cSDH carries a high morbidity, mortality, and healthcare resource burden.
Digital subtraction angiography is arguably the most valuable tool in the diagnosis and treatment of cerebrovascular disease. How benign is this procedure? Every fellow is taught their mentor’s semi-unique process of checking lines, clearing syringes, and preventing air embolism. Neurointerventional research is generally focused on safer technology, clinical outcomes, and quality improvement. Understanding air microemboli remains important for optimized neurointerventional practice. Studies from over 20 years ago first confirmed a high incidence of microemboli in cerebral angiography, but little has evolved in the techniques used to prepare and flush lines and syringes since. A prospective study in 1999 found new clinically-silent MRI diffusion weighted imaging (DWI) lesions in 23% of patients undergoing cerebral angiography.
Although patients with COVID-19 have a higher risk of acute ischemic stroke (AIS), the impact on stroke outcomes remains uncertain.
To determine the clinical outcomes of patients with AIS and COVID-19 (AIS-COVID+).
We performed a systematic review and meta-analysis following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Our protocol was registered with the International Prospective Register of Systematic Reviews (CRD42020211977). Systematic searches were last performed on June 3, 2021 in EMBASE, PubMed, Web-of-Science, Scopus, and CINAHL Databases. Inclusion criteria: (1) studies reporting outcomes on AIS-COVID+; (2) original articles published in 2020 or later; (3) study participants aged ≥18 years. Exclusion criteria: (1) case reports with <5 patients, abstracts, review articles; (2) studies analyzing novel interventions. Risk of bias was assessed using the Mixed Methods Appraisal Tool. Random-effects models estimated the pooled OR and 95% confidence intervals (95% CI) for mortality, modified Rankin Scale (mRS) score, length of stay (LOS), and discharge disposition.
Of the 43 selected studies, 46.5% (20/43) reported patients with AIS without COVID-19 (AIS-COVID–) for comparison. Random-effects model included 7294 AIS-COVID+ and 158 401 AIS-COVID–. Compared with AIS-COVID–, AIS-COVID+ patients had higher in-hospital mortality (OR=3.87 (95% CI 2.75 to 5.45), P<0.001), less mRS scores 0–2 (OR=0.53 (95% CI 0.46 to 0.62), P<0.001), longer LOS (mean difference=4.21 days (95% CI 1.96 to 6.47), P<0.001), and less home discharge (OR=0.31 (95% CI 0.21 to 0.47), P<0.001).
Patients with AIS-COVID had worse outcomes, with almost fourfold increased mortality, half the odds of mRS scores 0–2, and one-third the odds of home discharge. These findings confirm the significant impact of COVID-19 on early stroke outcomes.
Preliminary studies show that patients with large vessel occlusion (LVO) acute ischemic strokes have worse outcomes with concurrent COVID-19 infection. We investigated the outcomes for patients with LVO strokes undergoing mechanical thrombectomy (MT) with concurrent COVID-19 infection.
The National Inpatient Database (NIS) was used for our analysis. Patients in the year 2020 with an ICD-10 diagnosis code for acute ischemic stroke and procedural code for MT were included with and without COVID-19. Odds ratios (OR) were calculated using a logistic regression model with age, sex, stroke location, Elixhauser comorbidity score, and other patient variables deemed clinically relevant as covariates.
Patients in the COVID-19 group were younger (64.3±14.4 vs 69.4±14.5 years, P<0.001), had a higher rate of inpatient mortality (22.4% vs 10.1%, P<0.001), and a longer length of stay (10 vs 6 days, P<0.001). Patients with COVID-19 had higher odds of death (OR 2.78, 95% CI 2.11 to 3.65) and lower odds of a routine discharge (OR 0.65, 95% CI 0.48 to 0.89). There was no difference in the odds of subsequent stroke and cerebral hemorrhage, but patients with COVID-19 had statistically significantly higher odds of respiratory failure, pulmonary embolism, deep vein thrombosis, myocardial infarction, acute kidney injury, and sepsis.
Patients with LVOs undergoing MT within the 2020 NIS database had worse outcomes when co-diagnosed with COVID-19, likely due to non-neurological manifestations of COVID-19.
Among acute vertebrobasilar artery occlusion (VBAO) patients, successful reperfusion is a strong predictor of favorable outcomes. However, failed reperfusion (FR) with endovascular thrombectomy (EVT) in VBAO was observed to occur in 18–50% of cases. We aim to evaluate the safety and efficacy of rescue stenting (RS) for VBAO after failed EVT.
