Endovascular treatment of acute ischemic stroke patients with tandem lesions: antegrade versus retrograde approach

OBJECTIVE

The optimal technique for treating tandem lesions (TLs) with endovascular therapy is debatable. The authors evaluated the functional, safety, and procedural outcomes of different approaches in a multicenter study.

METHODS

Anterior circulation TL patients treated from January 2015 to December 2020 were divided on the basis of antegrade versus retrograde approach and included. The evaluated outcomes were favorable modified Rankin Scale (mRS) score (mRS score 0-2) at 3 months, ordinal shift in mRS score, successful recanalization, excellent recanalization, first-pass effect (FPE), time from groin puncture to successful recanalization, symptomatic intracranial hemorrhage (sICH), and 90-day mortality.

RESULTS

Among 691 patients treated at 16 centers, 286 patients (174 antegrade and 112 retrograde approach patients) with acute stenting were included in the final analysis. There were no significant differences in mRS score 0-2 at 90 days (52.2% vs 50.0%, adjusted odds ratio [aOR] 0.83, 95% CI 0.42-1.56, p = 0.54), favorable shift in 90-day mRS score (aOR 1.03, 95% CI 0.66-1.29, p = 0.11), sICH (4.0% vs 4.5%, aOR 0.64, 95% CI 0.24-1.51, p = 0.45), successful recanalization (89.4% vs 93%, aOR 0.49, 95% CI 0.19-1.28, p = 0.19), excellent recanalization (51.4% vs 58.9%, aOR 0.59, 95% CI 0.40-1.07, p = 0.09), FPE (58.3% vs 69.7%, aOR 0.62, 95% CI 0.44-1.15, p = 0.21), and mortality at 90 days (16.6% vs 14.0%, aOR 0.94, 95% CI 0.35-2.44, p = 0.81) between the groups. The median (interquartile range) groin puncture to recanalization time was significantly longer in the antegrade group (59 [43-90] minutes vs 49 [35-73] minutes, p = 0.036).

CONCLUSIONS

The retrograde approach was associated with faster recanalization times with a similar functional and safety profile when compared with the antegrade approach in patients with acute ischemic stroke with TL.

Mechanical thrombectomy for the treatment of primary and secondary distal medium-vessel occlusion stroke: systematic review and meta-analysis

BACKGROUND

There is limited evidence on the indication and role of mechanical thrombectomy (MT) in patients with distal medium-vessel occlusions (DMVOs). The aim of this systematic review and meta-analysis was to evaluate all the evidence available on the efficacy and safety of MT techniques (stent retriever, aspiration) in primary and secondary DMVOs.

METHODS

Five databases were searched from inception to January 2023 for studies of MT in primary and secondary DMVOs. Outcomes of interest included favorable functional outcome (90-day modified Rankin scale (mRS) 0-2), successful reperfusion (modified Thrombolysis in Cerebral Infarction (mTICI) 2b-3), symptomatic intracerebral hemorrhage (sICH), and 90-day mortality. Prespecified subgroup meta-analyses according to the specific MT technique and to the vascular territory (distal M2-M5, A2-A5, P2-P5) were also performed.

RESULTS

A total of 29 studies with 1262 patients were included. For primary DMVOs (n=971 patients), pooled rates of successful reperfusion, favorable outcome, 90-day mortality and sICH were 84% (95% confidence interval (CI) 76 to 90%), 64% (95% CI 54 to 72%), 12% (95% CI 8 to 18%), and 6% (95% CI 4 to 10%), respectively. For secondary DMVOs (n=291 patients), pooled rates of successful reperfusion, favorable outcome, 90-day mortality and sICH were 82% (95% CI 73 to 88%), 54% (95% CI 39 to 69%), 11% (95% CI 5 to 20%), and 3% (95% CI 1 to 9%), respectively. Subgroup analyses by MT technique and by vascular territory showed no differences in primary and secondary DMVOs.

CONCLUSION

Our findings suggest that MT using aspiration or stent retriever techniques appears to be effective and safe in primary and secondary DMVOs. However, given the level of evidence of our results, further confirmation in well-designed randomized controlled trials is needed.

Safety Outcomes of Antiplatelet Therapy During Endovascular Treatment of Tandem Lesions in Acute Ischemic Stroke Patients

Risk of hemorrhage remains with antiplatelet medications required with carotid stenting during endovascular therapy (EVT) for tandem lesion (TLs). We evaluated the safety of antiplatelet regimens in EVT of TLs. This multicenter study included anterior circulation TL patients from 2015 to 2020, stratified by periprocedural EVT antiplatelet strategy: (1) no antiplatelets, (2) single oral, (3) dual oral, and (4) intravenous IV (in combination with single or dual oral). Primary outcome was symptomatic intracranial hemorrhage (sICH). Secondary outcomes were any hemorrhage, favorable functional status (mRS 0-2) at 90 days, successful reperfusion (mTICI score ≥ 2b), in-stent thrombosis, and mortality at 90 days. Of the total 691 patients, 595 were included in the final analysis. One hundred and nineteen (20%) received no antiplatelets, 134 (22.5%) received single oral, 152 (25.5%) dual oral, and 196 (31.9%) IV combination. No significant association was found for sICH (ref: no antiplatelet: 5.7%; single:4.2%; aOR 0.64, CI 0.20-2.06, p = 0.45, dual:1.9%; aOR 0.35, CI 0.09-1.43, p = 0.15, IV combination: 6.1%; aOR 1.05, CI 0.39-2.85, p = 0.92). No association was found for parenchymal or petechial hemorrhage. Odds of successful reperfusion were significantly higher with dual oral (aOR 5.85, CI 2.12-16.14, p = 0.001) and IV combination (aOR 2.35, CI 1.07-5.18, p = 0.035) compared with no antiplatelets. Odds of excellent reperfusion (mTICI 2c/3) were significantly higher for cangrelor (aOR 4.41; CI 1.2-16.28; p = 0.026). No differences were noted for mRS 0-2 at 90 days, in-stent thrombosis, and mortality rates. Administration of dual oral and IV (in combination with single or dual oral) antiplatelets during EVT was associated with significantly increased odds of successful reperfusion without an increased rate of symptomatic hemorrhage or mortality in patients with anterior circulation TLs.

General anesthesia vs procedural sedation for failed NeuroThrombectomy undergoing rescue stenting: intention to treat analysis

BACKGROUND

There is little data available to guide optimal anesthesia management during rescue intracranial angioplasty and stenting (ICAS) for failed mechanical thrombectomy (MT). We sought to compare the procedural safety and functional outcomes of patients undergoing rescue ICAS for failed MT under general anesthesia (GA) vs non-general anesthesia (non-GA).

