"Stent-within-a-Stent" technique for the endovascular treatment of giant aneurysm of basilar artery bifurcation: A case report

Stents have become very important devices in the treatment of intracranial aneurysms. Flow diverters as high metal coverage stents are developed for hemodynamic treatment of challenging intracranial aneurysms. High level of metal coverage can also be achieved by implementing regular stents telescopically one in another. We present the case of a patient successfully treated for giant aneurysm of basilar artery bifurcation by a "Stent-within-a-Stent" technique. After stent implantation, coil embolization was performed using multiple-sized platinum helical coils. Control angiography performed at the end of the procedure revealed aneurysm occlusion. After 3 years, the patient is fully neurologically recovered, without pyramidal deficit, independently active and able to work.

EndoVAscular treatment and ThRombolysis for Ischemic Stroke Patients (EVA-TRISP) registry: basis and methodology of a pan-European prospective ischaemic stroke revascularisation treatment registry

PURPOSE

The Thrombolysis in Ischemic Stroke Patients (TRISP) collaboration was a concerted effort initiated in 2010 with the purpose to address relevant research questions about the effectiveness and safety of intravenous thrombolysis (IVT). The collaboration also aims to prospectively collect data on patients undergoing endovascular treatment (EVT) and hence the name of the collaboration was changed from TRISP to EVA-TRISP. The methodology of the former TRISP registry for patients treated with IVT has already been published. This paper focuses on describing the EVT part of the registry.

PARTICIPANTS

All centres committed to collecting predefined variables on consecutive patients prospectively. We aim for accuracy and completeness of the data and to adapt local databases to investigate novel research questions. Herein, we introduce the methodology of a recently constructed academic investigator-initiated open collaboration EVT registry built as an extension of an existing IVT registry in patients with acute ischaemic stroke (AIS).

FINDINGS TO DATE

Currently, the EVA-TRISP network includes 20 stroke centres with considerable expertise in EVT and maintenance of high-quality hospital-based registries. Following several successful randomised controlled trials (RCTs), many important clinical questions remain unanswered in the (EVT) field and some of them will unlikely be investigated in future RCTs. Prospective registries with high-quality data on EVT-treated patients may help answering some of these unanswered issues, especially on safety and efficacy of EVT in specific patient subgroups.

FUTURE PLANS

This collaborative effort aims at addressing clinically important questions on safety and efficacy of EVT in conditions not covered by RCTs. The TRISP registry generated substantial novel data supporting stroke physicians in their daily decision making considering IVT candidate patients. While providing observational data on EVT in daily clinical practice, our future findings may likewise be hypothesis generating for future research as well as for quality improvement (on EVT). The collaboration welcomes participation of further centres willing to fulfill the commitment and the outlined requirements.

How to Improve the Management of Acute Ischemic Stroke by Modern Technologies, Artificial Intelligence, and New Treatment Methods

Stroke remains one of the leading causes of death and disability in Europe. The European Stroke Action Plan (ESAP) defines four main targets for the years 2018 to 2030. The COVID-19 pandemic forced the use of innovative technologies and created pressure to improve internet networks. Moreover, 5G internet network will be helpful for the transfer and collecting of extremely big databases. Nowadays, the speed of internet connection is a limiting factor for robotic systems, which can be controlled and commanded potentially from various places in the world. Innovative technologies can be implemented for acute stroke patient management soon. Artificial intelligence (AI) and robotics are used increasingly often without the exception of medicine. Their implementation can be achieved in every level of stroke care. In this article, all steps of stroke health care processes are discussed in terms of how to improve them (including prehospital diagnosis, consultation, transfer of the patient, diagnosis, techniques of the treatment as well as rehabilitation and usage of AI). New ethical problems have also been discovered. Everything must be aligned to the concept of “time is brain”.

"Real life" impact of anesthesia strategy for mechanical thrombectomy on the delay, recanalization and outcome in acute ischemic stroke patients

BACKGROUND AND PURPOSE

Choice of anesthesia type on outcome for mechanical thrombectomy (MT) in acute ischemic stroke remains controversial. The goal of our research was to study the impact of anesthesia strategy on the delay, angiographic and neurological outcome of MT performed under general anesthesia (GA) vs. conscious sedation (CS).

