Our findings suggest that the performance of IOA to complement vascular neurosurgical procedures might have a valuable role in favoring patient outcomes.

What matters most to cerebral aneurysms patients: A digital analysis of 1127 social media posts

INTRODUCTION

Social media serves as a way for patients to post about their condition online, as well as for healthcare providers to disseminate information. Intrinsic bias exists exist when patients are given surveys by physicians or healthcare providers. We aim to investigate patient-centered social media posts regarding cerebral aneurysms on Instagram, Twitter, and TikTok.

METHODS

Posts that included "brain aneurysm", "#brainaneurysm", "#brainaneurysmsurvivor", and "#aneurysmsurvivor" were queried on Instagram, Twitter, and TikTok. Any posts unrelated to the patient experience were excluded. Five hundred and fourteen Instagram posts, fourty tweets, and five hundred seventy three TikTok posts about the patient experience were identified. Posts were coded for the relevant themes related to their experience with the disease.

RESULTS

Most posts made online were by women (892, 82.1%). Patients made the post most of the time (776, 67.5%), while other individuals posted less often (420, 36.5%). The most common themes on Instagram were survival (475, 87.3%), spreading positivity (385, 70.77%), and recovery/rehabilitation (329, 60.5%). TikTok users most often referred to survival (573, 97.1%), raising awareness (464. 78.6%), and spreading positivity (414, 70.2%). Patients were more likely to discuss pre-operative pain (p = 0.0382), postoperative pain (p < 0.0001), invisible illness (p = 0.0130), humor (p = 0.0028), recovery (p < 0.0001), angiograms (p < 0.0001), and resiliency (p < 0.0001) when compared to other individuals posting about a patients' experience.

CONCLUSION

Patients often focus on different aspects of their care than do other individuals. This may be useful for physicians discussing treatment plans and prognoses with the patient and their families.

Intraoperative angiography via popliteal artery access for spinal neurovascular lesions: an institutional experience and systematic review

BACKGROUND

Intraoperative DSA is used to confirm complete obliteration of neurovascular pathologies. For spinal neurovascular lesions, femoral access can be challenging given the need to flip the patient after sheath placement. Similarly, radial access can be complicated by arch navigation difficulties. Vascular access via the popliteal artery represents an appealing alternative option; however, data regarding its utility and efficacy in these cases are limited.

METHODS

A retrospective series of four consecutive patients between July 2016 and August 2022 who underwent intraoperative spinal DSA via the popliteal artery was analyzed. Additionally, a systematic review was conducted to collect previously reported such cases. Collective patient demographics and operative details are presented to consolidate the available evidence supporting popliteal access.

RESULTS

Four patients met the inclusion criteria from our institution. The systematic review yielded six previously published studies reporting 16 additional transpopliteal access cases. Of the 20 total cases (mean±SD age 60.8±17.2 years), 60% were men. Most treated lesions were dural arteriovenous fistulas (80%) located in the thoracic spine (55%) or cervical spine (25%). The left popliteal artery was most accessed and the highest visualized level was the craniocervical junction. All outcomes were either stable or improving after surgery, and no complications were observed.

CONCLUSIONS

We report the safety and feasibility of transpopliteal access for intraoperative DSA in the prone position in four cases in addition to 16 previously reported cases in the literature. Our case series highlights popliteal artery access as an alternative to transfemoral or transradial access in this setting.

Sonolucent Cranioplasty in Extracranial to Intracranial Bypass Surgery: Early Multicenter Experience of 44 Cases

BACKGROUND

The new sonolucent cranioplasty implant (clear polymethyl methacrylate, PMMA) adds functionality besides surgical reconstruction. One possible application uses the transcranioplasty ultrasound (TCUS) technique after PMMA cranioplasty to assess graft patency of extracranial-intracranial (EC-IC) bypass procedures.

OBJECTIVE

To report our early multicenter experience.

METHODS

This is a multicenter analysis of consecutive EC-IC bypass patients from 5 US centers (2019-2022) with closure postbypass using PMMA implant.