METHODS

We searched the data from the Stenting and Angioplasty In Neuro Thrombectomy (SAINT) study. In our review we included patients if they had anterior circulation large vessel occlusion strokes due to intracranial internal carotid artery (ICA) or middle cerebral artery (MCA-M1/M2) segments, failed MT, and underwent rescue ICAS. The cohort was divided into two groups: GA and non-GA. We used propensity score matching to balance the two groups. The primary outcome was the shift in the degree of disability as measured by the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included functional independence (90-day mRS0-2) and successful reperfusion defined as mTICI2B-3. Safety measures included symptomatic intracranial hemorrhage (sICH) and 90-day mortality.

RESULTS

Among 253 patients who underwent rescue ICAS, 156 qualified for the matching analysis at a 1:1 ratio. Baseline demographic and clinical characteristics were balanced between both groups. Non-GA patients had comparable outcomes to GA patients both in terms of the overall degree of disability (mRS ordinal shift; adjusted common odds ratio 1.29, 95% CI [0.69 to 2.43], P=0.43) and rates of functional independence (33.3% vs 28.6%, adjusted odds ratio 1.32, 95% CI [0.51 to 3.41], P=0.56) at 90 days. Likewise, there were no significant differences in rates of successful reperfusion, sICH, procedural complications or 90-day mortality among both groups.

CONCLUSIONS

Non-GA seems to be a safe and effective anesthesia strategy for patients undergoing rescue ICAS after failed MT. Larger prospective studies are warranted for more concrete evidence.

Safety and efficacy of the surpass streamline for intracranial aneurysms (SESSIA): A multi-center US experience pooled analysis

BACKGROUND AND PURPOSE

Flow diversion has established as standard treatment for intracranial aneurysms, the Surpass Streamline is the only FDA-approved braided cobalt/chromium alloy implant with 72-96 wires. We aimed to determine the safety and efficacy of the Surpass in a post-marketing large United States cohort.

MATERIALS AND METHODS

This is a retrospective multicenter study of consecutive patients treated with the Surpass for intracranial aneurysms between 2018 and 2021. Baseline demographics, comorbidities, and aneurysm characteristics were collected. Efficacy endpoint included aneurysm occlusion on radiographic follow-up. Safety endpoints were major ipsilateral ischemic stroke or treatment-related death.

RESULTS

A total of 277 patients with 314 aneurysms were included. Median age was 60 years, 202 (73%) patients were females. Hypertension was the most common comorbidity in 156 (56%) patients. The most common location of the aneurysms was the anterior circulation in 89% (279/314). Mean aneurysm dome width was 5.77 ± 4.75 mm, neck width was 4.22 ± 3.83 mm, and dome/neck ratio was 1.63 ± 1.26. Small-sized aneurysms were 185 (59%). Single device was used in 94% of the patients, mean number of devices per patient was 1.06. At final follow-up, complete obliteration rate was 81% (194/239). Major stroke and death were encountered in 7 (3%) and 6 (2%) cases, respectively.

CONCLUSION

This is the largest cohort study using a 72-96 wire flow diverter. The Surpass Streamline demonstrated a favorable safety and efficacy profile, making it a valuable option for treating not only large but also wide-necked small and medium-sized intracranial aneurysms.

Rescue intracranial stenting for failed posterior circulation thrombectomy: analysis from the Stenting and Angioplasty in NeuroThrombectomy (SAINT) study

BACKGROUNDS

Recent trials have shown improved outcomes after mechanical thrombectomy (MT) for vertebrobasilar occlusion (VBO) stroke. However, there is a paucity of data regarding safety and outcomes of rescue intracranial stenting (RS) after failed MT (FRRS+) for posterior circulation stroke. We sought to compare RS to failed reperfusion without RS (FRRS-).

METHODS

This is a retrospective analysis of the Stenting and Angioplasty in NeuroThrombectomy (SAINT) study, a multicenter collaboration involving prospectively collected databases. Patients were included if they had posterior circulation stroke and failed MT. The cohort was divided into two groups: FRRS+ and FRRS- (defined as modified Thrombolysis In Cerebral Infarction (mTICI) score 0-2a). The primary outcome was a shift in the degree of disability as measured by the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included mRS 0-2 and mRS 0-3 at 90 days. Safety measures included rates of symptomatic intracranial hemorrhage (sICH), procedural complications, and 90-day mortality. Sensitivity and subgroup analyses were performed to identify outcomes in a matched cohort and in those with VBO, respectively.

RESULTS

A total of 152 failed thrombectomies were included in the analysis. FRRS+ (n=84) was associated with increased likelihood of lower disability (acOR 2.24, 95% CI 1.04 to 4.95, P=0.04), higher rates of mRS 0-2 (26.8% vs 12.5%, aOR 4.43, 95% CI 1.22 to 16.05, P=0.02) and mRS 0-3 (35.4% vs 18.8%, aOR 3.13, 95% CI 1.08 to 9.10, P=0.036), and lower mortality (42.7% vs 59.4%, aOR 0.40, 95% CI 0.17 to 0.97, P=0.04) at 90 days compared with FRRS- (n=68). The rates of sICH and procedural complications were comparable between the groups. Sensitivity and subgroup analyses showed similar results.

CONCLUSION

In patients with posterior circulation stroke who had failed MT, RS resulted in better functional outcomes with comparable safety profile to procedure termination.

Direct to angiosuite strategy versus standard workflow triage for endovascular therapy: systematic review and meta-analysis

BACKGROUND

Reducing stroke workflow times when performing endovascular thrombectomy is associated with improvement in clinical outcomes. We compared outcomes among large vessel occlusion (LVO) stroke patients following the direct to angiosuite (DTAS) strategy versus standard workflow (SW) when undergoing endovascular therapy.

METHODS

We conducted a systematic review and meta-analysis to compare rates of functional outcomes, reperfusion, symptomatic intracranial hemorrhage (sICH) and stroke workflow metrics. We included observational studies and clinical trials that compared the DTAS strategy versus SW, and at least one outcome of interest was assessed. Clinical, methodological and statistical heterogeneity were measured, and a random-effects model was used.

RESULTS

12 studies were included in the systematic review and 8 in the meta-analysis (n=2890). The DTAS strategy was associated with significant higher odds of good functional outcome at 90 days (47.3% vs 34.9%; OR 1.58, 95% CI 1.16 to 2.14) and a significant average reduction of door-to-puncture (mean differences (MD) -35.09, 95% CI -49.76 to -20.41) and door-to-reperfusion times (MD -32.88, 95% CI -50.75 to -15.01). We found no differences in sICH (OR 0.80, 95% CI 0.53 to 1.20), mortality (OR 1.00, 95% CI 0.60 to 1.67) or successful reperfusion rates (OR 1.37, 95% CI 0.82 to 2.29). Moreover, the DTAS strategy was associated with greater odds of dramatic clinical improvement at 24 hours (OR 1.79, 95% CI 1.15 to 2.79).

