General anesthesia or conscious sedation for endovascular therapy of basilar artery occlusions: ETIS registry results

BACKGROUND AND PURPOSE

Acute basilar artery occlusions (BAO) are associated with poor outcome despite modern endovascular treatment (EVT). The best anesthetic management during EVT is not known and may affect the procedure and clinical outcome. We compared the efficacy and safety of general anesthesia (GA) and conscious sedation/local anesthesia (CS/LA) in a large cohort of stroke patients with BAO treated with EVT in current clinical practice.

METHODS

Data from the ongoing prospective multicenter Endovascular Treatment In Ischemic Stroke Registry of consecutive acute BAO patients who had EVT indication from January 1st, 2015, to December 31st, 2021, were retrospectively analyzed. Two groups were compared: patients treated with CS/LA versus GA (both types of anesthesia being performed in the angiosuite). Good outcome was defined as modified Rankin Scale (mRS) score 0-3 at 90 days.

RESULTS

Among the 524 included patients, 266 had GA and 246 had CS/LA (67 LA). Fifty-three patients finally did not undergo EVT: 15 patients (5.9%) in the GA group and 38 patients (16.1%) in the CS/LA group (P < 0.001). After matching, two groups of 129 patients each were retained for primary analysis. The two groups were well balanced in terms of baseline characteristics. After adjustment, CS/LA compared to GA was not associated with good outcome (OR=0.90 [95%CI 0.46-1.77] P=0.769) or mortality (OR=0.75 [0.37-1.49] P=0.420) or modified thrombolysis in cerebral infarction score 2b-3 (OR=0.43 [0.16-1.16] P=0.098). On mixed ordinal logistic regression, the modality of anesthesia was not associated with any significant change in the overall distribution of the 90-day mRS (adjusted OR=1.08 [0.62-1.88] P=0.767).

CONCLUSIONS

Safety, outcome and quality of EVT under either CS/LA or GA for stroke due to acute BAO appear similar. Further randomized trials are warranted.

Safety and Efficacy of Cangrelor in Acute Stroke Treated with Mechanical Thrombectomy: Endovascular Treatment of Ischemic Stroke Registry and Meta-analysis

BACKGROUND AND PURPOSE

Rescue therapies are increasingly used in the setting of endovascular therapy for large-vessel occlusion strokes. Among these, cangrelor, a new P2Y12 inhibitor, offers promising pharmacologic properties to join the reperfusion strategies in acute stroke. We assessed the safety and efficacy profiles of cangrelor combined with endovascular therapy in patients with large-vessel-occlusion stroke.

MATERIALS AND METHODS

We performed a retrospective patient data analysis in the ongoing prospective multicenter observational Endovascular Treatment in Ischemic Stroke Registry in France from July 2018 to December 2020 and conducted a systematic review and meta-analysis using several data bases. Indications for cangrelor administration were rescue strategy in case of refractory intracranial occlusion with or without intracranial rescue stent placement, and cervical carotid artery stent placement in case of cervical occlusion (tandem occlusion or isolated cervical carotid occlusion).

RESULTS

In the clinical registry, 44 patients were included (median initial NIHSS score, 12; prior intravenous thrombolysis, 29.5%). Intracranial stent placement was performed in 54.5% (n = 24/44), and cervical stent placement, in 27.3% (n = 12/44). Adjunctive aspirin and heparin were administered in 75% (n = 33/44) and 40.9% (n = 18/44), respectively. Rates of symptomatic intracerebral hemorrhage, parenchymal hematoma, and 90-day mortality were 9.5% (n = 4/42), 9.5% (n = 4/42), and 24.4% (n = 10/41). Favorable outcome (90-day mRS, 0-2) was reached in 51.2% (n = 21/41), and successful reperfusion, in 90.9% (n = 40/44). The literature search identified 6 studies involving a total of 171 subjects. In the meta-analysis, including our series data, symptomatic intracerebral hemorrhage occurred in 8.6% of patients (95% CI, 5.0%-14.3%) and favorable outcome was reached in 47.6% of patients (95% CI, 27.4%-68.7%). The 90-day mortality rate was 22.6% (95% CI, 13.6%-35.2%). Day 1 artery patency was observed in 89.7% (95% CI, 81.4%-94.6%).

CONCLUSIONS

Cangrelor offers promising safety and efficacy profiles, especially considering the complex endovascular reperfusion procedures in which it is usually applied. Further large prospective data are required to confirm these findings.

A regional strategy to decrease the time to thrombectomy in patients with low probability of treatment by thrombolysis

BACKGROUND AND PURPOSE

The best transportation strategy for patients with suspected large vessel occlusion (LVO) is unknown. Here, we evaluated a new regional strategy of direct transportation to a Comprehensive Stroke Center (CSC) for patients with suspected LVO and low probability of receiving intravenous thrombolysis (IVT) at the nearest Primary Stroke Center (PSC).

METHODS

Patients could be directly transported to the CSC (bypass group) if they met our pre-hospital bypass criteria: high LVO probability (i.e., severe hemiplegia) with low IVT probability (contraindications) and/or travel time difference between CSC and PSC<15 minutes. The other patients were transported to the PSC according to a "drip-and-ship" strategy. Treatment time metrics were compared in patients with pre-hospital bypass criteria and confirmed LVO in the bypass and drip-and-ship groups.

RESULTS

In the bypass group (n=79), 54/79 (68.3%) patients met the bypass criteria and 29 (36.7%) had confirmed LVO. The positive predictive value of the hemiplegia criterion for LVO detection was 0.49. In the drip-and-ship group (n=457), 92/457 (20.1%) patients with confirmed LVO met our bypass criteria. Among the 121 patients with bypass criteria and confirmed LVO, direct routing decreased the time between symptom discovery and groin puncture by 55 minutes compared with the drip-and-ship strategy (325 vs. 229 minutes, P<0.001), without significantly increasing the time to IVT (P=0.19).

CONCLUSIONS

Our regional strategy led to the correct identification of LVO and a significant decrease of the time to mechanical thrombectomy, without increasing the time to IVT, and could be easily implemented in other territories.

Influence of operator experience on the technical and clinical results of Woven EndoBridge endovascular treatment for intracranial aneurysms

BACKGROUND & PURPOSE

The safety and efficacy of the Woven EndoBridge (WEB) device has been proven in recent multicenter trials. This study investigated whether operator experience influences WEB treatment-related outcomes.