RESULTS

Forty-four patients (median age 53 years, 68.2% females) were included. The most common indication for bypass was Moyamoya disease/syndrome (77.3%), and superficial temporal artery to middle cerebral artery bypass was the most common procedure (79.5%). Pretreatment modified Rankin Scales of 0 and 1 to 2 were noted in 11.4% and 59.1% of patients, respectively. Intraoperative imaging for bypass patency involved a combination of modalities; Doppler was the most used modality (90.9%) followed by indocyanine green and catheter angiography (86.4% and 61.4%, respectively). Qualitative TCUS assessment of graft patency was feasible in all cases. Postoperative inpatient TCUS confirmation of bypass patency was recorded in 56.8% of the cases, and outpatient TCUS surveillance was recorded in 47.7%. There were no cases of bypass failure necessitating retreatment. Similarly, no implant-related complications were encountered in the cohort. Major complications requiring additional surgery occurred in 2 patients (4.6%) including epidural hematoma requiring evacuation (2.3%) and postoperative surgical site infection (2.3%) that was believed to be unrelated to the implant.

CONCLUSION

This multicenter study supports safety and feasibility of using sonolucent PMMA implant in EC-IC bypass surgery with the goal of monitoring bypass patency using TCUS.

Middle meningeal artery embolization as a perioperative adjunct to surgical evacuation of nonacute subdural hematomas: An multicenter analysis of safety and efficacy

BACKGROUND

By 2030, nonacute subdural hematomas (NASHs) will likely be the most common cranial neurosurgery pathology. Treatment with surgical evacuation may be necessary, but the recurrence rate after surgery is as high as 30%. Minimally invasive middle meningeal artery embolization (MMAE) during the perioperative period has been posited as an adjunctive treatment to decrease the potential for recurrence after surgical evacuation. We evaluated the safety and efficacy of concurrent MMAE in a multi-institutional cohort.

METHODS

Data from 145 patients (median age 73 years) with NASH who underwent surgical evacuation and MMAE in the perioperative period were retrospectively collected from 15 institutions. The primary outcome was the rate of recurrence requiring repeat surgical intervention. We collected clinical, treatment, and radiographic data at initial presentation, after evacuation, and at 90-day follow-up. Outcomes data were also collected.

RESULTS

Preoperatively, the median hematoma width was 18 mm, and subdural membranes were present on imaging in 87.3% of patients. At 90-day follow-up, median NASH width was 6 mm, and 51.4% of patients had at least a 50% decrease of NASH size on imaging. Eight percent of treated NASHs had recurrence that required additional surgical intervention. Of patients with a modified Rankin Scale score at last follow-up, 87.2% had the same or improved mRS score. The total all-cause mortality was 6.0%.

CONCLUSION

This study provides evidence from a multi-institutional cohort that performing MMAE in the perioperative period as an adjunct to surgical evacuation is a safe and effective means to reduce recurrence in patients with NASHs.

Neurosurgeons Deliver Similar Quality Care Regardless of First Assistant Type: Resident Physician Versus Non-Physician Surgical Assistant

OBJECTIVE

There are limited data evaluating the outcomes of attending neurosurgeons with different types of first assistants. This study considers a common neurosurgical procedure (single-level, posterior-only lumbar fusion surgery) and examines whether attending surgeons deliver equal patient outcomes, regardless of the type of first assistant (resident physician versus non-physician surgical assistant), among otherwise exact-matched patients.

METHODS

The authors retrospectively analyzed 3,395 adult patients undergoing single-level, posterior-only lumbar fusion at a single academic medical center. Primary outcomes included readmissions, emergency department (ED) visits, reoperation, and mortality within 30 and 90 days after surgery. Secondary outcome measures included discharge disposition, length of stay, and length of surgery. Coarsened exact matching was used to match patients on key demographics and baseline characteristics known to independently affect neurosurgical outcomes.

RESULTS

Among exact-matched patients (n = 1402) there was no significant difference in adverse postsurgical events (readmission, ED visits, reoperation, or mortality) within 30 days or 90 days of the index operation between patients who had resident physicians versus NPSAs as first assistants. Patients who had resident physicians as first assistants demonstrated a longer length of stay (mean 100.0 vs. 87.4 hours, p < 0.001) and a shorter duration of surgery (mean 187.4 vs. 213.8 minutes, p < 0.001). There was no significant difference between the two groups in the percentage of patients discharged home.