CONCLUSION

Patients undergoing the DTAS strategy had a significant reduction in door-to-puncture and door-to-reperfusion times. This resulted in an increased rate of early neurological and 90-day functional recovery without compromising safety in LVO patients undergoing endovascular thrombectomy.

Predictors of tissue infarction from distal emboli after mechanical thrombectomy

BACKGROUND

Distal embolization after endovascular thrombectomy (EVT) is common. We aimed to determine factors associated with tissue infarction in the territories of distal emboli.

METHODS

This is a retrospective cohort study of consecutive patients with anterior circulation large vessel occlusions who underwent EVT from 2015 to 2021. Patients with Thrombolysis In Cerebral Infarction (TICI) 2b reperfusion and follow-up imaging were identified. Baseline characteristics, procedural details, and imaging findings were reviewed. Primary outcome was categorized according to the occurrence of infarction at the territory of distal embolus on follow-up diffusion-weighted imaging MRI.

RESULTS

Of 156 subjects, 97 (62%) had at least one infarction in the territories at risk. Hypertension was significantly more prevalent in the infarct group (83% vs 53%, P=0.001). General anesthesia was more commonly used in the infarct group (60% vs 43%, P=0.037). The median number of distal emboli and diameter of the occluded vessel were similar. After adjusting for confounders, hypertension (aOR 4.73, 95% CI 1.81 to 13.25, P=0.002), higher blood glucose (aOR 1.01, 95% CI 1.00 to 1.03, P=0.023), and general anesthesia (aOR 2.75, 95% CI 1.15 to 6.84, P=0.025) were independently associated with infarction. The presence of angiographic leptomeningeal collaterals predicted tissue survival (aOR 0.13, 95% CI 0.05 to 0.33, P<0.001). 90-day modified Rankin scale (mRS) scores were worse for the infarction patients (mRS 0-2: infarct, 39% vs 55%, P=0.046).

CONCLUSIONS

Nearly 40% of patients with TICI 2b had no tissue infarction in the territory of a distal embolus. The association of infarction with hypertension and general anesthesia suggests late or post-procedural blood pressure management could be a modifiable factor. Patients with poor leptomeningeal collaterals or hyperglycemia may benefit from further attempts at revascularization.

Functional and Safety Outcomes of Carotid Artery Stenting and Mechanical Thrombectomy for Large Vessel Occlusion Ischemic Stroke With Tandem Lesions

Importance

Approximately 10% to 20% of large vessel occlusion (LVO) strokes involve tandem lesions (TLs), defined as concomitant intracranial LVO and stenosis or occlusion of the cervical internal carotid artery. Mechanical thrombectomy (MT) may benefit patients with TLs; however, optimal management and procedural strategy of the cervical lesion remain unclear.

Objective

To evaluate the association of carotid artery stenting (CAS) vs no stenting and medical management with functional and safety outcomes among patients with TL-LVOs.

Design, Setting, and Participants

This cross-sectional study included consecutive patients with acute anterior circulation TLs admitted across 17 stroke centers in the US and Spain between January 1, 2015, and December 31, 2020. Data analysis was performed from August 2021 to February 2022. Inclusion criteria were age of 18 years or older, endovascular therapy for intracranial occlusion, and presence of extracranial internal carotid artery stenosis (>50%) demonstrated on pre-MT computed tomography angiography, magnetic resonance angiography, or digital subtraction angiography.

Exposures

Patients with TLs were divided into CAS vs nonstenting groups.

Main Outcomes and Measures

Primary clinical and safety outcomes were 90-day functional independence measured by a modified Rankin Scale (mRS) score of 0 to 2 and symptomatic intracranial hemorrhage (sICH), respectively. Secondary outcomes were successful reperfusion (modified Thrombolysis in Cerebral Infarction score ≥2b), discharge mRS score, ordinal mRS score, and mortality at 90 days.

Results

Of 685 patients, 623 (mean [SD] age, 67 [12.2] years; 406 [65.2%] male) were included in the analysis, of whom 363 (58.4%) were in the CAS group and 260 (41.6%) were in the nonstenting group. The CAS group had a lower proportion of patients with atrial fibrillation (38 [10.6%] vs 49 [19.2%], P = .002), a higher proportion of preprocedural degree of cervical stenosis on digital subtraction angiography (90%-99%: 107 [32.2%] vs 42 [20.5%], P < .001) and atherosclerotic disease (296 [82.0%] vs 194 [74.6%], P = .003), a lower median (IQR) National Institutes of Health Stroke Scale score (15 [10-19] vs 17 [13-21], P < .001), and similar rates of intravenous thrombolysis and stroke time metrics when compared with the nonstenting group. After adjustment for confounders, the odds of favorable functional outcome (adjusted odds ratio [aOR], 1.67; 95% CI, 1.20-2.40; P = .007), favorable shift in mRS scores (aOR, 1.46; 95% CI, 1.02-2.10; P = .04), and successful reperfusion (aOR, 1.70; 95% CI, 1.02-3.60; P = .002) were significantly higher for the CAS group compared with the nonstenting group. Both groups had similar odds of sICH (aOR, 0.90; 95% CI, 0.46-2.40; P = .87) and 90-day mortality (aOR, 0.78; 95% CI, 0.50-1.20; P = .27). No heterogeneity was noted for 90-day functional outcome and sICH in prespecified subgroups.

Conclusions and Relevance

In this multicenter, international cross-sectional study, CAS of the cervical lesion during MT was associated with improvement in functional outcomes and reperfusion rates without an increased risk of sICH and mortality in patients with TLs.

Use of the Woven EndoBridge Device for Sidewall Aneurysms: Systematic Review and Meta-analysis

BACKGROUND

The Woven EndoBridge device was originally approved to treat intracranial wide-neck saccular bifurcation aneurysms. Recent studies have suggested its use for the treatment of sidewall intracranial aneurysms with variable success.

PURPOSE

Our aim was to evaluate the safety and efficacy of the Woven EndoBridge device for sidewall aneurysms using a meta-analysis of the literature.

DATA SOURCES

We performed a systematic review of all studies including patients treated with the Woven EndoBridge device for sidewall aneurysms from inception until May 2022 on Scopus, EMBASE, MEDLINE, the Web of Science, and the Cochrane Central Register of Controlled Trials.