Patients with VBAO who received EVT were enrolled retrospectively. Propensity score matching was performed as the primary analysis to compare the outcomes between patients with RS and FR. Furthermore, a comparison between using the self-expanding stent (SES) and balloon-mounted stent (BMS) in the RS group was also conducted. The primary and secondary outcomes were defined as a 90-day modified Rankin Scale (mRS) score 0–3, and a 90-day mRS score 0–2, respectively. Safety outcomes included all-cause mortality at 90 days and symptomatic intracranial hemorrhage (sICH).
The RS group showed a significantly higher rate of 90-day mRS score 0–3 (46.6% vs 20.7%; adjusted OR (aOR) 5.06, 95% CI 1.88 to 13.59, P=0.001) and a lower rate of 90-day mortality (34.5% vs 55.2%; aOR 0.42, 95% CI 0.23 to 0.90, P=0.026) than the FR group. The rates of 90-day mRS score 0–2 and sICH were not significantly different between the RS group and FR group. There were no differences in all outcomes between SES and BMS groups.
RS appeared to be a safe and effective rescue approach in patients with VBAO who failed EVT, and there was no difference between using SES and BMS.
Thrombi retrieved from patients with acute ischemic stroke may contain prognostic information.
To investigate the relationship between the immunologic phenotype of thrombi and future vascular events in patients with a stroke.
This study included patients with acute ischemic stroke who underwent endovascular thrombectomy at Chung-Ang University Hospital in Seoul, Korea, between February 2017 and January 2020. Laboratory and histological variables were compared between patients with and without recurrent vascular events (RVEs). Kaplan–Meier analysis followed by the Cox proportional hazards model was used to identify factors related to RVE. Receiver operating characteristic (ROC) analysis was conducted to evaluate the performance of the immunologic score by combining immunohistochemical phenotypes to predict RVE.
A total of 46 patients were included in the study with 13 RVEs (mean±SD age, 72.8±11.3 years; 26 (56.5%) men). Thrombi with a lower percentage of programmed death ligand-1 expression (HR=11.64; 95% CI 1.60 to 84.82) and a higher number of citrullinated histone H3 positive cells (HR=4.19; 95% CI 0.81 to 21.75) were associated with RVE. The presence of high-mobility group box 1 positive cell was associated with reduced risk of RVE, but the association was lost after adjustment for stroke severity. The immunologic score, which consists of the three immunohistochemical phenotypes, showed good performance in predicting RVE (area under the ROC curve, 0.858; 95% CI 0.758 to 0.958).
The immunological phenotype of thrombi could provide prognostic information after stroke.
To evaluate the non-inferiority of endovascular treatment (EVT) alone versus intravenous thrombolysis (IVT) followed by EVT and to assess its heterogeneity across prespecified subgroups.
We pooled data from two trials (SKIP in Japan; DEVT in China). Individual patient data were pooled to assess outcomes and heterogeneity of treatment effect. The primary outcome was functional independence (modified Rankin Scale score 0–2) at 90 days. Safety outcomes included symptomatic intracranial hemorrhage (sICH) and 90-day mortality.
We included 438 patients (217 EVT alone; 221 combined IVT+EVT). The meta-analysis failed to demonstrate the non-inferiority of EVT alone over combined IVT+EVT in achieving 90-day functional independence (56.7% vs 51.6%; adjusted common odds ratio (cOR)=1.27, 95% CI 0.84 to 1.92, pnon-inferiority=0.06). Effect sizes favoring EVT alone were present with stroke onset to puncture time longer than 180 min (cOR=2.28, 95% CI 1.18 to 4.38, pinteraction ≤180 vs >180 min=0.02) and intracranial internal carotid artery ICA occlusions (for ICA cOR=3.04, 95% CI 1.10 to 8.43, pinteraction ICA vs MCA=0.08). The rates of sICH (6.5% vs 9.0%; cOR=0.77, 95% CI 0.37 to 1.61) and 90-day mortality (12.9% vs 13.6%; cOR=1.05, 95% CI 0.58 to 1.89) were comparable.
The cumulative data of these two recent Asian trials failed to unequivocally demonstrate the non-inferiority of EVT alone over combined IVT+EVT. However, our study suggests a potential role for more individualized decision-making. Specifically, Asian patients with stroke onset to EVT longer than 180 min, as well as those with intracranial ICA occlusions and those with atrial fibrillation might have better outcomes with EVT alone than with combined IVT+EVT.