MATERIAL AND METHODS

This was a retrospective analysis of a prospectively collected multicenter database. The data of all patients who underwent WEB treatment for an intracranial aneurysm from March 2014 to June 2020 in two high-volume centers were pooled. Operator experience was indexed by the number of WEB treatments performed previously. The primary endpoint was the overall complication rate. Secondary endpoints were long-term adequate (Raymond-Roy classification of 1-2.) angiographic occlusion, WEB-related complications, number of WEB not deployed, procedure duration, and radiation exposure (air kerma).

RESULTS

Among 237 patients (mean age 59.4 +/- 11.5 years) treated with WEB (median aneurysm diameter, 5.8 mm; interquartile range 4.5-7 mm), WEB-related complications occurred in 28 patients (11.8%) and adequate long-term occlusion was achieved for 154 aneurysms (86%). The median number of WEB treatment performed previously per operator was 20 (IQR, 9-41). The overall complication rate, WEB-related complication rate and aneurysm occlusion rate were not significantly correlated with WEB operator experience. There were also no significant correlations between the WEB operator experience and the number of WEB not deployed, procedure duration or radiation exposure.

CONCLUSION

There was no significant association between the number of WEB treatments previously performed per operator and any technical or clinical results after intracranial aneurysm treatment with WEB. These results imply a relatively short learning curve for this device in high-volume neurovascular centers.

A Multicenter Preliminary Study of Cangrelor following Thrombectomy Failure for Refractory Proximal Intracranial Occlusions

BACKGROUND AND PURPOSE

Rescue endovascular and pharmacologic approaches are increasingly being adopted after recanalization failure of acute large-vessel occlusion strokes with mechanical thrombectomy, with encouraging results. The safety and efficacy of glycoprotein IIb/IIIa inhibitors in ischemic stroke have been investigated, though cangrelor, a recent intravenous P2Y12-receptor inhibitor with a rapid onset/offset of action and a short half-life, may be a valuable option. We compared the safety and efficacy of cangrelor with those of glycoprotein IIb/IIIa inhibitors for refractory occlusions.

MATERIALS AND METHODS

We performed a retrospective analysis of the ongoing prospective, multicenter, observational Endovascular Treatment in Ischemic Stroke Registry in France between May 2012 and February 2020. Refractory intracranial occlusions of the anterior and posterior circulation were included and defined as recanalization failure of large-vessel occlusion stroke, perioperative target artery reocclusion, or high risk of early reocclusion related to an arterial wall lesion. The primary end point was a favorable outcome, defined as a 90-day mRS of 0-2. Secondary end points were reperfusion, intracranial hemorrhage, and procedural complications.

RESULTS

Among 69 patients, 15 were treated with cangrelor, and 54, with glycoprotein IIb/IIIa inhibitors. The favorable outcome (adjusted OR = 2.22; 95% CI, 0.42-11.75; P = .348) and mortality (adjusted OR = 0.44; 95% CI, 0.06-3.16; P = .411) rates were similar in both groups. There was no difference in the rates of any intracranial hemorrhage (adjusted OR = 0.40; 95% CI, 0.08-2.09; P = .280), symptomatic intracranial hemorrhage (6.7% versus 0.0%, P = .058), or procedural complications (6.7% versus 20.4%, P = .215). Reperfusion rates were higher in the cangrelor group, though the difference did not reach statistical significance (93.3% versus 75.0% for modified TICI 2b-3; adjusted OR =10.88; 95% CI, 0.96-123.84; P = .054).

CONCLUSIONS

Cangrelor seems to be as safe as glycoprotein IIb/IIIa inhibitors for managing refractory intracranial occlusion and leads to satisfactory brain reperfusion. Cangrelor is a promising agent in this setting, and additional studies are warranted to confirm our findings.

Flow-Diversion Treatment for Unruptured ICA Bifurcation Aneurysms with Unfavorable Morphology for Coiling

BACKGROUND AND PURPOSE

Few reports described flow diversion for ICA bifurcation aneurysms. Our aim was to provide further insight into flow diversion for ICA bifurcation aneurysms difficult to treat with other strategies.

MATERIALS AND METHODS

Consecutive patients receiving flow diverters for unruptured ICA bifurcation aneurysms were collected. Aneurysm occlusion (O'Kelly-Marotta grading scale) and clinical outcomes were evaluated.

RESULTS

Twenty saccular ICA bifurcation aneurysms were treated with the Pipeline Embolization Device deployed from the M1 to the ICA, covering the aneurysm and the A1 segment. All patients presented with an angiographic visualized contralateral flow from the anterior communicating artery. Mean aneurysm size was 6.5 (SD, 3.2) mm (range, 4.5-20 mm). All lesions had an unfavorable dome-to-neck ratio (mean/median, 1.6/1.6; range, 0.8-2.8; interquartile range = 0.5) or aspect ratio for coiling (mean/median = 1.5/1.55; range, 0.8-2.5; interquartile range = 0.6). One was a very large aneurysm (20 mm). Nineteen medium-sized lesions were completely occluded during the angiographic follow-up (13 months). No cases of aneurysm rupture or retreatment were reported. No adverse events were described. Aneurysm occlusion was associated with the asymptomatic flow modification of the covered A1 that was occluded and contralaterally filled among 10 patients (50%), narrowed among 9 patients (45%), and unchanged in 1 subject (5%). There was no difference in the mean initial diameter of the occluded (2.1 [SD 0.4] mm; range, 1.6-3 mm) and narrowed (2 [SD, 0.2] mm; range, 1.7-2.6 mm) A1 segments.

CONCLUSIONS

Medium-sized unruptured ICA bifurcation aneurysms with unfavorable morphology for coiling can be treated with M1 ICA flow diversion. Aneurysm occlusion is associated with flow modifications of the covered A1 that seems safe in the presence of a favorable collateral anatomy through the anterior communicating artery complex.

Prevalence of carotid web in a French cohort of cryptogenic stroke

BACKGROUND AND PURPOSE

Carotid webs (CaW) may be an under-recognized cause of anterior circulation cryptogenic ischemic stroke (ACIS). Prevalence is still unknown in European patients with ACIS.