STUDY SELECTION

Ten studies were selected, and 285 patients with 288 sidewall aneurysms were included.

DATA ANALYSIS

A random-effects meta-analysis of proportions using a generalized linear mixed model was performed as appropriate. Statistical heterogeneity across studies was assessed with I2 statistics.

DATA SYNTHESIS

The adequate occlusion rate at last follow-up was 89% (95% CI, 81%-94%; I2, = 0%), the composite safety outcome was 8% (95% CI, 3%-17%; I2 = 34%), and the mortality rate was 2% (95% CI, 1%-7%; I2 = 0%). Aneurysm width (OR = 0.5; P = .03) was the only significant predictor of complete occlusion.

LIMITATIONS

Given the level of evidence, our results should be interpreted cautiously until confirmation from larger prospective studies is obtained.

CONCLUSIONS

The initial evidence evaluating the use of the Woven EndoBridge device for the treatment of wide-neck sidewall intracranial aneurysms has demonstrated high rates of adequate occlusion with low procedural complications. Our findings favor the consideration of the Woven EndoBridge device as an option for the treatment of sidewall aneurysms.

Hyperacute immune responses associate with immediate neuropathology and motor dysfunction in large vessel occlusions

OBJECTIVE

Despite successful endovascular therapy, a proportion of stroke patients exhibit long-term functional decline, regardless of the cortical reperfusion. Our objective was to evaluate the early activation of the adaptive immune response and its impact on neurological recovery in patients with large vessel occlusion (LVO).

METHODS

Nineteen (13 females, 6 males) patients with acute LVO were enrolled in a single-arm prospective cohort study. During endovascular therapy (EVT), blood samples were collected from pre and post-occlusion, distal femoral artery, and median cubital vein (controls). Cytokines, chemokines, cellular and functional profiles were evaluated with immediate and follow-up clinical and radiographic parameters, including cognitive performance and functional recovery.

RESULTS

In the hyperacute phase (within hours), adaptive immune activation was observed in the post-occlusion intra-arterial environment (post). Ischemic vascular tissue had a significant increase in T-cell-related cytokines, including IFN-γ and MMP-9, while GM-CSF, IL-17, TNF-α, IL-6, MIP-1a, and MIP-1b were decreased. Cellularity analysis revealed an increase in inflammatory IL-17+ and GM-CSF+ helper T-cells, while natural killer (NK), monocytes and B-cells were decreased. A correlation was observed between hypoperfused tissue, infarct volume, inflammatory helper, and cytotoxic T-cells. Moreover, helper and cytotoxic T-cells were also significantly increased in patients with improved motor function at 3 months.

INTERPRETATION

We provide evidence of the activation of the inflammatory adaptive immune response during the hyperacute phase and the association of pro-inflammatory cytokines with greater ischemic tissue and worsening recovery after successful reperfusion. Further characterization of these immune pathways is warranted to test selective immunomodulators during the early stages of stroke rehabilitation.

Multiple brain arteriovenous malformations: systematic review and individual patient data meta-analysis

Multiple brain arteriovenous malformations (bAVM) are rare neurovascular lesions usually related to genetic syndromes. Its management is not well established given its rarity. The objective of this study was to describe the clinical and angiographic features of published cases and to explore their associations with treatment outcomes. We performed a literature search of published cases in Medline and the Regional Index Medici. Additional cases were searched in our single-center registry. Data on the proportions of patients and clinical and angiographic characteristics were extracted. The study outcomes were nidal instability in patients who underwent staged treatment and radiological cure in patients who underwent treatment using any treatment modality. Logistic regression models for the study outcomes were analyzed. Data on the proportions of multiple bAVM patients were summarized with meta-analyses of proportions. We included 118 patients (reported in 68 studies) from the literature and 6 cases identified in our registry. A total of 124 patients harboring 339 bAVM nidi were included in the analyses. Differences between syndromic and non-syndromic cases were observed. The logistic regression analyses showed that angiographically occult untreated bAVM was associated (OR 14.37; 95% CI 2.17 to 95.4) with nidal instability after staged treatment, and deep (OR 5.11; 95% CI 1.51 to 17.27) and eloquent (OR 3.91; 95% CI 1.22 to 12.52) locations were associated with residual disease after treatment. Inconsistent reporting of relevant data throughout the included studies undermined the planned analyses. Some prognostic factors were found to be related to the study outcomes. Study Registration: The protocol of the systematic review was registered in PROSPERO as CRD42021245814.

Angiography suite cone-beam CT perfusion for selection of thrombectomy patients: A pilot study

BACKGROUND AND PURPOSE

The availability of cone-beam CT perfusion (CBCTP) in angiography suites may improve large-vessel occlusion (LVO) triage and reduce reperfusion times for patients presenting during extended time window. We aim to evaluate the perfusion maps correlation and agreement between multidetector CT perfusion (MDCTP) and CBCTP when obtained sequentially in patients undergoing endovascular therapy.

METHODS

This is a prospective, pilot, single-arm interventional cohort study of consecutive patients with anterior circulation LVO. All patients underwent MDCTP and CBCTP prior to endovascular therapy, generating cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), and time-to-maximum/time to peak contrast concentration maps. We compared the two imaging modalities using three different methods: (1) six regions of interest (ROIs) placed in the anterior circulation territory; (2) ROIs placed in all 10 Alberta Stroke Program Early CT Score regions; and (3) ROI drawn around the entire ischemic area. ROI ratios (unaffected/affected area) were compared for all sequences in each method. We used the intraclass correlation coefficient to calculate the correlation between the studies. Bland-Altman plots were also created to measure the degree of agreement. Finally, a sensitivity analysis was done comparing both modalities in patients with low infarct growth rate.

RESULTS

Fourteen patients were included (median age 81 years [74-87], 50% males, median National Institutes of Health Stroke Scale 19 [14-22]). Median time between studies was 42 minutes (interquartile range 29-61). Independently of the method used, we found moderate to excellent correlation in CBF, CBV, and MTT between modalities. CBF correlation further improved in patients with low infarct growth.

CONCLUSION

These results demonstrate promising accuracy of CBCTP in evaluating ischemic tissue in patients presenting with LVO ischemic stroke.