Evidence on clinical outcome after endovascular treatment (EVT) vs neurosurgical clipping of intracranial aneurysms (IAs) is based on one randomized and one pseudo-randomized trial for ruptured aneurysms. Herein, we analyze nationwide real-world hospital outcomes after EVT vs clipping of ruptured and unruptured IAs.
This cohort study analyzed all EVT and clipping procedures for IAs in Germany between 2007 and 2019. The data basis was the billing-data of all German hospitals from the German Federal Statistical Office. EVT and clipping interventions, comorbidities, and in-hospital outcomes were identified using International Classification of Diseases (ICD) and Operation and Procedure (OPS) codes. Discharge type was used as a surrogate marker for functional independence. Poor clinical outcome at discharge was additionally defined by the dichotomous US National Inpatient Sample-Subarachnoid hemorrhage Outcome Measure score (NIH-SOM). Secondary outcomes included length of hospital stay, prolonged mechanical ventilation (>48 hour), and hospital reimbursement.
We analyzed 90 039 procedures (62.6% EVT, 35.52% clipping, 1.8% combined) for the treatment of IAs. After adjustment in-hospital mortality was equal after EVT compared with clipping, in ruptured IAs (adjusted OR (aOR) 0.98, p=0.707) and unruptured IAs (aOR 0.92, p=0.482). Functional independence was more likely after EVT for ruptured (aOR 0.81, p<0.001) and unruptured IAs (aOR 0.4, p<0.001). Poor clinical outcome was more likely after clipping for ruptured (aOR 0.67, p<0.001) and unruptured IAs (aOR 0.56, p<0.001).
In German clinical practice, we observed higher rates of functional independence and lower rates of poor outcomes at discharge with equal mortality for EVT.
Flow-diverting devices (FDDs), such as the Pipeline Embolization Device, have been gaining traction for treating challenging posterior circulation aneurysms. Few previous studies have focused on using FDDs to treat aneurysms of the basilar quadrifurcation.
We retrospectively reviewed the use of FDDs to treat patients with basilar quadrifurcation aneurysms. Patients were assessed for aneurysm type, previous aneurysm treatment, technical success, periprocedural complications, and long-term aneurysm occlusion.
34 patients were assessed; aneurysms of the basilar apex (n=23) or superior cerebellar artery (SCA) (n=7), or both (n=1), and posterior cerebral artery (PCA) (n=3). The mean (SD) largest aneurysm dimension was 8.7 (6.1) mm (range 1.9–30.8 mm). 14 aneurysms were previously surgically clipped or endovascularly coiled. All aneurysms had a saccular morphology. Complete or near-complete occlusion was achieved in 30 of 34 patients (88%) at final angiographic follow-up, a mean (SD) of 6.6 (5.4) months (range 0–19 months) postoperatively. No patient experienced postoperative symptomatic occlusions of the SCA or PCA; 4 patients developed asymptomatic posterior communicating artery occlusions; 28 patients (82%) experienced no complications; whereas 3 (9%) experienced major complications and 3 (9%) experienced minor complications; and 1 patient died as a result of subarachnoid hemorrhage.
Flow diversion may be a safe and effective option to treat basilar quadrifurcation aneurysms. Previously treated basilar quadrifurcation aneurysms with recurrence or residual lesion may benefit from additional treatment with an FDD. Further prospective studies should be directed toward validating these findings.
Stent assisted coiling (SAC) and flow diverters (FDs) are common endovascular treatments for wide necked cerebral aneurysms, but studies comparing the new generation Atlas SAC and FDs are scarce. We performed a propensity score matched (PSM) cohort study to compare the Atlas SAC and the pipeline embolization device (PED) for proximal internal carotid artery (ICA) aneurysms.
Consecutive ICA aneurysms treated at our institution with either the Atlas SAC or PED were studied. PSM was used to control for age, sex, smoking, hypertension, and hyperlipidemia, and the rupture status, maximal diameter, and neck size of the aneurysm (aneurysms >15 mm and non-saccular aneurysms were excluded). Midterm outcomes and hospital costs were compared between these two devices.