CONCLUSIONS

For single-level posterior spinal fusion, in the setting described, there are no differences in short-term patient outcomes delivered by attending surgeons assisted by resident physicians versus NPSAs.

Case report: Utilization and efficacy of large-bore catheters in mechanical thrombectomies

Thrombotic strokes are caused by occlusion of flow in a blood vessel by a clot or thrombus, resulting in disruption of oxygen and nutrients to the brain that can result in neurological deficits. There are many devices now available for safe and effective removal of thrombi from large blood vessels. This report focuses on the Zoom 0.088" large-bore catheter, which has the potential to be navigated into a large vessel for thrombus removal via aspiration, and weigh the risks and benefits of its utilization in thrombectomy patients. In this case, we discuss the use of this device for thrombectomy of a left M1 middle cerebral artery occlusion that resulted in a distal left MCA dissection and eventual loss of access to the site of the thrombus. Ultimately, the patient died from a large stroke in the left MCA territory. In light of this occurrence, we seek to explore the utility and feasibility of large-bore catheters and their risks in thrombectomy candidates.

Microsurgical Obliteration of Craniocervical Junction Dural Arteriovenous Fistulas: Multicenter Experience

BACKGROUND

Dural arteriovenous fistulas (dAVFs) located at craniocervical junction are extremely rare (1%-2% of intracranial/spinal dAVFs). Their angio-architectural complexity renders endovascular embolization to be challenging given multiple small feeders with risk of embolysate reflux into vertebral artery and limited transvenous access. The available literature discussing microsurgery for these lesions is limited to few case reports.

OBJECTIVE

To report a multicenter experience assessing microsurgery safety/efficacy.

METHODS

Prospectively maintained registries at 13 North American centers were queried to identify craniocervical junction dAVFs treated with microsurgery (2006-2021).

RESULTS

Thirty-eight patients (median age 59.5 years, 44.7% female patients) were included. The most common presentation was subarachnoid/intracranial hemorrhage (47.4%) and myelopathy (36.8%) (92.1% of lesions Cognard type III-V). Direct meningeal branches from V3/4 vertebral artery segments supplied 84.2% of lesions. All lesions failed (n = 5, 13.2%) or were deemed inaccessible/unsafe to endovascular treatment. Far lateral craniotomy was the most used approach (94.7%). Intraoperative angiogram was performed in 39.5% of the cases, with angiographic cure in 94.7% of cases (median imaging follow-up of 9.2 months) and retreatment rate of 5.3%. Favorable last follow-up modified Rankin Scale of 0 to 2 was recorded in 81.6% of the patients with procedural complications of 2.6%.

CONCLUSION

Craniocervical dAVFs represent rare entity of lesions presenting most commonly with hemorrhage or myelopathy because of venous congestion. Microsurgery using a far lateral approach provides robust exposure and visualization for these lesions and allows obliteration of the arterialized draining vein intradurally as close as possible to the fistula point. This approach was associated with a high rate of angiographic cure and favorable clinical outcomes.

National Survey on Flow-Diverting Stents for Intracranial Aneurysms in the United States

BACKGROUND

The Pipeline Embolization Device (PED) has been the only flow-diverting device (FDD) approved by the Food and Drug Administration (FDA) in the U.S. market for nearly a decade, with more FDD choices in the United States following recent FDA approval of the Flow Redirection Endoluminal Device and Surpass. We sought to explore the integration patterns of these devices into practice by U.S. neurointerventionalists.

METHODS

A 34-question electronic survey was distributed to the U.S. neurointerventional community from different backgrounds (neurosurgery, neurology, radiology) through different organizational links, focusing on technical aspects of device selection and personal preferences/experiences regarding FDD in aneurysms treatment.