Mechanical Thrombectomy Access for All? Challenges in Increasing Endovascular Treatment for Acute Ischemic Stroke in the United States

Mechanical thrombectomy (MT) is the most effective treatment for selected patients with an acute ischemic stroke due to emergent large vessel occlusions (LVOs). There is an urgent need to identify and address challenges in access to MT to maximize the numbers of patients who can benefit from this treatment. Barriers in access to MT include delays in evaluation and accurate diagnosis of LVO leading to inappropriate triage, logistical delays related to availability of facilities and trained interventionalists, and financial hurdles that affect treatment reimbursement. Collection of regional data related to these barriers is critical to better understand current access gaps and a measurable access score to thrombectomy could be useful to plan local public health intervention.

Acute Carotid Artery Stenting Versus Balloon Angioplasty for Tandem Occlusions: A Systematic Review and Meta-Analysis

Background Despite thrombectomy having become the standard of care for large-vessel occlusion strokes, acute endovascular management in tandem occlusions, especially of the cervical internal carotid artery lesion, remains uncertain. We aimed to compare efficacy and safety of acute carotid artery stenting to balloon angioplasty alone on treating the cervical lesion in tandem occlusions. Similarly, we aimed to explore those outcomes' associations with technique approaches and use of thrombolysis. Methods and Results We performed a systematic review and meta-analysis to compare functional outcomes (modified Rankin Scale), reperfusion, and symptomatic intracranial hemorrhage and 3-month mortality. We explored the association of first approach (anterograde/retrograde) and use of thrombolysis with those outcomes as well. Two independent reviewers performed the screening, data extraction, and quality assessment. A random-effects model was used for analysis. Thirty-four studies were included in our systematic review and 9 in the meta-analysis. Acute carotid artery stenting was associated with higher odds of modified Rankin Scale score ≤2 (odds ratio [OR], 1.95 [95% CI, 1.24-3.05]) and successful reperfusion (OR, 1.89 [95% CI, 1.26-2.83]), with no differences in mortality or symptomatic intracranial hemorrhage rates. Moreover, a retrograde approach was significantly associated with modified Rankin Scale score ≤2 (OR, 1.72 [95% CI, 1.05-2.83]), and no differences were found on thrombolysis status. Conclusions Carotid artery stenting and a retrograde approach had higher odds of successful reperfusion and good functional outcomes at 3 months than balloon angioplasty and an anterograde approach, respectively, in patients with tandem occlusions. A randomized controlled trial comparing these techniques with structured antithrombotic regimens and safety outcomes will offer definitive guidance in the optimal management of this complex disease.

Carotid artery angioplasty versus stenting for management of acute tandem occlusions

Background The optimal approach to treat the cervical carotid artery lesion during endovascular thrombectomy (EVT) for acute strokes with tandem occlusions is unclear. While carotid artery stenting (CAS) might be a more definitive recanalization method, the potential risk of intracranial hemorrhage (ICH) limits its routine usage. In this study, we aimed to evaluate the safety outcomes of CAS and carotid artery angioplasty (CAA) in patients with acute tandem occlusions. Methods In this retrospective cohort study, data were obtained from the Nationwide Readmissions Database 2016-2017. The primary safety outcome was a composite of ICH and all-cause in-hospital mortality. Logistic regression analysis was used to compare the in-hospital outcomes. Survival analysis was used to estimate the 30-day readmissions. Results We identified 2042 hospitalizations meeting the study inclusion criteria (median age: 66 years, female 31.3%). Of these, 1391 (68.1%) had undergone CAS and 651 (31.9%) CAA alone. Baseline characteristics between the two groups were similar, except patients with CAS were more likely to be on anti-thrombotic medications and were less likely to have received intravenous thrombolysis. There was no significant difference in the clinical outcomes including ICH, in-hospital mortality, gastrostomy tube placement, prolonged mechanical ventilation, length of stay, hospital charges, and 30-day readmissions between the two groups, however, patients with CAS were more likely to be discharged home after adjusting for the confounding variables [odds ratio (OR) 1.49, 95% confidence interval (CI) 1.05-2.12, P 0.025]. Conclusion The emergent CAS-EVT approach appears to be safe with no adverse outcomes compared to CAA alone.

Endovascular embolization of high-grade cerebral dural arteriovenous fistulas - assessment of long-term recurrences

INTRODUCTION

Endovascular therapy has shown to be safe and effective for the treatment of cerebral dural arteriovenous fistulas; however, recurrence after complete occlusion is not uncommon, and the timing of recurrence remains unknown.

METHODS

A retrospective single-center cohort study was conducted from January 2005 to December 2020. Patients with high-grade (≥Borden II-Cognard IIB) dural arteriovenous fistulas treated with endovascular therapy were included in this study. Clinical and angiographic characteristics were collected for hospitalization and at follow-up.

RESULTS

A total of 51 patients with a median age of 61 years were studied; 57% were female. High-flow symptoms related to the high-flow fistula were the most common presentation (67%), and 24% presented with intracranial hemorrhage. Transverse-sigmoid (26%) and cavernous (26%) sinuses were the most common dural arteriovenous fistula locations. A total of 40 patients (70%) had middle meningeal arterial feeders and 4 (7%) had deep cerebral venous drainage. The mean number of embolization procedures per patient was 1.4. Transarterial access was the most frequent approach (61%). Onyx alone was the most common embolic agent (26%). Complete occlusion rate was achieved in 46 patients (80.1%). Last mean radiographic follow-up time was 26.7 months for all 57 dural arteriovenous fistulas. Dural arteriovenous fistula recurrence after radiographic resolution at last treatment was seen in six cases (6/46, 13.1%). Mean time for recurrence was 15.8 months. Mean time of last clinical follow-up was 46.1 months for the 51 patients (100%). A total of 10 (20%) experienced any procedural complications, among which two (4%) became major thromboembolic events.

CONCLUSION

Endovascular therapy is safe and effective for the treatment of high-grade dural arteriovenous fistulas. Given the significant recurrence rate of embolized dural arteriovenous fistulas even after 2 years, long-term angiographic follow-up might be needed.

Safety and efficacy of balloon-mounted stent in the treatment of symptomatic intracranial atherosclerotic disease: a multicenter experience

BACKGROUND

Randomized clinical trials have failed to prove that the safety and efficacy of endovascular treatment for symptomatic intracranial atherosclerotic disease (ICAD) is better than that of medical management. A recent study using a self-expandable stent showed acceptable lower rates of periprocedural complications.

OBJECTIVE

To study the safety and efficacy of a balloon-mounted stent (BMS) in the treatment of symptomatic ICAD.

METHODS

Prospectively maintained databases from 15 neuroendovascular centers between 2010 and 2020 were reviewed. Patients were included if they had severe symptomatic intracranial stenosis in the target artery, medical management had failed, and they underwent intracranial stenting with BMS after 24 hours of the qualifying event. The primary outcome was the occurrence of stroke and mortality within 72 hours after the procedure. Secondary outcomes were the occurrence of stroke, transient ischemic attacks (TIAs), and mortality on long-term follow-up.