OBJECTIVE

To evaluate the prevalence of CaW in ACIS and describe patients with CaW phenotype in a cohort of patients from a French stroke center.

METHODS

We conducted a retrospective monocentric cohort study from 01/01/2015 to 31/12/2019 (Montpellier University Hospital, France), in consecutive anterior ischemic stroke (AIS) patients ≤65 years old from a prospective stroke database. Using ASCOD phenotyping, ACIS patients were selected and cervical CTA were reviewed to find CaW.

RESULTS

Among 1053 consecutive AIS patients, 266 ACIS patients with CTA were included. Among patients included (mean age 50, women 58%), CaW was in the ipsilateral carotid (iCaW) in 21 patients: 7.9% (95%CI [4.6-11.1]), (mean age 51, 11 women, 16 Caucasian). iCaW were uncovered during study review of CTA in 6/21 (29%) patients. Comparison between patients with iCaW and those without iCaW showed no differences except that of a higher rate of intracranial large vessel occlusion (LVO) (62.4 vs 37.6%; p = 0.03). Patients with iCaW under conservative medical therapy had an annualized stroke recurrence rate (SRR) of 11.4% (95%CI [8.4-15.1].

CONCLUSIONS

iCaW was identified as a source of stroke in about 8% of a French population ≤65 years with ACIS. iCaW was associated with a higher rate of LVO and a high SRR under conservative medical therapy.

Mechanical Thrombectomy in Nighttime Hours: Is There a Difference in 90-Day Clinical Outcome for Patients with Ischemic Stroke?

BACKGROUND AND PURPOSE

Few data are available regarding the influence of the timing of ischemic stroke management, such as daytime and nighttime hours, on the delay of mechanical thrombectomy, the effectiveness of revascularization, and clinical outcomes. We aimed to investigate whether admission during nighttime hours could impact the clinical outcome (mRS at 90 days) of patients with acute ischemic stroke treated by mechanical thrombectomy.

MATERIALS AND METHODS

We retrospectively analyzed 169 patients (112 treated during daytime hours and 57 treated during nighttime hours) with acute ischemic stroke in the anterior cerebral circulation. The main outcome was the rate of patients achieving functional independence at 90 days (mRS ≤2), depending on admission time.

RESULTS

In patients admitted during nighttime hours, the rate of mRS ≤ 2 at 90 days was significantly higher (51% versus 35%, P = .05) compared with those admitted in daytime hours. Patients in daytime and nighttime hours were comparable regarding admission and treatment characteristics. However, patients in nighttime hours tended to have a higher median NIHSS score at admission (P = .08) and to be younger (P = .08), especially among the mothership group (P = .09). The multivariate logistic regression analysis confirmed that patients in nighttime hours had better functional outcomes at 90 days than those in daytime hours (P = .018; 95% CI, 0.064-0.770; OR = 0.221).

CONCLUSIONS

In a highly organized stroke care network, mechanical thrombectomy is quite effective in the nighttime hours among acute ischemic stroke presentations. Unexpectedly, we found that those patients achieved favorable clinical outcomes more frequently than those treated during daytime hours. Larger series are needed to confirm these results.

Neurological improvement predicts clinical outcome after acute basilar artery stroke thrombectomy

BACKGROUND AND PURPOSE

Mechanical thrombectomy (MT) is the standard of care for patients with anterior circulation large vessel occlusion. Early neurological improvement (ENI), defined as a reduction of ≥ 8 on the National Institutes of Health Stroke Scale (NIHSS) compared with baseline score, or an NIHSS score of 0 or 1 at 24 h after MT, is a strong predictor of 3-month favorable outcome in such patients. The impact of ENI after MT in stroke patients with basilar artery occlusion (BAO) on 3-month outcome is not clear. We aimed to study the effects of ENI in patients with BAO.

METHODS

We performed a retrospective analysis of a multicenter prospective cohort of all consecutive stroke patients with BAO who underwent MT. We compared clinical outcomes between BAO patient groups according to ENI status. Multivariate analyses were performed to determine the impact of ENI on favorable 90-day outcome (modified Rankin scale score 0-3) and to report factors contributing to ENI.

RESULTS

A total of 237 patients were included. ENI was observed in 70 patients (30%). Outcomes were significantly better in ENI-positive patients, with 84% achieving favorable outcome (mRS score 0-3) at 3 months versus 30% for ENI-negative patients (P < 0.0001). In multivariate analysis, ENI was an independent predictive factor associated with higher rates of favorable outcome {odds ratio (OR) 18.12 [95% confidence interval (CI) 3.95-83.10]; P = 0.0001}. Higher number of passes [OR 0.62 (95% CI 0.43-0.89); P = 0.010] and need for stenting [OR 0.27 (95% CI 0.07-0.95); P = 0.041] were negatively associated with ENI.

CONCLUSION

Early neurological improvement on day 1 following MT for BAO is a strong independent predictor of a favorable 3-month clinical outcome.

Flow-Diversion Treatment for Unruptured Nonsaccular Intracranial Aneurysms of the Posterior and Distal Anterior Circulation: A Meta-Analysis

BACKGROUND

Treatment management and outcomes of unruptured nonsaccular aneurysms are different compared with their saccular counterparts.

PURPOSE

Our aim was to analyze the outcomes after flow diversion among nonsaccular unruptured lesions.

DATA SOURCES

A systematic search of 3 data bases (2005-2019) was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

STUDY SELECTION

We included studies reporting flow diversion for nonsaccular unruptured aneurysms of the posterior and distal anterior circulations. Anterior circulation lesions were included if located distal to the petrocavernous and supraclinoid ICA (MCA, A1, anterior communicating artery, A2). Giant dolichoectatic holobasilar lesions were excluded because of their poor treatment outcomes.

DATA ANALYSIS

Aneurysm occlusion and complication rates were calculated (random effects meta-analysis).