RESULTS

Responses were collected from 120 neurointerventionalists across the United States; operators from a neurosurgery background constituted the majority of respondents (47.5%; 85% of dual-trained). The largest age block was early-to mid-career operators (70.8% aged 36-50 years). Most participants (78.8%) treated a range of 25-100 aneurysms/year with FDDs, with 49.2% of respondents having all the FDA-approved FDDs available in their centers (80.8% academic practice). Femoral access was used by the 67.7% of respondents, without impact of FDD-device on access-type (89.2%). PED was the most commonly used device (70.9%), with 66.7% of respondents reporting using different FDD based on case specifics. Comparing devices preferences by training backgrounds, more neurosurgical operators endorsed PED as their most commonly used device, whereas more interventional neuroradiologists/neurologists reported Surpass and Flow Redirection Endoluminal Device as their most commonly used devices.

CONCLUSIONS

The results of this survey identify common themes in FDD choices among neurointerventionalists in the U.S. market, along with their integration patterns of the newly introduced devices into clinical practice.

The neurosurgical marriage: evaluating the interplay of work life and home life from the perspective of partners of neurosurgical residents

OBJECTIVE

Burnout and work-life balance have been noted to be problems for residents across all fields of medicine, including neurosurgery. No studies to date have evaluated how these factors may contribute to issues outside of the hospital, specifically residents' home lives. This study aimed to evaluate the interplay between home life and work life of neurosurgical residents, specifically from the point of view of residents' significant others.

METHODS

Online surveys were distributed to the significant others of neurosurgical residents at 12 US neurosurgery residencies. Residents' partners were asked about relationship dynamics, their views on neurosurgery residency (work-life balance and burnout), and their views of neurosurgery as a career.

RESULTS

The majority of residents' significant others (84%) reported being satisfied with their relationship. Significant others who reported dissatisfaction with their relationship were more likely to report frustration with work-life balance and more likely to report their resident partner as having higher levels of burnout.

CONCLUSIONS

From the perspective of neurosurgery residents' significant others, higher perceived levels of burnout and lower satisfaction with work-life balance are correlated with lower levels of relationship satisfaction. These findings speak to the complex interplay of work life and home life and can be used to inform future interventions into improving the quality of life for both the resident and the significant other.

North American multicenter experience with the Flow Redirection Endoluminal Device in the treatment of intracranial aneurysms

OBJECTIVE

Flow diverters have revolutionized the endovascular treatment of intracranial aneurysms. Here, the authors present the first large-scale North American multicenter experience using the Flow Redirection Endoluminal Device (FRED) in the treatment of cerebral aneurysms.

METHODS

Consecutive cerebral aneurysms treated with FRED at 7 North American centers between June 2020 and November 2021 were included. Data collected included patient demographic characteristics, aneurysm characteristics, periprocedural and long-term complications, modified Rankin Scale (mRS) scores, and radiological follow-up.

RESULTS

In total, 133 aneurysms in 116 patients were treated with 123 FRED deployment procedures and included in this study. One hundred twenty-six aneurysms (94.7%) were unruptured, 117 (88.0%) saccular, and 123 (92.5%) located in anterior circulation. The mean (range) aneurysm maximal width and neck width sizes were 7.2 (1.5-42.5) mm and 4.1 (1.0-15.1) mm, respectively. Successful FRED deployment was achieved in 122 procedures (99.2%). Adjunctive coiling was used in 4 procedures (3.3%). Radiological follow-up was available for 101 aneurysms at a median duration of 7.0 months. At last follow-up, complete occlusion was observed in 55.4% of patients, residual neck in 8.9%, and filling aneurysm in 35.6%; among cases with radiological follow-up duration > 10 months, these values were 21/43 (48.8%), 3/43 (7.0%), and 19/43 (44.2%), respectively. On multivariate regression analysis, age (OR 0.93, p = 0.001) and aneurysm neck size (OR 0.83, p = 0.048) were negatively correlated with odds of complete occlusion at latest follow-up. The retreatment rate was 6/124 (4.8%). The overall complication rate was 31/116 (26.7%). Parent vessel occlusion, covered branch occlusion, and in-stent stenosis were detected in 9/99 (9.1%), 6/63 (9.5%), and 15/99 (15.2%) cases, respectively. The FRED-related, symptomatic, thromboembolic, and hemorrhagic complication rates were 22.4%, 12.9%, 6.9%, and 0.9% respectively. The morbidity rate was 10/116 patients (8.6%). There was 1 death due to massive periprocedural internal carotid artery stroke, and 3.6% of the patients had an mRS score > 2 at the last follow-up (vs 0.9% at baseline).