RESULTS

A total of 232 patients were eligible for the analysis (mean age 62.8 years, 34.1% female). The intracranial stenotic lesions were located in the anterior circulation in 135 (58.2%) cases. Recurrent stroke was the qualifying event in 165 (71.1%) while recurrent TIA was identified in 67 (28.9%) cases. The median (IQR) time from the qualifying event to stenting was 5 (2-20.75) days. Strokes were reported in 13 (5.6%) patients within 72 hours of the procedure; 9 (3.9%) ischemic and 4 (1.7%) hemorrhagic, and mortality in 2 (0.9%) cases. Among 189 patients with median follow-up time 6 (3-14.5) months, 12 (6.3%) had TIA and 7 (3.7%) had strokes. Three patients (1.6%) died from causes not related to stroke.

CONCLUSION

Our study has shown that BMS may be a safe and effective treatment for medically refractory symptomatic ICAD. Additional prospective randomized clinical trials are warranted.

Repeated Mechanical Endovascular Thrombectomy for Recurrent Large Vessel Occlusion: A Multicenter Experience

BACKGROUND AND PURPOSE

Mechanical thrombectomy (MT) is now the standard of care for large vessel occlusion (LVO) stroke. However, little is known about the frequency and outcomes of repeat MT (rMT) for patients with recurrent LVO.

METHODS

This is a retrospective multicenter cohort of patients who underwent rMT at 6 tertiary institutions in the United States between March 2016 and March 2020. Procedural, imaging, and outcome data were evaluated. Outcome at discharge was evaluated using the modified Rankin Scale.

RESULTS

Of 3059 patients treated with MT during the study period, 56 (1.8%) underwent at least 1 rMT. Fifty-four (96%) patients were analyzed; median age was 64 years. The median time interval between index MT and rMT was 2 days; 35 of 54 patients (65%) experienced recurrent LVO during the index hospitalization. The mechanism of stroke was cardioembolism in 30 patients (56%), intracranial atherosclerosis in 4 patients (7%), extracranial atherosclerosis in 2 patients (4%), and other causes in 18 patients (33%). A final TICI recanalization score of 2b or 3 was achieved in all 54 patients during index MT (100%) and in 51 of 54 patients (94%) during rMT. Thirty-two of 54 patients (59%) experienced recurrent LVO of a previously treated artery, mostly the pretreated left MCA (23 patients, 73%). Fifty of the 54 patients (93%) had a documented discharge modified Rankin Scale after rMT: 15 (30%) had minimal or no disability (modified Rankin Scale score ≤2), 25 (50%) had moderate to severe disability (modified Rankin Scale score 3-5), and 10 (20%) died.

CONCLUSIONS

Almost 2% of patients treated with MT experience recurrent LVO, usually of a previously treated artery during the same hospitalization. Repeat MT seems to be safe and effective for attaining vessel recanalization, and good outcome can be expected in 30% of patients.

Safety and Feasibility of Symptomatic Carotid Artery Stent-Assisted Revascularization within 48 Hours after Symptoms Onset

OBJECTIVE

We aimed to evaluate the safety and feasibility of carotid artery stenting (CAS) performed in the hyperacute period.

METHODS

We analyzed a retrospective database of CAS patients from our center. We included patients with symptomatic isolated ipsilateral extracranial carotid stenosis and acute tandem occlusions who underwent CAS. Hyperacute CAS (HCAS) and acute CAS (ACAS) groups were defined as CAS within 48 hours and >48 hours to 14 days from symptoms onset, respectively. The primary outcome was a composite of any stroke, myocardial infarction, or death at 3 months of follow-up. Secondary outcomes were periprocedural complications and restenosis or occlusion rates.

RESULTS

We included 97 patients, 39 with HCAS and 58 with ACAS. There was no significant difference between groups for the primary outcome (HCAS 3.3% vs. ACAS 6.1%; p = 1). There were no differences in the rate of perioperative complications between groups although a trend was observed (HCAS 15.3% vs. ACAS 3.4%; p = .057). The rate of restenosis or occlusion between groups (HCAS 8.1% vs. ACAS 9,1%; log-rank test p = .8) was similar with a median time of follow-up of 13.7 months.

CONCLUSION

Based on this study, CAS may be feasible in the hyperacute period. However, there are potential higher rates of perioperative complications in the hyperacute group, primarily occurring in MT patients with acute tandem occlusion. A larger multicenter study may be needed to further corroborate our findings.

Absent hyperdense middle cerebral artery sign is associated with poor functional outcome after mechanical thrombectomy

BACKGROUND

The hyperdense middle cerebral artery sign on computed tomography indicates proximal middle cerebral artery occlusion. Recent reports suggest an association between the hyperdense sign and successful reperfusion. The prognostic value of the hyperdense middle cerebral artery sign in patients receiving mechanical thrombectomy has not been extensively studied.

AIMS

Our study aims to evaluate the association between the hyperdense middle cerebral artery sign and functional outcome in patients with M1 occlusions that had undergone mechanical thrombectomy.

METHODS

We conducted a single-center retrospective observational cohort study of 102 consecutive patients presenting with acute M1 occlusions that had undergone mechanical thrombectomy. Patients were stratified into cohorts based on the presence of hyperdense middle cerebral artery sign visually assessed on computed tomography by two readers. The outcomes of interests were functional disability measured by the ordinal Modified Rankin Scale (mRS) at 90 days, mortality, reperfusion status and hemorrhagic conversion.

RESULTS

Out of the 102 patients with M1 occlusions, 71 had hyperdense middle cerebral artery sign. There was no significant difference between the cohorts in age, baseline mRS, NIHSS, ASPECTS, and time to reperfusion. The absence of hyperdense middle cerebral artery sign was associated with increased odds of being dependent or dying (higher mRS) (OR: 3.24, 95% CI: 1.30-8.06, p = 0.011) after adjusting for other significant predictors, including age, female sex, hypertension, presenting serum glucose, ASPECTS, CTA collateral score, and successful reperfusion.

CONCLUSION

The absence of hyperdense middle cerebral artery sign is associated with worse functional outcome in patients presenting with M1 occlusions undergoing thrombectomy.

Proximal Internal Carotid artery Acute Stroke Secondary to tandem Occlusions (PICASSO) international survey

BACKGROUND

While mechanical thrombectomy (MT) is the standard of care for large vessel occlusion strokes, the optimal management of tandem occlusions (TO) remains uncertain. We aimed to determine the current practice patterns among stroke physicians involved in the treatment of TO during MT.

