How to use the Contour intrasaccular device: two illustrative cases

Contour (Stryker, Kalamazoo, MI) is a relatively new endosaccular device for the treatment of intracranial aneurysms.1 2 Its unique cup-like shape permits treatment of most lesions, including wide-necked, irregular, and shallowed-shaped aneurysms. The sizing of the device only requires two parameters: neck size and equatorial plane (width). It must be positioned at the neck of the aneurysm with the device proximal marker in the parent artery. In our experience, dual antiplatelet therapy is usually not required for intrasaccular devices and this is also an advantage of the Contour device. We report two illustrative cases of wide-neck aneurysms in the anterior and posterior circulation, respectively (video 1). In this video we demonstrate the feasibility of this treatment in a middle cerebral artery bifurcation with atypical triangular shape and typical tip-basilar aneurysm. neurintsurg;16/3/225/V1F1V1Video 1 .

Defining the optimal size of an aspiration catheter in relation to the arterial diameter during mechanical thrombectomy for stroke

BACKGROUND

Mechanical thrombectomy for acute ischemic stroke is effective and includes different technical approaches. Operators use direct aspiration, a stent retriever, or a combination of both. Direct aspiration can be performed with various catheters of different sizes depending on the diameter of the occluded vessel.

PURPOSE

We studied the relationship between the catheter diameter in regards to the occluded vessel diameter and the rate of successful recanalization.

MATERIALS AND METHODS

We conducted a retrospective, monocentric study on a series of consecutive patients treated with mechanical thrombectomy. For each procedure, we extracted each attempt that used direct aspiration and rated the attempt as successful or unsuccessful. We also measured the occluded artery diameter and calculated the ratio between the occluded artery and the aspiration catheter diameters. We tested the association between the diameter ratio and the recanalization status. We also performed inter-rater agreement for the arterial diameter measurement between three interventional neuroradiologists.

RESULTS

We included 119 patients with 201 attempts of direct aspiration. A higher diameter ratio was associated with a higher recanalization rate. The analysis in terciles showed that the odds of success were 4.80 higher when the ratio was >0.71 vs <0.54 (p < 0.01). Inter-rater agreement showed near-perfect intraclass correlation with 0.93 (0.91-0.94) consistency and 0.92 (0.90-0.94) absolute agreement.

CONCLUSIONS

We demonstrated an association between higher recanalization and a diameter of ratio >0.71 between the aspiration catheter and the occluded artery. These results could guide intraoperative decisions regarding the appropriate selection of aspiration catheters during mechanical thrombectomy increasing the rate of successful recanalisation. A larger study could provide additional data to further specify the optimal ratio.

Embryology of the vertebral artery and variants of the adult

The vertebral arteries represent in the adult the main blood supply of the posterior cranial fossa, even if they appear relatively late during the embryological life. We reviewed all the most important steps of the vertebral artery's embryological development and the most common variants that can occur in the adult. The aim of this review is to summarize the main events of the development of this artery and to give an embryological explication for the most common variants of this artery.

Middle column Stent-screw Assisted Internal Fixation (SAIF): a modified minimally-invasive approach to rescue vertebral middle column re-fractures

BACKGROUND

There is limited literature regarding the re-fracture of a previously augmented vertebral compression fracture (VCF). These re-fractures may present as an asymptomatic remodeling of the vertebral body around the cement cast while in other cases they involve the middle column, at the transition zone between the cement-augmented and non-augmented vertebral body. In the latter, a posterior wall retropulsion is possible and, if left untreated, might progress to vertebral body splitting, central canal stenosis, and kyphotic deformity. There is no consensus regarding the best treatment for these re-fractures. There are cases in which a repeated augmentation relieves the pain, but this is considered an undertreatment in cases with middle column involvement, posterior wall retropulsion, and kyphosis.

METHODS

We report four cases of re-fracture with middle column collapse of a previously augmented VCF, treated with the stent-screw assisted internal fixation (SAIF) technique. A modified more postero-medial deployment of the anterior metallic implants was applied, to target the middle column fracture. This modified SAIF allowed the reduction and stabilization of the middle column collapse as well as the partial correction of the posterior wall retropulsion and kyphosis.

RESULTS

Complete relief of back pain with stable clinical and radiographic findings at follow-up was obtained in all cases.

CONCLUSIONS

In selected cases, the middle column SAIF technique is safe and effective for the treatment of the re-fracture with middle column collapse of a previously cement-augmented VCF. This technique requires precision in trocar placement and could represent a useful addition to the technical armamentarium for VCF treatment.

European Multicenter Study of ET-COVID-19

BACKGROUND AND PURPOSE

Acute ischemic stroke and large vessel occlusion can be concurrent with the coronavirus disease 2019 (COVID-19) infection. Outcomes after mechanical thrombectomy (MT) for large vessel occlusion in patients with COVID-19 are substantially unknown. Our aim was to study early outcomes after MT in patients with COVID-19.