A total of 309 patients with 316 ICA aneurysms were included. Following PSM, 178 aneurysms treated with the Atlas SAC and PED were matched (n=89 in each group). Aneurysms treated with the Atlas SAC required a slightly longer procedure time, but had lower hospital costs than those treated with the PED (115.2±24.6 vs 102.4±40.8 min, P=0.012; $27 650.2±$6961.4 vs $34 107.0±$3707.2, P<0.001). Atlas SAC and PED treatments showed equivalent aneurysm occlusion rates (89.9% vs 86.5%, P=0.486), complication rates (5.6% vs 11.2%, P=0.177), and a favorable functional outcome (96.6% vs 97.8%, P=1.0) at follow-up (8.2±3.0 vs 8.4±4.2 months, P=0.652).
In this PSM study, midterm outcomes of the PED and Atlas SAC in the treatment of ICA aneurysms were similar. However, SAC required a longer operation time, and the PED may increase the economic cost of inpatients in Beijing, China.
The Pipeline Flex embolization device with Shield technology (PED Shield) is the first flow diverter for brain aneurysm treatment approved in the United States using surface-modified technology. The effect of PED Shield on decreasing perioperative diffusion-weighted imaging positive (DWI+) hits, as a marker for in-human decrease thrombogenicity, is unclear.
To determine if the number of periprocedural DWI+ lesions differs between patients with an aneurysm treated with PED Flex and PED Shield.
This retrospective study compares the outcomes of consecutive patients with an aneurysm treated with PED Flex and PED Shield. The primary outcome of interest was the occurrence of DWI+ lesions. We also assessed potential predictors of DWI+ lesions and compared the outcomes between on-label and off-label treatment indications.
89 patients were included, 48 (54%) treated with PED Flex and 41 (46%) with PED Shield. After matching, the incidence of DWI+ lesions was 61% and 62% for the PED Flex and PED Shield groups, respectively. Results were consistent across each model with no significant differences in DWI+ lesions between treatment groups, and effect sizes ranging from OR=1.08 (95% CI 0.41 to 2.89) after propensity score matching to OR=1.84 (95% CI 0.65 to 5.47) after multivariable regression. Multivariable models demonstrated reduced DWI+ lesions with balloon-assisted therapies and posterior circulation treatment, while a significant linear relationship was encountered with fluoroscopy time.
There was no significant difference in the incidence of perioperative DWI+ lesions between patients with an aneurysm treated with PED Flex and PED Shield. Larger cohorts are likely needed to demonstrate differences between the devices.
The presence of blebs increases the rupture risk of intracranial aneurysms (IAs).
To evaluate whether cross-sectional bleb formation models can identify aneurysms with focalized enlargement in longitudinal series.
Hemodynamic, geometric, and anatomical variables derived from computational fluid dynamics models of 2265 IAs from a cross-sectional dataset were used to train machine learning (ML) models for bleb development. ML algorithms, including logistic regression, random forest, bagging method, support vector machine, and K-nearest neighbors, were validated using an independent cross-sectional dataset of 266 IAs. The models' ability to identify aneurysms with focalized enlargement was evaluated using a separate longitudinal dataset of 174 IAs. Model performance was quantified by the area under the receiving operating characteristic curve (AUC), the sensitivity and specificity, positive predictive value, negative predictive value, F1 score, balanced accuracy, and misclassification error.
The final model, with three hemodynamic and four geometrical variables, along with aneurysm location and morphology, identified strong inflow jets, non-uniform wall shear stress with high peaks, larger sizes, and elongated shapes as indicators of a higher risk of focal growth over time. The logistic regression model demonstrated the best performance on the longitudinal series, achieving an AUC of 0.9, sensitivity of 85%, specificity of 75%, balanced accuracy of 80%, and a misclassification error of 21%.
Models trained with cross-sectional data can identify aneurysms prone to future focalized growth with good accuracy. These models could potentially be used as early indicators of future risk in clinical practice.
Retinoblastoma (Rb) is the most common primary ocular malignancy of childhood. Left untreated, it is 100% fatal and carries a substantial risk of impaired vision and removal of one or both eyes. Intra-arterial chemotherapy (IAC) has become a pillar in the treatment paradigm for Rb that allows for better eye salvage and vision preservation without compromising survival. We describe the evolution of our technique over 15 years.
A retrospective chart review was conducted of 571 patients (697 eyes) and 2391 successful IAC sessions over 15 years. This cohort was separated into three 5-year periods (P1, P2, P3) to assess trends in IAC catheterization technique, complications, and drug delivery.