DATA SYNTHESIS

We included 15 studies (213 aneurysms). The long-term adequate occlusion rate was 85.3% (137/168; 95% CI, 78.2%-92.4%; I² = 42.3%). Treatment-related complications were 17.4% (41/213; 95% CI, 12.45%-22.4%; I² = 0%). Overall, 15% (37/213; 95% CI, 10%-20%; I² = 0%) were ischemic events. Procedure-related morbidity was 8% (20/213; 95% CI, 5%-12%; I² = 0%). Fusiform or dissecting types had comparable adequate occlusion (116/146 = 83%; 95% CI, 74%-92%; I² = 48% versus 33/36 = 89%; 95% CI, 80%-98%; I² = 0%; P = .31) and complication rates (35/162 = 17%; 95% CI, 10%-25%; I² = 24% versus 11/51 = 19%; 95% CI, 10%-31%; I² = 0%; P = .72). Aneurysm size (>10 versus ≤10 mm) was independently associated with a higher rate of complications (OR = 6.6; 95% CI, 1.3-15; P = .02). The rate of ischemic events after discontinuation of the antiplatelet therapy was 5% (5/93; 95% CI, 2%-9%; I² = 0%).

LIMITATIONS

Small and retrospective studies were available for this meta-analysis.

CONCLUSIONS

Unruptured nonsaccular aneurysms located in the posterior and distal anterior circulations can be effectively treated with flow diversion. Nevertheless, treatment-related complications are not negligible, with about 15% ischemic events and 8% morbidity. Larger size (>10 mm) significantly increases the risk of procedure-related adverse events.

Predictors of Favorable Outcome after Endovascular Thrombectomy in MRI: Selected Patients with Acute Basilar Artery Occlusion

BACKGROUND AND PURPOSE

Clinical outcomes after endovascular treatment for acute basilar artery occlusions need further investigation. Our aim was to analyze predictors of a 90-day good functional outcome defined as mRS 0-2 after endovascular treatment in MR imaging-selected patients with acute basilar artery occlusions.

MATERIALS AND METHODS

We analyzed consecutive MR imaging-selected patients with acute basilar artery occlusions endovascularly treated within the first 24 hours after symptom onset. Successful and complete reperfusion was defined as modified TICI scores 2b-3 and 3, respectively. Outcome at 90 days was analyzed in univariate and multivariate analysis regarding baseline patient treatment characteristics and periprocedural outcomes.

RESULTS

One hundred ten patients were included. In 10 patients, endovascular treatment was aborted for failed proximal/distal access. Overall, successful reperfusion was achieved in 81.8% of cases (n = 90; 95% CI, 73.3%-88.6%). At 90 days, favorable outcome was 31.8%, with a mortality rate of 40.9%; the prevalence of symptomatic intracranial hemorrhage within 24 hours was 2.7%. The median time from symptom onset to groin puncture was 410 minutes (interquartile range, 280-540 minutes). In multivariable analysis, complete reperfusion (OR = 6.59; 95% CI, 2.17-20.03), lower pretreatment NIHSS (OR = 0.77; 95% CI, 0.64-0.94), the presence of posterior communicating artery collateral flow (OR = 2.87; 95% CI, 1.05-7.84), the absence of atrial fibrillation (OR = 0.18; 95% CI, 0.03-0.99), and intravenous thrombolysis administration (OR = 2.75; 95% CI, 1.04-7.04) were associated with 90-day favorable outcome.

CONCLUSIONS

In our series of MR imaging-selected patients with acute basilar artery occlusions, complete reperfusion was the strongest predictor of a good outcome. Lower pretreatment NIHSS, the presence of posterior communicating artery collateral flow, the absence of atrial fibrillation, and intravenous thrombolysis administration were associated with favorable outcome.

Predicting Factors of Angiographic Aneurysm Occlusion after Treatment with the Woven EndoBridge Device: A Single-Center Experience with Midterm Follow-Up

BACKGROUND AND PURPOSE

Flow disruption with the Woven EndoBridge is increasingly used for the treatment of intracranial aneurysms. We examined factors leading to aneurysm occlusion and Woven EndoBridge shape change during a midterm follow-up.

MATERIALS AND METHODS

Patients with a minimum 12-month angiographic follow-up were included. Through a univariate and multivariate analysis, independent predictors of adequate occlusion (Raymond-Roy 1/Raymond-Roy 2) and Woven EndoBridge shape change (decrease of the height of the device) were assessed.

RESULTS

Eighty-six patients/aneurysms were included. The aneurysm mean size was 5.5 mm (range, 3-11.5 mm). The most common locations were the MCA (43/86 = 50%), basilar tip (13/86 = 15.1%), and anterior communicating artery (12/86 = 14%). Twenty-one patients (21/86 = 24%) had acute SAH. Immediate and long-term Raymond-Roy 1/Raymond-Roy 2 occlusion rates were 49% (42/86) and 80% (68/86), respectively. Woven EndoBridge shape change was detected among 22% (19/86) of cases. At binary logistic regression, wide ostium (≥4 mm) (OR = 0.2; 95% CI, 0.01-1; P = .04) and regular aneurysm morphology (OR = 5.9; 95% CI, 1.4-24; P = .01) were independent factors of incomplete and adequate aneurysm occlusion, respectively. In addition, irregular morphology (OR = 5.4; 95%CI, 1.4-19; P = .01) and a wide ostium (OR = 9.8; 95% CI, 1.6-60; P = .03) significantly increased the probability of the Woven EndoBridge shape change. Decrease of the Woven EndoBridge height was more common among incompletely occluded aneurysms (6/12 = 50% versus 13/74 = 17.5%), but it was not an independent prognosticator of occlusion at the multivariate model.

CONCLUSIONS

The likelihood of good occlusion was 5 times lower in the presence of a wide ostium, whereas aneurysms with regular morphology were 6 times more likely to be occluded. Woven EndoBridge shape modification was strongly influenced by the aneurysm shape and ostium size, and it was not independently associated with the angiographic occlusion.

Antiplatelet Therapy in Patients with Aneurysmal SAH: Impact on Delayed Cerebral Ischemia and Clinical Outcome. A Meta-Analysis

BACKGROUND AND PURPOSE

Delayed cerebral ischemia strongly impacts clinical outcome after aneurysmal SAH. The effect of antiplatelet therapy on delayed cerebral ischemia has been described with heterogeneous results. Our aim was to analyze the efficacy of antiplatelet therapy on delayed cerebral ischemia and clinical outcome in patients with SAH.

DATA SOURCES

A systematic search of 3 databases was performed for studies published from 1990 to 2019.