METHODS

We distributed an online survey to neurovascular practitioners (stroke neurologists, neurointerventionalists, neurosurgeons, and radiologists), members of professional societies. After 2 months the site was closed and data were extracted and analyzed. We divided respondents into acute stenting and delayed treatment groups and responses were compared between the two groups.

RESULTS

We received 220 responses from North America (48%), Latin America (28%), Asia (15%), Europe (5%), and Africa (4%). Preferred timing for cervical revascularization varied among respondents; 51% preferred treatment in a subsequent procedure during the same hospitalization whereas 39% preferred to treat during MT. Angioplasty and stenting (41%) was the preferred technique, followed by balloon angioplasty and local aspiration (38%). The risk of intracerebral hemorrhage was the most compelling reason for not stenting acutely (68%). There were no significant differences among practice characteristics and timing groups. Most practitioners (70%) agreed that there is equipoise regarding the optimal endovascular treatment of cervical lesions in TO; hence, 77% would participate in a randomized controlled trial.

CONCLUSIONS

The PICASSO survey demonstrates multiple areas of uncertainty regarding the medical and endovascular management of TOs. Experts acknowledged the need for further evidence and their willingness to participate in a randomized controlled trial to evaluate the best treatment for the cervical TO lesion.

Safety and efficacy of symptomatic carotid artery stenting performed in an emergency setting

INTRODUCTION

Carotid artery stenting (CAS) has increasingly emerged as an alternative strategy to carotid endarterectomy in the treatment of patients with symptomatic carotid stenosis. Optimal timing for CAS after symptoms onset remains unclear. We aimed to evaluate the safety and efficacy of CAS when performed in an emergency setting.

PATIENTS AND METHODS

We performed a retrospective analysis of CAS patients admitted to our CSC with symptomatic extracranial carotid occlusion or significant stenosis from January 2014-September 2019. Emergency CAS was defined as CAS performed during the same hospitalization from TIA/stroke onset, whereas elective CAS as CAS performed on a subsequent admission. The primary outcome was defined as the occurrence of any stroke, myocardial infarction, or death related to the procedure at 3 months of follow-up. Secondary outcomes included periprocedural complications and the rate of restenosis/occlusion at follow-up. Logistic regression and survival analyses were used to compare outcomes and restenosis at follow-up.

RESULTS

We identified 75 emergency and 104 elective CAS patients. Emergency CAS patients had significantly higher rates of ipsilateral carotid occlusion (17% vs. 2%, p < 0.001) and use of general anesthesia (19% vs. 4%, p = 0.001) than elective CAS. There were no significant differences between emergency and elective CAS in the primary (5.7% vs. 1%, p = 0.161) and secondary (9% vs. 4.8%, p = 0.232) outcomes. We did not find differences in the rate of restenosis/occlusion (7% vs. 11.6%; log-rank test p = 0.3) at a median of 13 months follow-up.

CONCLUSION

In our study, emergency CAS in symptomatic patients might have a similar safety and efficacy profile to elective CAS at 3 months and long-term follow-up.

Patterns of Care and Clinical Outcomes in Patients with Cerebral Sinus Venous Thrombosis

OBJECTIVES

To explore the association between rurality, transfer patterns and level of care with clinical outcomes of CVST patients in a rural Midwestern state.

MATERIALS AND METHODS

CVST patients admitted to the hospitals between 2005 and 2014 were identified by inpatient diagnosis codes from statewide administrative claims dataset. Records were linked across interhospital transfers using probabilistic linkage. Rurality was defined by Rural-Urban Commuting Areas using the 2-category approximation. Driving distances were estimated using GoogleMaps Application Programming Interface. Hospital stroke certification was defined by the Joint Commission. Severity of CVST was estimated by cost of care corrected for inflation and cost-to-charge ratios. Outcome was discharge disposition and total length of stay (LOS). Wilcoxon rank-sum, Chi-square, Fisher's exact tests and linear and logistic regressions were used.

RESULTS

168 CVST patients were identified (79.8% female; median age = 32, IQR = 24.0-45.5). Median LOS was four days (IQR = 2-7) and patients traveled a median of 8.1 miles (IQR = 2.5-28.5) to the first hospital; 42% of patients were transferred to a second hospital, 5% to a third. More than half (58.3%) bypassed the nearest hospital. 86% visit a primary or comprehensive stroke center (CSC) during their acute care. Rurality was not significantly associated with LOS or discharge disposition after adjusting for age, sex and cost of care. Patients in CSC demonstrated greater likelihood of being discharged home compared to at a primary stroke center after adjusting for age and disease severity (p = 0.008).

CONCLUSIONS

While rurality was not significantly associated with LOS or disposition outcome, care at a CSC increases likelihood of being discharge home.

Retrieval of distally migrated coil using stent retriever and proximal aspiration

Endovascular coiling has become the preferred treatment of many centers for the management of both ruptured and unruptured aneurysms. Coil migration is a rare complication that can lead to vessel occlusion in 90% of the cases. Endovascular techniques for coil retrieval have shown less complication rates than open surgery. Stent retriever devices have been successfully used for the retrieval of proximally migrated coils, however, distally migrated coils still represent a challenge with greater risk of complications. In the present technical video 1, we demonstrate the successful retrieval of a distally M3 migrated coil using a 3 mm Trevo XP ProVue stent riever (Stryker Neurovascular, Fremont, CA, USA) in combination with proximal aspiration. neurintsurg;13/9/860/V1F1V1Video 1.

Greater intraprocedural systolic blood pressure and blood pressure variability are associated with contrast-induced neurotoxicity after neurointerventional procedures

BACKGROUND

Contrast-induced neurotoxicity (CIN) is a rare complication of neurointerventional procedures and its understanding remains limited. We evaluated the association of CIN with systemic hemodynamics in patients undergoing neuroendovascular interventions.

METHODS

We conducted a 1:2 matched case-control study from a prospectively collected database of 2510 neurointerventional patients. We defined CIN as new neurological deficits presented ≤24 h post-operation after excluding other possible etiologies. We obtained demographic, clinical and imaging data, and baseline and intraprocedural blood pressures (BP) from medical records. The area between baseline and intraprocedural BP was used to measure sustained variability of BP over time. A generalized linear mixed model and generalized estimating equation were used to analyze the BP difference between groups over time.