CONCLUSIONS

As the first large-scale North American multicenter FRED experience, this study confirmed the ease of successful FRED deployment but suggested lower efficacy and a higher rate of complications than reported by previous European and South American studies on FRED and other flow-diverting devices. The authors recommend judicious use of this device until future studies can better elucidate the long-term outcomes of FRED treatment.

Understanding the Pathogenesis of Lateral Supratentorial Neurenteric Cysts in Close Proximity to Other Vascular Pathologies: A Case Report and Review of Embryology

Several theories have been postulated to explain the embryogenesis of central nervous system (CNS) neurenteric cysts (NCs), but the exact mechanism remains poorly understood. Of those, the neurenteric canal migration hypothesis suggesting endodermal cell migration through the neurenteric canal and settling among ectodermal cells prior to neural tube closure might be the most robust as it explains, in contrast to other hypotheses, the existence of lateral supratentorial lesions, which are extremely rare, compared to their infratentorial counterparts. This mechanism might be supported by past medical history or the coexistence of CNS epidermoid cysts, which are thought to arise due to improper neural tube closure potentially increasing the probability of endodermal migration and subsequent NC development, yet there are no reported cases in the literature. We present a case of a patient with a history of a previously resected intracranial epidermoid cyst, representing three simultaneous pathologies including a laterally based right frontal NC along with a right corona radiata cavernous malformation lesion, and right middle cerebral artery bifurcation aneurysm. The three lesions were treated microsurgically in one operative session without complications. We discuss the case and review the relevant pathoembryology of laterally based supratentorial NC.

The Pennsylvania Postmarket Multicenter Experience With Flow Redirection Endoluminal Device

BACKGROUND

The flow redirection endoluminal device (FRED) is a novel self-expanding double-layer nitinol braided flow diverter that recently received FDA approval. However, early postmarket studies from the United States are lacking.

OBJECTIVE

To report our short-term multicenter experience.

METHODS

Series of consecutive patients undergoing FRED treatment for intracranial aneurysms were queried from prospectively maintained registries at 4 North-American Centers in Pennsylvania (February 2020-June 2021). The pertinent baseline demographics, aneurysmal characteristics, and procedural outcomes were collected and analyzed, with primary outcome of aneurysmal occlusion and secondary outcome of safety and complications.

RESULTS

Sixty-one patients (median age 58 years, 82% female) underwent 65 FRED treatment procedures for 72 aneurysms. Most (86.1%) of the aneurysms were unruptured; 80.5% were saccular in morphology, and 87.5% were located along the internal carotid artery, with a median size of 7.1 mm (IQR 5.2-11.9 mm). Radiographic follow-up was available in 86.1% of the aneurysms, showing complete occlusion in 74.2% (80% in catheter angiography-only group), and near-complete occlusion in 11.3% of the cases (median 6.3 months), with 2.8% re-treated. Permanent ischemic complications were encountered in 2.8% of the cases, with no procedural mortality. A modified Rankin Scale of 0 to 2 was documented in 98.1% of the patients at the last clinical follow-up (median 6.1 months).

CONCLUSION

The results of the early postmarket experience with the FRED device show reasonable safety and adequate aneurysmal occlusion rates comparable with other flow diverters. However, more extensive multicenter studies with more extended follow-up data are needed to assess the long-term safety and durability of the device.

Endoluminal flow diverting stents for middle cerebral artery bifurcation aneurysms: multicenter cohort

BACKGROUND

Data regarding the safety and efficacy of flow diverting stents (FDS) in the treatment of middle cerebral artery (MCA) bifurcation aneurysms are scarce and limited to small single center series, with particular concern for increased risk of ischemic complications with jailing one of the M2 branches.

METHODS

Prospectively-maintained databases at six North American and European centers were queried for patients harboring MCA bifurcation aneurysms undergoing treatment with FDS (2011-2018). The pertinent clinical and radiographic data were collected and analyzed.