STUDY SELECTION

According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we included studies comparing the rates of delayed cerebral ischemia and clinical outcomes among patients with SAH with and without antiplatelet therapy.

DATA ANALYSIS

Random-effects meta-analysis was used to pool the following: delayed cerebral ischemia, mortality, and good outcome rates.

DATA SYNTHESIS

Including 7 studies, 1060 and 1762 patients with SAH were endovascularly or surgically treated with (cases) and without (controls) antiplatelet therapy, respectively. Overall, antiplatelet therapy did not significantly decrease delayed cerebral ischemia rates compared with the control group (219/1060 versus 485/1762, OR = 0.781; 95% CI, 0.46-1.31; P = .33). Among patients treated endovascularly, there was a trend toward lower delayed cerebral ischemia rates after antiplatelet therapy (157/778 versus 413/1410, OR = 0.552; 95% CI, 0.273-1.115; P = .06). Long-term (>2 weeks) antiplatelet therapy tended to be associated with a lower incidence of delayed cerebral ischemia (63/438 versus 96/353, OR = 0.379; 95% CI, 0.12-1.2; P = .06). The good-outcome rate was significantly higher (803/1144 versus 1175/1775, OR = 1.368; 95% CI, 1.117-1.676; P = .002) and the mortality rate was significantly lower (79/672 versus 97/571, OR = 0.656; 95% CI, 0.47-0.91; P = .01) among the antiplatelet therapy group.

LIMITATIONS

Heterogeneity was high for most outcomes.

CONCLUSIONS

Overall, the incidence of delayed cerebral ischemia seems not to be significantly reduced among the antiplatelet therapy group. However, delayed cerebral ischemia tended to be lower among subjects with both long-term antiplatelet therapy and endovascular treatment and antiplatelet administration. Poor outcome and mortality rates were significantly reduced among the antiplatelet therapy group.

Treatment of Wide-Neck Intracranial Aneurysms with the Woven EndoBridge Device Associated with Stenting: A Single-Center Experience

BACKGROUND AND PURPOSE

The intrasaccular flow disruptor, the Woven EndoBridge device, is increasingly used for the treatment of wide-neck intracranial aneurysms. Due to unfavorable anatomy, additional stent placement is sometimes required to avoid Woven EndoBridge protrusion into bifurcation branches. We report our experience with the Woven EndoBridge associated with stent placement for the treatment of complex intracranial aneurysms.

MATERIALS AND METHODS

Patients with aneurysms treated with the Woven EndoBridge Single-Layer plus stent placement were evaluated retrospectively with prospectively maintained data. The technical feasibility, procedural complications, aneurysm occlusion, and clinical outcome were studied.

RESULTS

Seventeen patients and aneurysms treated with the Woven EndoBridge plus stent placement were included. The mean aneurysm size was 7 ± 3.1 mm. Aneurysm locations were the following: MCA (10 patients), anterior communicating artery (3 patients), basilar tip (3 patients), and posterior communicating artery (1 patient). Two lesions were ruptured and treated in the acute phase. The Woven EndoBridge and stent placement were successfully delivered in all cases. There were no permanent/major complications. Among the 2 patients with SAH, minor and completely reversible in-stent thrombosis occurred during treatment. An asymptomatic occlusion of the angular artery with a distal nonbifurcation aneurysm was discovered during the angiographic follow-up. Long-term (10.4 months) angiographic complete (Raymond-Roy I) and near-complete (Raymond-Roy II) occlusion was obtained in 11 (69%) and 2 (12.5%) aneurysms, respectively. The mean sizes of aneurysms showing Raymond-Roy I/Raymond-Roy II and Raymond-Roy III occlusion were 5.5 ± 2.1 mm and 10 ± 1 mm, respectively (P = .003). The mean fluoroscopy time was 35 ± 14 minutes.

CONCLUSIONS

Aneurysm embolization with the Woven EndoBridge device associated with stent placement appears technically feasible and effective for the treatment of lesions with unfavorable anatomy. In our study, this strategy was relatively safe with a low rate of relevant procedure-related adverse events.

Treatment of Unruptured Distal Anterior Circulation Aneurysms with Flow-Diverter Stents: A Meta-Analysis

BACKGROUND

The safety and efficacy of flow diversion among distal anterior circulation aneurysms must be proved.

PURPOSE

Our aim was to analyze the outcomes after flow diversion among MCA, anterior communicating artery, and distal anterior cerebral artery aneurysms.

DATA SOURCES

A systematic search of 3 databases was performed for studies published from 2005 to 2018.

STUDY SELECTION

According to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we included studies reporting flow diversion of distal anterior circulation aneurysms.

DATA ANALYSIS

Random-effects meta-analysis was used to pool aneurysm occlusion and complication rates. From the individual patient data, univariate and multivariate analyses were used to test predictors of occlusion and complications.

DATA SYNTHESIS

We included 27 studies (484 aneurysms). The long-term adequate occlusion rate (O'Kelly-Marotta scale, C-D) was 82.7% (295/364; 95% CI, 77.4%-87.9%; I² = 52%). Treatment-related complications were 12.5% (63/410; 95% CI, 9%-16%%; I² = 18.8%), with 5.4% (29/418; 95% CI, 3.2%-7.5%; I² = 0%) morbidity. MCA location was an independent factor associated with lower occlusion (OR = 0.5, P = .03) and higher complication rates (OR = 1.8, P = .02), compared with anterior communicating artery and distal anterior cerebral artery aneurysms. The Pipeline Embolization Device (versus other stents) gave better occlusion rates (OR = 2.6, P = .002), whereas large/giant aneurysms were associated with higher odds of complications (OR = 2.2, P = .03). The rates of occlusion and narrowing of arteries covered by flow-diverter stents were 6.3% (29/283; 95% CI, 3.5%-9.1%; I² = 4.2%) and 23.8% (69/283; 95% CI, 15.7%-32%; I² = 80%), respectively. Symptoms related to occlusion and narrowing of the jailed arteries were 3.5% (6/269; 95% CI, 1.1%-5%; I² = 0%) and 3% (6/245; 95% CI, 1%-4%; I² = 0%), respectively.

LIMITATIONS

We reviewed small and retrospective series.