METHODS

Multicenter, European, cohort study involving 34 stroke centers in France, Italy, Spain, and Belgium. Data were collected between March 1, 2020 and May 5, 2020. Consecutive laboratory-confirmed COVID-19 cases with large vessel occlusion, who were treated with MT, were included. Primary investigated outcome: 30-day mortality.

SECONDARY OUTCOMES

early neurological improvement (National Institutes of Health Stroke Scale improvement ≥8 points or 24 hours National Institutes of Health Stroke Scale 0-1), successful reperfusion (modified Thrombolysis in Cerebral Infarction grade ≥2b), and symptomatic intracranial hemorrhage.

RESULTS

We evaluated 93 patients with COVID-19 with large vessel occlusion who underwent MT (median age, 71 years [interquartile range, 59-79]; 63 men [67.7%]). Median pretreatment National Institutes of Health Stroke Scale and Alberta Stroke Program Early CT Score were 17 (interquartile range, 11-21) and 8 (interquartile range, 7-9), respectively. Anterior circulation acute ischemic stroke represented 93.5% of cases. The rate modified Thrombolysis in Cerebral Infarction 2b to 3 was 79.6% (74 patients [95% CI, 71.3-87.8]). Thirty-day mortality was 29% (27 patients [95% CI, 20-39.4]). Early neurological improvement was 19.5% (17 patients [95% CI, 11.8-29.5]), and symptomatic intracranial hemorrhage was 5.4% (5 patients [95% CI, 1.7-12.1]). Patients who died at 30 days exhibited significantly lower lymphocyte count, higher levels of aspartate, and LDH (lactate dehydrogenase). After adjustment for age, initial National Institutes of Health Stroke Scale, Alberta Stroke Program Early CT Score, and successful reperfusion, these biological markers remained associated with increased odds of 30-day mortality (adjusted odds ratio of 2.70 [95% CI, 1.21-5.98] per SD-log decrease in lymphocyte count, 2.66 [95% CI, 1.22-5.77] per SD-log increase in aspartate, and 4.30 [95% CI, 1.43-12.91] per SD-log increase in LDH).

CONCLUSIONS

The 29% rate of 30-day mortality after MT among patients with COVID-19 is not negligible. Abnormalities of lymphocyte count, LDH and aspartate may depict a patient's profiles with poorer outcomes after MT. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT04406090.

Alternative route to a hypoglossal canal dural arteriovenous fistula in case of failed jugular vein approach

Hypoglossal canal dural arteriovenous fistulas (HC-DAVF) involve the anterior condylar vein (ACV) and anterior condylar confluence (ACC). They often present with tinnitus, bruit, and hypoglossal nerve palsy. The most common treatment in HC-DAVFs is transvenous embolization using coils and the most direct transvenous route is the trans-internal jugular vein access. When this approach is not feasible, a treatment attempt is possible through alternative routes. We report 2 patients with DAVFs involving the anterior condylar confluence. The first patient presented with pulsatile tinnitus and hypoglossal nerve palsy, and was treated by a standard transjugular approach. The second patient presented with pulse-synchronous bruit. Following an unsuccessful attempt of the transjugular approach, the fistulous point was reached via the deep cervical vein and complete occlusion was achieved by coil deployment. Both patients had complete regression of symptoms. Endovascular therapy is the elective treatment for HC-DAVFs and the transjugular approach is the most commonly used. The deep cervical vein (DCV) can be an alternative transvenous route when the transjugular approach fails.

Woven EndoBridge Device immediate post-detachment tilt with later displacement: Case report, rescue techniques, and review of the literature

The Woven EndoBridge Device (WEB) is efficient and safe in the treatment of wide-neck bifurcation intracranial aneurysms. A crucial step in operative planning is establishing the appropriate dimension of the device, and there are limitations to the therapeutic solutions provided by WEBs. We describe a case of a right middle cerebral artery bifurcation wide-neck aneurysm treated with WEB. After the initial deployment of a WEB proven oversized, we substituted it with a smaller one that presented immediate post-detachment intra-aneurysmal tilt probably resulting from undersizing. The 24-h angiographic control identified a partial displacement of the device in the superior middle cerebral artery branch. We describe rescue techniques with review of the literature and our treatment strategy, including effort to reposition the device followed by stent deployment. The treatment was electively completed by the coil-through technique. The post-detachment WEB tilt should be considered an unstable position and treated either by removal of the device or with adjunctive implants. Each WEB size adapts to a range of aneurysmal height and width. This range is not always the same for each specific WEB dimension, based on the table provided by the manufacturer. This eventually predisposes to a different behavior of different WEB sizes regarding the modification of the device's height in relation to the modification of the diameter after deployment.