From a total of 2402 attempted IAC sessions, there were 2391 successful IAC deliveries, consistent with a 99.5% success rate. The rate of successful super-selective catheterizations over the three periods ranged from 80% in P1 to 84.9% in P2 and 89.2% in P3. Catheterization-related complication rates were 0.7% in P1, 1.1% in P2, and 0.6% in P3. Chemotherapeutics used included combinations of melphalan, topotecan and carboplatin. The rate of patients receiving triple therapy among all groups was 128 (21%) in P1, 487 (41.9%) in P2, and 413 (66.7%) in P3.
The overall rate of successful catheterization and IAC started high and has improved over 15 years, and catheterization-related complications are rare. There has been a significant trend towards triple chemotherapy over time.
Robotic-assisted neurointervention was recently introduced, with implications that it could be used to treat neurovascular diseases.
To evaluate the effectiveness and safety of the robotic-assisted platform CorPath GRX for treating cerebral aneurysms.
This prospective, international, multicenter study enrolled patients with brain aneurysms that required endovascular coiling and/or stent-assisted coiling. The primary effectiveness endpoint was defined as successful completion of the robotic-assisted endovascular procedure without any unplanned conversion to manual treatment with guidewire or microcatheter navigation, embolization coil(s) or intracranial stent(s) deployment, or an inability to navigate vessel anatomy. The primary safety endpoint included intraprocedural and periprocedural events.
The study enrolled 117 patients (74.4% female) with mean age of 56.6 years from 10 international sites. Headache was the most common presenting symptom in 40/117 (34.2%) subjects. Internal carotid artery was the most common location (34/122, 27.9%), and the mean aneurysm height and neck width were 5.7±2.6 mm and 3.5±1.4 mm, respectively. The overall procedure time was 117.3±47.3 min with 59.4±32.6 min robotic procedure time. Primary effectiveness was achieved in 110/117 (94%) subjects with seven subjects requiring conversion to manual for procedure completion. Only four primary safety events were recorded with two intraprocedural aneurysm ruptures and two strokes. A Raymond-Roy Classification Scale score of 1 was achieved in 71/110 (64.5%) subjects, and all subjects were discharged with a modified Rankin Scale score of ≤2.
This first-of-its-kind robotic-assisted neurovascular trial demonstrates the effectiveness and safety of the CorPath GRX System for endovascular embolization of cerebral aneurysm procedures.
Despite the growing sophistication of robot-assisted surgery, it is necessary to demonstrate that robots can reliably perform complex procedures on site and then remotely. Although a flow diverter stent is one of the most effective and widely used devices, its placement is sometimes challenging.
To evaluate the feasibility and safety of the CorPath GRX robotic platform for the embolization of cerebral and cervical aneurysms using flow diverter stents.
We performed a single-center technical study of the first 10 flow diverter stent deployments with the CorPath GRX Robotic System (Corindus Inc, Waltham, Massachusetts, USA) for the treatment of cerebral aneurysms between April and October 2022.
Ten patients underwent robot-assisted embolization with flow diverter stents: there were nine intracranial aneurysms (paraclinoid n=6; posterior communicating artery aneurysm n=1; anterior communicating artery n=2) and one cervical aneurysm. Four procedures were performed with coils plus a flow diverter stent, one was performed with woven endobridge plus a flow diverter stent and four were performed with flow diverter stents alone. Of these procedures, two were performed with telescoping flow diverters.
All flow diverter stents were deployed with robotic assistance, with only one partial conversion to a manual technique (caused by guidewire torquability limitations). No perioperative complications were observed.
Robot-assisted flow diverter stent deployment using the CorPath GRX platform is feasible and appears to be safe. Larger, in-depth studies of the technique’s safety and benefits are now warranted.
Administrative databases are adequate for comparing specific and relatively homogeneous elements within pathologies or treatment modalities over time, such as observing broad trends. These types of data are meant for billing and reimbursement, and not clinical studies. Studies using these databases for clinical outcomes must be very narrow in scope to overcome this limitation.
In this study, missing information includes aneurysm location, aneurysm size, why a treatment was chosen, whether a pathology was a comorbidity or...]]>
First, the authors point out and nicely describe a major limitation of our study
We fully agree with this major limitation of our study. When conducting the study we were aware of this limitation and included two paragraphs describing details of it in the Limitations section at the end of the discussion. Furthermore, we decided against sophisticated matching or weighting methods but showed unadjusted ORs as well as ORs that were adjusted for age, sex, the Charlson index and year of treatment only....]]>
However, we would like to highlight some concerns about the methodology of the study. Heterogeneity is defined as observed intervention effects being more different from each other than one would expect due to random error (chance) alone.