CONCLUSIONS

Flow diversion among distal anterior circulation aneurysms is effective, leading to adequate aneurysm occlusion in 83% of cases. However, this strategy has some limitations among MCA and larger lesions, especially related to the higher rate of complications. Compared with the other devices, the Pipeline Embolization Device seems to be associated with a higher occlusion rate.

Comparison of Prasugrel and Clopidogrel Used as Antiplatelet Medication for Endovascular Treatment of Unruptured Intracranial Aneurysms: A Meta-Analysis

BACKGROUND

Clopidogrel is routinely used to decrease ischemic complications during neurointerventional procedures. However, the efficacy may be limited by antiplatelet resistance.

PURPOSE

Our aim was to analyze the efficacy of prasugrel compared with clopidogrel in the cerebrovascular field.

DATA SOURCES

A systematic search of 2 large databases was performed for studies published from 2000 to 2018.

STUDY SELECTION

According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we included studies reporting treatment-related outcomes of patients undergoing neurointerventional procedures under prasugrel, and studies comparing prasugrel and clopidogrel.

DATA ANALYSIS

Random-effects meta-analysis was used to pool the overall rate of complications, ischemic and hemorrhagic events, and influence of the dose of prasugrel.

DATA SYNTHESIS

In the 7 included studies, 682 and 672 unruptured intracranial aneurysms were treated under prasugrel (cases) and clopidogrel (controls), respectively. Low-dose (20 mg/5 mg; loading and maintenance doses) prasugrel compared with the standard dose of clopidogrel (300 mg/75 mg) showed a significant reduction in the complication rate (OR = 0.36; 95% CI, 0.17-74, P = .006; I² = 0%). Overall, the ischemic complication rate was significantly higher in the clopidogrel group (40/672 = 6%; 95% CI, 3%-13%; I² = 83% versus 16/682 = 2%; 95% CI, 1%-5%; I² = 73%; P = .03). Low and high loading doses of prasugrel were associated with 0.6% (5/535; 95% CI, 0.1%-1.6%; I² = 0%) and 9.3% (13/147; 95% CI, 0.2%-18%; I² = 60%) intraperiprocedural hemorrhages, respectively (P = .001), whereas low and high maintenance doses of prasugrel were associated with 0% (0/433) and 0.9% (2/249; 95% CI, 0.3%-2%; I² = 0%) delayed hemorrhagic events, respectively (P = .001).

LIMITATIONS

Retrospective series and heterogeneous endovascular treatments were limitations.

CONCLUSIONS

In our study, low-dose prasugrel compared with clopidogrel premedication was associated with an effective reduction of the ischemic events with an acceptable rate of hemorrhagic complications.

Flow-Diversion Effect of LEO Stents: Aneurysm Occlusion and Flow Remodeling of Covered Side Branches and Perforators

BACKGROUND AND PURPOSE

Flow diversion with intermediate-porosity stents (braided stents) has been recently reported for distally located small aneurysms. The aim of this study was to evaluate the flow-diversion effect of LEO stents on covered vessels and for aneurysms treated with sole stent-placement therapy.

MATERIALS AND METHODS

We retrospectively evaluated the following outcomes: 1) remodeling of covered side branches and perforators (extra-aneurysmal flow remodeling), and 2) the occlusion rate of aneurysms treated with sole stent-placement therapy (intra-aneurysmal flow remodeling).

RESULTS

Seventy-six patients with 98 covered vessels were studied. Overall, 89 covered arteries (91%) were normal, 7 showed narrowing (7%), and 2 (2%) were occluded (1 posterior communicating artery and 1 MCA) without related complications (mean DSA follow-up, 14 months). Univariate and multivariate analyses highlighted smoking (P = .03) and the length of follow-up (P = .002) as factors associated with arterial remodeling. Of the 17 Sylvian (lenticulostriate arteries) and 7 basilar perforators, 1 (4%) group of Sylvian perforators covered with double stents had asymptomatic remodeling. Ten aneurysms (mean size, 3.5 mm) were treated with LEO stents as stent monotherapy (5 recanalized after coiling and 5 directly treated with the LEO). Complete occlusion (Raymond-Roy I) was achieved in 70% of aneurysms (mean follow-up, 14 months). The Raymond-Roy I occlusion rate among recanalized aneurysms and those directly treated with LEO stents was 80% and 60%, respectively (P = .9).

CONCLUSIONS

The rate of flow remodeling on the covered arteries and perforators was 9% and 4%, respectively, and was clinically irrelevant in all cases. Complete occlusion of aneurysms treated with sole stent-placement therapy was 70%. These data stress the flow-diversion properties of LEO stents.

Treatment of Intracranial Aneurysms with Self-Expandable Braided Stents: A Systematic Review and Meta-Analysis

BACKGROUND

The safety and efficacy of treatment with self-expandable braided stents (LEO and LVIS) required further investigation.

PURPOSE

Our aim was to analyze the outcomes after treatment with braided stents.

DATA SOURCES

A systematic search of 3 databases was performed for studies published from 2006 to 2017.

STUDY SELECTION

According to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we included studies reporting patients treated with LEO or LVIS stents.

DATA ANALYSIS

Random-effects meta-analysis was used to pool the following: aneurysm occlusion rate, complications, and neurologic outcomes.

DATA SYNTHESIS

Thirty-five studies evaluating 1426 patients treated with braided stents were included in this meta-analysis. Successful stent delivery and complete aneurysm occlusion were 97% (1041/1095; 95% CI, 95%-98%) (I² = 44%) and 88.3% (1097/1256; 95% CI, 85%-91%) (I² = 72%), respectively. Overall, treatment-related complications were 7.4% (107/1317; 95% CI, 5%-9%) (I² = 44%). Ischemic/thromboembolic events (48/1324 = 2.4%; 95% CI, 1.5%-3.4%) (I² = 27%) and in-stent thrombosis (35/1324 = 1.5%; 95% CI, 0.6%-1.7%) (I² = 0%) were the most common complications. Treatment-related morbidity was 1.5% (30/1324; 95% CI, 0.9%-2%) and was comparable between the LEO and LVIS groups. Complication rates between the anterior (29/322 = 8.8%; 95% CI, 3.4%-12%) (I² = 41%) versus posterior circulation (10/84 = 10.5%; 95% CI, 4%-16%) (I² = 0%) and distal (30/303 = 8%; 95% CI, 4.5%-12%) (I² = 48%) versus proximal aneurysms (14/153 = 9%; 95% CI, 3%-13%) (I² = 46%) were comparable (P > .05).