RESULTS

87 patients (median age 60 years, 69% females) harboring 87 aneurysms were included. The majority of aneurysms were unruptured (79%); 75.9% were saccular with a median maximal diameter of 8.5 mm. Radiographic imaging follow-up was available in 88.5% of cases at a median of 16.3 months post-treatment, showing complete occlusion in 59% and near complete occlusion (90-99%) in 18% of aneurysms. The overall rate of ischemic and hemorrhagic complications was 8% and 1.1%, respectively. Symptomatic and permanent complications were encountered in 5.7% and 2.3% of patients respectively, with retreatment pursued in 2.3% of patients. Jailed branch occlusion was detected in 11.5% of cases, with clinical sequelae in 2.3%. Last follow-up modified Rankin Scale of 0-2 was noted in 96.8% of patients. On multivariate analysis, male sex was the only independent predictor of aneurysmal persistence at last follow-up imaging (p=0.019).

CONCLUSION

FDS treatment for MCA bifurcation aneurysms is feasible, with comparable safety and efficacy profiles to other available endovascular options when utilized in carefully selected aneurysms. Jailing of M2 branches was not associated with a higher risk of post-procedural ischemic complications.

Carotid artery revascularization using the Walrus balloon guide catheter: safety and feasibility from a US multicenter experience

INTRODUCTION

The Walrus balloon guide catheter (BGC) is a new generation of BGC, designed to eliminate conventional limitations during mechanical thrombectomy.

OBJECTIVE

To report a multi-institutional experience using this BGC for proximal flow control (PFC) in the setting of carotid artery angioplasty/stenting (CAS) in elective (eCAS) and tandem strokes (tCAS).

METHODS

Prospectively maintained databases at 8 North American centers were queried to identify patients with cervical carotid disease undergoing eCAS/tCAS with a Walrus BGC.

RESULTS

110 patients (median age 68, 64.6% male), 80 (72.7%) undergoing eCAS and 30 (27.3%) tCAS procedures, were included (median cervical carotid stenosis 90%; 46 (41.8%) with contralateral stenosis). Using a proximal flow-arrest technique in 95 (87.2%) and flow-reversal in 14 (12.8%) procedures, the Walrus was navigated into the common carotid artery successfully in all cases despite challenging arch anatomy (31, 28.2%), with preferred femoral access (103, 93.6%) and in monitored anesthesia care (90, 81.8%). Angioplasty and distal embolic protection devices (EPDs) were used in 91 (83.7%) and 58 (52.7%) procedures, respectively. tCAS led to a modified Thrombolysis in Cerebral Infarction 2b/3 in all cases. Periprocedural ischemic stroke (up to 30 days postoperatively) rate was 0.9% (n=1) and remote complications occurred in 2 (1.8%) cases. Last follow-up modified Rankin Scale score of 0-2 was seen in 95.3% of eCAS cohort, with no differences in complications in the eCAS subgroup between PFC only versus PFC and distal EPD (median follow-up 4.1 months).

CONCLUSION

Walrus BGC for proximal flow control is safe and effective during eCAS and tCAS. Procedural success was achieved in all cases, with favorable safety and functional outcomes on short-term follow-up.

Intraparenchymal hematoma and intraventricular catheter placement using robotic stereotactic assistance (ROSA): A single center preliminary experience

BACKGROUND

Large supratentorial intraparenchymal hemorrhages are managed emergently with image-guided catheters that aim to minimize injury to surrounding parenchyma. Robotic assistance may offer advantages for stereotactic guidance and placement of such catheters. We describe our center's experience with minimally invasive ROSA-assisted intraventricular and intraparenchymal hemorrhage catheter placement and delineate its safety and outcomes.

METHODS

A retrospective analysis was performed including all patients with intraparenchymal hematoma that underwent ROSA-assisted intraparenchymal and intraventricular catheter placement at the University of Pittsburgh Medical Center between 2017 and 2019. All patients received tissue plasminogen activator (tPA) through the intraparenchymal catheter. We performed a manual chart review of these patients. Pertinent clinical and radiological characteristics and patient outcomes were recorded and analyzed. Catheter trajectory was independently quantified and analyzed by two independent reviewers. Error between the planned trajectory and final position was calculated and analyzed.