METHODS

This prospective, single-center observational study included patients with anterior circulation large vessel occlusion (ACLVO) strokes treated with MT within 6 hours of symptom onset. All time metrics were evaluated. Angiographic and clinical outcomes were assessed by recanalization rate (mTICI) and 3-month functional independence (mRs). Complications and mortality rate were recorded as safety outcomes.

RESULTS

In total, 303 consecutive thrombectomies were performed, 86.8% under GA. NIHSS was higher in GA, with median of 19.0 for GA and 16.5 for CS (P = 0.049). Median time from arrival in hospital (door) to groin puncture was 83 min (IQR = 45.0-109.5) for GA compared to 72 min (IQR = 35.0-85.3) for CS, P = 0.170). Median time from arrival in the angiosuite to groin puncture was 20 min (IQR = 15.0-29.0) for GA compared to 15 min (IQR = 10.0-20.0) for CS, P = 0.017). There were no significant differences in recanalization time metrics, successful revascularization rate, functional independence and mortality rate at three months.

CONCLUSIONS

GA induced a 5 to 10 minutes delay for groin puncture, without impact on recanalization time metrics, or neurological outcome at 3 months. Our results demonstrate that a well-organized workflow is associated with reasonable delay in performing GA for MT, without effect on outcome compared to sedation.

PTA Stent of Dural Sinuses in Brain DAVF : A Report of 4 Cases

BACKGROUND AND PURPOSE

Type I and IIa dural arteriovenous fistulas (DAVFs) have a low hemorrhagic risk, but are often the cause of debilitating tinnitus that requires treatment. While Onyx® and PHIL™ (Precipitating hydrophobic injectable liquid) transarterial embolization represent the first endovascular option, there are occasional cases where performing angioplasty and stenting of the affected sinus may lead to satisfactory results.

MATERIAL AND METHODS

We retrospectively analyzed four consecutive cases of patients with DAVF-induced pulsatile tinnitus secondary to type I and II DAVFs who were treated with angioplasty and stenting of the sinus only. All the patients had clinical and radiological long-term follow-up.

RESULTS

We noticed a significant radiological and clinical improvement in all the cases. Of the patients two were completely cured at follow-up with eradication of the neurological symptoms as well as the fistula, one was retreated with Onyx® for a very small residual shunt despite having no more tinnitus, and one showed improvement in venous drainage (from type IIa+b to type I fistula) without resolution of the fistula.

CONCLUSION

In cases of type I and II DAVFs associated with sinus stenosis, angioplasty and stenting alone seem to be safe and effective. This treatment probably compresses the venules within the sinus walls, promoting thrombosis of the shunts thus solving the underlying cause of the fistula.

Simultaneous Endovascular Treatment of Tandem Internal Carotid Lesions

The incidence of concomitant extracranial carotid artery stenosis and ipsilateral intracranial carotid aneurysm has been reported to vary between 2.8% and 5%. These complex lesions may present a challenge for treatment decision-making. This case report describes an asymptomatic male patient with severe carotid bifurcation stenosis, coupled with an unruptured supraclinoid internal carotid aneurysm. Both lesions were treated simultaneously. Patient underwent carotid stenting followed by aneurysm coiling in the same setting without any complication.

Endovascular treatment of distal cerebral aneurysms

Distal cerebral aneurysms are difficult to treat. Endovascular treatment (EVT) although challenging, in many cases allows sparing of the parent artery. If a deconstructive approach is necessary, EVT enables hyperselective catheterization with sacrificing only the branch on which aneurysm is located. Consequently much of the surrounding arterial circulation is spared. We describe our series of endovascularly treated distal cerebral aneurysms in 2009. This is a retrospective review of seven consecutive patients (five women) with eight distal cerebral aneurysms (four ruptured) who underwent embolization in 2009. Patient ages ranged from 44 to 69 years. Aneurysm size distribution was: seven small (0-10 mm) and one large (11-24 mm). Two aneurysms required a deconstructive approach. Embolization was performed with coils in six cases, and with liquid embolic material Onyx in two cases. Endovascular treatment was successful in all cases. Immediate angiograms revealed complete occlusion in six aneurysms, none with neck remnants, and incomplete occlusion in two aneurysms. On first follow-up (3-6 month) obtained in six patients, five aneurysms showed stabile occlusion, and one recanalization due to coil impaction. None of the patients died. One patient had neurological deficit GOS (Glasgow Outcome Scale) score three caused by parent artery occlusion, which gradually improved to GOS score 4. EVT is safe and effective technique for distal cerebral aneurysms.