LIMITATIONS

Limitations were selection and publication biases.

CONCLUSIONS

In this analysis, treatment with the LEO and LVIS stents was relatively safe and effective. The most common complications were periprocedural thromboembolisms and in-stent thrombosis. The rate of complications was comparable among anterior and posterior circulation aneurysms, as well as for proximal and distally located lesions.

Endovascular Treatment of Very Large and Giant Intracranial Aneurysms: Comparison between Reconstructive and Deconstructive Techniques-A Meta-Analysis

BACKGROUND

The safety and efficacy of reconstructive and deconstructive endovascular treatments of very large/giant intracranial aneurysms are not completely clear.

PURPOSE

Our aim was to compare treatment-related outcomes between these 2 techniques.

DATA SOURCES

A systematic search of 3 data bases was performed for studies published from 1990 to 2017.

STUDY SELECTION

We selected series of reconstructive and deconstructive treatments with >10 patients.

DATA ANALYSIS

Random-effects meta-analysis was used to analyze occlusion rates, complications, and neurologic outcomes.

DATA SYNTHESIS

Thirty-nine studies evaluating 894 very large/giant aneurysms were included. Long-term occlusion of unruptured aneurysms was 71% and 93% after reconstructive and deconstructive treatments, respectively (P = .003). Among unruptured aneurysms, complications were lower after parent artery occlusion (16% versus 30%, P = .05), whereas among ruptured lesions, complications were lower after reconstructive techniques (34% versus 38%). Parent artery occlusion in the posterior circulation had higher complications compared with in the anterior circulation (36% versus 15%, P = .001). Overall, coiling yielded lower complication and occlusion rates compared with flow diverters and stent-assisted coiling. Complication rates of flow diversion were lower in the anterior circulation (17% versus 41%, P < .01). Among unruptured lesions, early aneurysm rupture (within 30 days) was slightly higher after reconstructive treatment (5% versus 0%, P = .08) and after flow diversion alone compared with flow diversion plus coiling (7% versus 0%).

LIMITATIONS

Limitations were selection and publication biases.

CONCLUSIONS

Parent artery occlusion allowed high rates of occlusion with an acceptable rate of complications for unruptured, anterior circulation aneurysms. Coiling should be preferred for posterior circulation and ruptured lesions, whereas flow diversion is relatively safe and effective for unruptured anterior circulation aneurysms.

Treatment of Distal Anterior Cerebral Artery Aneurysms with Flow-Diverter Stents: A Single-Center Experience

BACKGROUND AND PURPOSE

Flow diversion for aneurysms beyond the circle of Willis is still debated. Our aim was to evaluate the safety and efficacy of flow diversion treatment of distal anterior cerebral artery aneurysms.

MATERIALS AND METHODS

Consecutive patients with distal anterior cerebral artery aneurysms treated from January 2014 to October 2017 were evaluated retrospectively with prospectively maintained data. Treatment was performed only for unruptured or recanalized aneurysms after coiling. Technical feasibility, procedural complications, aneurysm occlusion (O'Kelly-Marotta grading scale), and clinical outcome were evaluated.

RESULTS

Fifteen patients were included in the study, with 17 distal anterior cerebral artery saccular aneurysms treated with flow-diverter stents. Mean aneurysm size was 4.25 ± 3.9 mm; range, 2-9 mm. Flow diversion was used as retreatment among 6 previously coiled aneurysms (5 ruptured and coiled in the acute phase, and 1 unruptured and recanalized). Stent deployment was technically successful in all cases. During the perioperative period, 1 patient experienced a transient minor stroke (6%), whereas 2 patients reported acute in-stent thrombosis with disabling ischemic complications (13%). Fourteen patients and 16 aneurysms were available during a mean radiologic follow-up of 12 months (range, 3-24 months). Overall, 12 (75%) aneurysms were completely occluded (O'Kelly-Marotta grading scale score D), 1 aneurysm (6%) showed near-complete occlusion (O'Kelly-Marotta grading scale score C), and 3 aneurysms (19%) were incompletely occluded (O'Kelly-Marotta grading scale, score B). All 6 aneurysms previously coiled were completely occluded after flow diversion, whereas 70% of aneurysms treated with flow diverters alone showed complete/near-complete occlusion (O'Kelly-Marotta grading scale C-D). There were no cases of aneurysm rupture, in-stent occlusion, or retreatment during long-term follow-up.

CONCLUSIONS

Treatment of distal anterior cerebral artery aneurysms with flow-diverter stents is feasible and effective, with high rates of aneurysm occlusion. Flow diversion plus coiling, in the retreatment of lesions previously coiled, allowed higher rates of occlusion compared with flow diverters alone. However, the risk of ischemic complications is not negligible, and flow-diversion treatment should be evaluated only for aneurysms not amenable to simple coil embolization.

Anterior Circulation Acute Ischemic Stroke Associated with Atherosclerotic Lesions of the Cervical ICA: A Nosologic Entity Apart

BACKGROUND AND PURPOSE

Mechanical thrombectomy for patients with acute ischemic stroke with tandem occlusions has been shown to present varying reperfusion successes and clinical outcomes. However, the heterogeneity of tandem occlusion etiology has been strongly neglected in previous studies. We retrospectively investigated patients with acute ischemic stroke atherothrombotic tandem occlusion.

MATERIALS AND METHODS

All consecutive patients with acute ischemic stroke with atherothrombotic tandem occlusions treated with mechanical thrombectomy in our center between September 2009 and April 2015 were analyzed. They were compared with patients with acute ischemic stroke with dissection-related tandem occlusion and isolated intracranial occlusion treated during the same period. Comparative univariate and multivariate analyses were conducted, including demographic data, safety, and rates of successful recanalization and good clinical outcome.

RESULTS

Despite comparable baseline severity of neurologic deficits and infarct core extension, patients with atherothrombotic tandem occlusions were older (P < .001), were more frequently smokers (P < .001), and had globally more cardiovascular risk factors (P < .001) than the other 2 groups of patients. The patients with atherothrombotic tandem occlusions had significantly longer procedural times (P < .001), lower recanalization rates (P = .004), and higher global burden of procedural complications (P < .001). In this group, procedural complications (OR = 0.15, P = .02) and the TICI 2b/3 reperfusion scores (OR = 17.76, P = .002) were independently predictive factors of favorable clinical outcome.