RESULTS

Four patients (2 males and 2 females, mean age of 64 years) with deep brain large volume intraparenchymal hemorrhages were treated with catheter evacuation with robotic assistance. For 2 of the 4 patients, thin-cut CT imaging allowed for the real trajectory of the catheter to be compared to the targeted trajectory to calculate error. The mean error of catheter placement was 3.48 mm. ROSA-assisted catheter placement achieved up to 95% reduction of intraparenchymal hematoma volume with a statistically significant decrease following catheter drainage (pre- 51.8 ± 19.1 cc vs. post- 13.0 ± 14.4; p < 0.01).

CONCLUSION

Robotic stereotactic assistance offers a safe and sufficiently accurate technique for intraparenchymal hematoma and intraventricular catheter placement.

Symptomatic nonstenotic carotid disease: Evaluation of a proposed classification scheme in a prospective cohort

INTRODUCTION

Unraveling symptomatic nonstenotic carotid disease (SyNC) as a stroke etiology from other cryptogenic stroke may have important implications for defining natural history and for tailoring secondary prevention strategies. We aim to describe the characteristics of the plaques in a prospectively-collected cohort of patients with non-invasive imaging suggesting symptomatic carotid stenosis but whose DSA demonstrated nonstenotic atheromatous disease, and to evaluate the recurrence rate depending on the type of SyNC.

METHODS

We reviewed prospectively-collected data for patients presenting with new neurologic events and non-invasive imaging suggestive of moderate or severe (≥50%) carotid stenosis between July 2016 and October 2018. Patients were included in the present study if the degree of stenosis on DSA was < 50%. We assigned these patients into groups based on a previously-proposed working definition of SyNC, and analyzed the rate of recurrent stroke in the following 6 months.

RESULTS

28 patients had DSA-confirmed < 50% stenosis and constituted the study cohort. The median age was 73 years and 64% were male; median presenting NIHSS was 1 (IQR 0-3). The great majority (86%) of carotid plaques had high-risk features including ulcerated plaque (n = 21, 75%) and plaque > 3 mm thick (n = 18, 64%). 17 of 28 patients (61%) met classification criteria for "definite" or "probable" SyNC. Three of five patients in the "definite SyNC" group experienced recurrent neurologic events.

CONCLUSION

The majority of patients with non-invasive imaging suggesting carotid stenosis harbor symptomatic carotid disease per current classifications despite DSA stenosis < 50%. Current classification schema may allow for risk stratification of SyNC patients and these findings warrant further study.

Bigger is Still Better: A Step Forward in Reperfusion With React 71

BACKGROUND

While multiple new larger-bore aspiration catheters have been introduced for stroke thrombectomy, sizeable cohort outcome studies are lacking along with meaningful comparative studies to evaluate whether they represent a clinically relevant improvement compared to predecessors.

OBJECTIVE

To evaluate comparative angiographic and clinical outcomes between an 071 and 068 aspiration catheter.

METHODS

The authors reviewed an institutional thrombectomy database extracting the first 150 consecutive cases utilizing React 71 (Medtronic, Dublin, Ireland) with a comparison of background/demographic, procedural, angiographic, and clinical outcome variables to a cohort of patients treated with our previously most frequently utilized 0.068-inch aspiration catheter.

RESULTS

In our React 71 cohort, successful reperfusion (thrombolysis in cerebral infarction [TICI] 2b-3) was achieved in 95% of cases. In comparison to a prior cohort of 96 patients treated with a 0.068-inch catheter, there was no statistically significant difference in rates of successful reperfusion (TICI 2b-3), initial disposition, and 90-d outcome. However, the frequency of single pass cases was significantly higher in the React 71 cohort (47% vs 35%, P = .019 on multivariate analysis) along with the rate of TICI 2c-3 reperfusion after the first pass (26% vs 14%, P = .019 on multivariate analysis), and final TICI 2c-3 reperfusion (39% vs 28%, P = .04 on multivariate analysis).

CONCLUSION

While rates of TICI 2b-3 reperfusion and clinical outcome results were similar, our study suggests that a newer, larger bore aspiration catheter may be associated with a greater frequency of single pass cases and higher quality reperfusion, judged as TICI 2c-3 frequency after the first and final pass.