RESULTS

We evaluated 11 CIN cases and 22 controls. 2746 and 5837 min of continued BP data were analyzed for cases and controls, respectively. CIN cases had higher measurements and greater variability for: Systolic BP (SBP) [median 125 (IQR:121-147) vs. 114 (IQR:107-124) mmHg], median area above baseline [median 350 (IQR:25-1328) vs. 52 (IQR:0-293) mmHg*minutes] and mean arterial pressure (MAP) [median 85 (IQR:79-98) vs. 80 (IQR:74-89) mmHg]. CIN cases demonstrated a significant mean increase in SBP and MAP of 23.41 mmHg (p < 0.01) and 13.79 mmHg (p < 0.01) when compared to controls, respectively, over the perioperative time.

CONCLUSION

Sustained hypertension and high BP variability may contribute to the pathophysiology of CIN. Acute hypertension can increase blood-brain barrier permeability and potentially allow contrast to leak into the brain parenchyma causing direct toxicity and CIN symptoms.

Comparing the outcomes of two independent computed tomography perfusion softwares and their impact on therapeutic decisions in acute ischemic stroke

BACKGROUND

To compare the computed tomography perfusion (CTP) outcomes derived from two commercial CTP processing software and evaluate their concordance in terms of eligibility for mechanical thrombectomy (MT) in acute ischemic stroke (AIS), based on DEFUSE III criteria.

METHODS

A total of 118 patients (62 patients in the MT group and 56 patients in the non-MT (NMT) group) were included. Volumetric perfusion outputs were compared between Syngo.via (package A) and RAPID (package B). Influence on proceeding or not-proceeding with MT was based on DEFUSE III imaging eligibility criteria.

RESULTS

Median core infarct/hypoperfusion volumes were 12.3/126 mL in the MT group and 7.7/29.3 ml in the NMT group with package A and 10.5/138 mL and 1.9/24.5 mL with package B, respectively. In the MT group (n=62), concordant perfusion results in terms of patient triage were noted in all but two cases. Of these, one patient would not have qualified (low ASPECTS), while the other qualified based on package A results. For the NMT group (n=56), there was discordance in terms of MT eligibility in seven cases. However, none of these patients qualified for MT based on DEFUSE III criteria.

CONCLUSIONS

Both perfusion softwares showed high concordance in correctly triaging patients in the MT versus NMT groups (110/118, 93.2%), which further improved when all DEFUSE III imaging criteria were considered (117/118, 99.1%). The core/hypoperfusion volumes in the NMT group and core infarct volumes in the MT groups were comparable. The hypoperfusion volumes in the MT group varied slightly but did not affect triage between groups.

Overestimation of core infarct by computed tomography perfusion in the golden hour

A nonagenarian patient developed a right middle cerebral artery syndrome during recovery after a right internal carotid artery (ICA) balloon angioplasty. Emergent head computed tomography (CT) revealed no acute ischemic changes; CT angiography (CTA) and CT perfusion (CTP) demonstrated a right ICA occlusion with a large right hemispheric predicted core infarct by cerebral blood flow thresholds and minimal mismatch volume. She underwent complete reperfusion in <45 min from symptom onset. Magnetic resonance imaging brain obtained within 48 h showed a decreased infarct volume as that estimated by CTP. This case emphasizes the limitations of estimating the ischemic core with CTP in the golden hour with ultra-early reperfusion and suggests that CTP thresholds should not be used to exclude patients from treatment in the very early time window.

Ischemic Factors Precipitate a Shift in Immune Cell Populations at the Site of Cerebrovascular Blockage

The incidence of stroke has risen over the past decade and will continue to be one of the leading causes of adult disability and death worldwide. Reperfusion therapy or endovascular thrombectomy (EVT) for large vessel occlusion (LVO) remains the only proven stroke therapy during the acute phase. But a select set of patients still exhibit poor recovery of neurological function, despite active cortical reorganization. The mechanisms that underlie this neurological dysfunction is still poorly understood. Subsequent to ischemic injury, a massive inflammatory response is seen for days, which exacerbates neuropathology in stroke models. Within the draining lymph nodes of ischemic patients, innate immune cells are actively phagocytizing brain antigen and presenting them to adaptive immune cells.

The focus of this project is to determine if early changes in immune cells near the site of occlusion can be used as predictors of long-term neurofunctional decline. Acute anterior circulation LVO patients treated with EVT will be enrolled in this study. At the time of thrombectomy, blood was collected proximal and distal to the thrombus prior to recanalization. As a control, blood was also collected from the femoral artery. Deep immune profiling of innate and adaptive immune cells using 13-parameter flow cytometry was performed revealing a specific increase in post-thrombus CD4 T-cells, as compared to pre-thrombus. Cytokine analysis revealed a decrease in pre- and post-thrombus IFN-γ and IL1α. Induction of in vitro hypoxia in healthy peripheral blood mononuclear cells revealed a similar reduction in IFN-γ.

We hypothesize that ischemia precipitates a shift in immune cells at the site of cerebrovascular blockage that modulates stroke recovery.

Second Generation Drug-Eluting Stents for Endovascular Treatment of Ostial Vertebral Artery Stenosis: A Single Center Experience

Objective: To report a single-center experience using drug-eluting balloon mounted stents (DES) for endovascular treatment of atherosclerotic ostial vertebral artery stenosis (OVAS).

Background: Posterior circulation is affected in up to 25% of strokes, 20% of them resulting from atherosclerotic OVAS. The optimal management of symptomatic OVAS remains controversial. DES have been introduced to improve restenosis rates.

Methods: We retrospectively analyzed prospectively collected data from patients with dominant OVAS who underwent endovascular treatment with second-generation DES placement. Patient demographics, clinical presentation, comorbidities, stenosis severity, stent features, technical success, complications, and imaging follow-up were assessed.

Results: Thirty patients were treated, predominantly male (86.6%). Sixteen patients presented with an acute stroke or TIA and fourteen were treated on an elective basis due to symptomatic chronic stenosis and contralateral occlusion. Comorbidities included hyperlipidemia (83%), hypertension (70%) and prior stroke (63.3%). Mean ostial stenosis at presentation was 80 ± 14.8%. Twenty-one patients had contralateral VA involvement. DES deployment was technically successful in all patients using everolimus eluting stents in 30 lesions and zotarolimus eluting stents in two. One technical complication (stent migration) and three (10%) minor peri-procedural complications occurred. Complications included one asymptomatic ischemic infarct in the posterior circulation, one femoral artery thrombosis and one post-procedure altered mental status secondary to contrast induced neurotoxicity. Mean imaging follow-up was 8.8 months. Two (7.6%) patients had in-stent restenosis and underwent retreatment with angioplasty. There were no procedure-related mortalities.

Conclusion: Our study confirms the feasibility of deploying DES for the treatment of ostial vertebral artery stenosis with low peri-procedural risk and low medium-term rates of re-stenosis.