CONCLUSIONS

Our study suggests that atherothrombotic tandem occlusions represent a peculiar and different nosologic entity compared with dissection-related tandem occlusions. This challenging cause of acute ischemic stroke should be differentiated from other etiologies in patient management in future prospective studies.

Treatment of Middle Cerebral Artery Aneurysms with Flow-Diverter Stents: A Systematic Review and Meta-Analysis

BACKGROUND

The safety and efficacy of flow-diversion treatment of MCA aneurysms have not been well-established.

PURPOSE

Our aim was to evaluate angiographic and clinical outcomes after flow diversions for MCA aneurysms.

DATA SOURCES

A systematic search of PubMed, MEDLINE, and Embase was performed for studies published from 2008 to May 2017.

STUDY SELECTION

According to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we selected studies with >5 patients describing angiographic and clinical outcomes after flow-diversion treatment of MCA aneurysms.

DATA ANALYSIS

Random-effects meta-analysis was used to pool the following outcomes: aneurysm occlusion rate, procedure-related complications, rupture rate of treated aneurysms, and occlusion of the jailed branches.

DATA SYNTHESIS

Twelve studies evaluating 244 MCA aneurysms were included in this meta-analysis. Complete/near-complete occlusion was obtained in 78.7% (95% CI, 67.8%-89.7%) of aneurysms. The rupture rate of treated aneurysms during follow-up was 0.4% per aneurysm-year. The rate of treatment-related complications was 20.7% (95% CI, 14%-27.5%), and approximately 10% of complications were permanent. The mortality rate was close to 2%. Nearly 10% (95% CI, 4.7%-15.5%) of jailed arteries were occluded during follow-up, whereas 26% (95% CI, 14.4%-37.6%) had slow flow. Rates of symptoms related to occlusion and slow flow were close to 5%.

LIMITATIONS

Small and retrospective series could affect the strength of the reported results.

CONCLUSIONS

Given the not negligible rate of treatment-related complications, flow diversion for MCA aneurysms should be considered an alternative treatment when traditional treatment methods are not feasible. However, when performed in this select treatment group, high rates of aneurysm occlusion and protection against re-rupture can be achieved.

Impact of Modified TICI 3 versus Modified TICI 2b Reperfusion Score to Predict Good Outcome following Endovascular Therapy

BACKGROUND AND PURPOSE

The TICI score is widely used to evaluate cerebral perfusion before and after the endovascular treatment of stroke. Recent studies showing the effectiveness and safety of mechanical thrombectomy combine modified TICI 2b and modified TICI 3 to assess the technical success of endovascular treatment. The purpose of this study was to determine how much clinical outcomes differ between patients achieving modified TICI 2b and modified TICI 3 reperfusion.

MATERIALS AND METHODS

We analyzed 222 consecutive patients with acute large intracranial artery occlusion of the anterior circulation having achieved modified TICI 2b or modified TICI 3 reperfusion after thrombectomy. The primary end point was the rate of favorable outcome defined as the achievement of a modified Rankin Scale score of 0-2 at 3 months.

RESULTS

Patients with modified TICI 3 more often had favorable collateral circulation and atherosclerosis etiology, with a shorter time from onset to reperfusion than patients with modified TICI 2b (all P < .05). The number of total passes to achieve reperfusion was higher in the modified TICI 2b group (median, 2; interquartile range, 1-3, 1-9) versus (median, 1; interquartile range, 1-2, 1-8) in the modified TICI 3 group (P = .0002). Favorable outcome was reached more often for patients with modified TICI 3 than for those with modified TICI 2b (71.7% versus 50.5%, P = .001), with a similar difference when considering excellent outcome. In addition, patients with modified TICI 3 had a lower intracerebral hemorrhage rate (23.0% versus 45.0%, P < .001).

CONCLUSIONS

Patients with modified TICI 3 reperfusion have better functional outcomes than those with modified TICI 2b. Given the improving reperfusion rates obtained with thrombectomy devices, future thrombectomy trials should consider modified TICI 2b and modified TICI 3 status separately.

Patient selection for stroke endovascular therapy--DWI-ASPECTS thresholds should vary among age groups: insights from the RECOST study

BACKGROUND AND PURPOSE

The purpose of this study was to evaluate the benefits of endovascular intervention in large-vessel occlusion strokes, depending on age class.

MATERIALS AND METHODS

A clinical management protocol including intravenous treatment and mechanical thrombectomy was instigated in our center in 2009 (Prognostic Factors Related to Clinical Outcome Following Thrombectomy in Ischemic Stroke [RECOST] study). All patients with acute ischemic stroke with an anterior circulation major-vessel occlusion who presented within 6 hours were evaluated with an initial MR imaging examination and were analyzed according to age subgroups (younger than 50 years, 50-59 years, 60-69 years, 70-79 years; 80 years or older). The mRS score at 3 months was the study end point.

RESULTS

One hundred sixty-five patients were included in the analysis. The mean age was 67.4 years (range, 29-90 years). The mean baseline NIHSS score was 17.24 (range, 3-27). The mean DWI-derived ASPECTS was 6.4. Recanalization of TICI 2b/3 was achieved in 80%. At 3 months, 41.72% of patients had a good outcome, with a gradation of prognosis depending on the age subgroup and a clear cutoff at 70 years. Only 19% of patients older than 80 years had a good outcome at 3 months (mean ASPECTS = 7.4) with 28% for 70-79 years (mean ASPECTS = 6.8), but 58% for 60-69 years (mean ASPECTS = 6), 52% for 50-59 years (mean ASPECTS = 5.91), and 72% for younger than 50 years (mean ASPECTS = 6.31). In contrast, the mortality rate was 35% for 80 years and older, and 26% for 70-79 versus 5%-9% for younger than 70 years.

CONCLUSIONS

The elderly may benefit from thrombectomy when their ischemic core volume is low in comparison with younger patients who still benefit from acute recanalization despite larger infarcts. Stroke volume thresholds should, therefore, be related and adjusted to the patient's age group.