Dear Editor,
I am writing to address the significant findings presented in the article "Short- versus long-term Dual AntiPlatelet Therapy for Stent-Assisted treatment of CErebral aneurysm (DAPTS ACE)." This research, a randomized clinical trial aimed at unraveling the ideal duration of Dual AntiPlatelet Therapy (DAPT) after stent-assisted coil embolization (SACE) for cerebral aneurysms, raises crucial questions regarding the management of these delicate cases.
The article reports that the trial, DAPTS ACE, investigated whether extending DAPT for 12 months could effectively reduce the risk of ischemic stroke in comparison to a shorter 3-month DAPT regimen for patients who underwent SACE for cerebral aneurysms. The study, conducted in 17 hospitals in Japan, enrolled 142 patients between November 4, 2016, and January 7, 2019, and assigned them randomly to either the long-term or short-term DAPT group. The primary outcome was the occurrence of ischemic stroke events during the period of 3 to 12 months after SACE.
The results are undeniably important, as they indicate that there was no statistically significant difference in the rate of ischemic strokes between the long-term and short-term DAPT groups. In fact, ischemic stroke was a rare occurrence in both groups, and the data show that the extended duration of DAPT did not offer a significant advantage in preventing ischemic events. This is the first randomized controlled trial to tackle the duratio...
Dear Editor,
I am writing to address the significant findings presented in the article "Short- versus long-term Dual AntiPlatelet Therapy for Stent-Assisted treatment of CErebral aneurysm (DAPTS ACE)." This research, a randomized clinical trial aimed at unraveling the ideal duration of Dual AntiPlatelet Therapy (DAPT) after stent-assisted coil embolization (SACE) for cerebral aneurysms, raises crucial questions regarding the management of these delicate cases.
The article reports that the trial, DAPTS ACE, investigated whether extending DAPT for 12 months could effectively reduce the risk of ischemic stroke in comparison to a shorter 3-month DAPT regimen for patients who underwent SACE for cerebral aneurysms. The study, conducted in 17 hospitals in Japan, enrolled 142 patients between November 4, 2016, and January 7, 2019, and assigned them randomly to either the long-term or short-term DAPT group. The primary outcome was the occurrence of ischemic stroke events during the period of 3 to 12 months after SACE.
The results are undeniably important, as they indicate that there was no statistically significant difference in the rate of ischemic strokes between the long-term and short-term DAPT groups. In fact, ischemic stroke was a rare occurrence in both groups, and the data show that the extended duration of DAPT did not offer a significant advantage in preventing ischemic events. This is the first randomized controlled trial to tackle the duration of DAPT following SACE for intracranial aneurysms.
The study's findings underscore a critical point of discussion among neurointerventionalists. With the expanded use of stents for treating cerebral aneurysms, the challenge of thromboembolic complications has come to the forefront. While DAPT, combining aspirin and clopidogrel, is considered a standard regimen post-SACE, the optimal duration has remained a matter of conjecture. Various studies have explored different timeframes, from 3 months to 6 months to 9 months or more, with varying conclusions. The debate extends to the potential hemorrhagic complications associated with DAPT.
The DAPTS ACE trial brings us one step closer to addressing these uncertainties. One of the reasons cited for the lack of significant differences in outcomes is the diminishing rate of delayed thromboembolic events after SACE, largely due to advancements in stent technology. As the study indicates, the event rate was low and similar between the randomized and non-randomized cohorts, implying that the choice of enrollment may not significantly affect the results.
Moreover, the discussion delves into the importance of individualized patient therapy, particularly in terms of platelet function testing. The study highlights the significance of understanding individual variations, especially in response to clopidogrel, which is affected by genetic polymorphism. Therefore, platelet aggregation testing plays a crucial role in optimizing patient care.
While this trial offers invaluable insights, it's essential to acknowledge its limitations. The small sample size and the number of patients who achieved the primary endpoint were lower than expected. Larger studies are warranted to delve deeper into the benefits of long-term DAPT after SACE. Furthermore, the post-procedure timing of registration could have introduced some selection bias, as high-risk cases might have been avoided. However, it's noteworthy that the event rate in the non-randomized cohort was also low.
In conclusion, the DAPTS ACE trial represents a significant step in the quest to determine the ideal duration of DAPT following SACE for cerebral aneurysms. While it doesn't provide a clear verdict, it contributes significantly to the ongoing discussion in the field. The implications are not only relevant for neurointerventionalists but also for the patients who depend on these treatments. As we await further studies with larger cohorts, this research sheds light on the complexity of patient care in the realm of cerebral aneurysm treatment.
I am writing to express my appreciation for the recent publication of the multicenter study entitled "Non-ischemic cerebral enhancing (NICE) lesions after flow diversion for intracranial aneurysms: a multicenter study." The investigation sheds light on a relatively underexplored aspect of neuroendovascular procedures and provides valuable insights into the incidence, clinical presentation, and potential device-related factors associated with NICE lesions.
The study, conducted across eight centers, presents a meticulous analysis of 15 patients with NICE lesions following flow diversion. Notably, the reported incidence of 1% raises concerns given its contrast with rates observed in previous studies on various neuroendovascular procedures. This finding underscores the need for a closer examination of the potential risks and implications of flow diversion in the context of NICE lesions.
One of the notable contributions of this study is the identification of a concerning accumulation of NICE lesion cases associated with specific product lines—Pipeline devices and Derivo devices. While the study rules out the device material itself as the exclusive culprit, the hypotheses put forth regarding mechanical properties, vendor-specific catheters, and the call for further bench testing and transparent disclosure of technical details add depth to the discussion. This nuanced exploration of potential contributing factors sets the stage for more...
I am writing to express my appreciation for the recent publication of the multicenter study entitled "Non-ischemic cerebral enhancing (NICE) lesions after flow diversion for intracranial aneurysms: a multicenter study." The investigation sheds light on a relatively underexplored aspect of neuroendovascular procedures and provides valuable insights into the incidence, clinical presentation, and potential device-related factors associated with NICE lesions.
The study, conducted across eight centers, presents a meticulous analysis of 15 patients with NICE lesions following flow diversion. Notably, the reported incidence of 1% raises concerns given its contrast with rates observed in previous studies on various neuroendovascular procedures. This finding underscores the need for a closer examination of the potential risks and implications of flow diversion in the context of NICE lesions.
One of the notable contributions of this study is the identification of a concerning accumulation of NICE lesion cases associated with specific product lines—Pipeline devices and Derivo devices. While the study rules out the device material itself as the exclusive culprit, the hypotheses put forth regarding mechanical properties, vendor-specific catheters, and the call for further bench testing and transparent disclosure of technical details add depth to the discussion. This nuanced exploration of potential contributing factors sets the stage for more targeted research and a deeper understanding of the mechanisms behind NICE lesions.
The acknowledgment of study limitations, including its retrospective nature, reduced external validity, and potential selection bias due to a limited response from centers, is commendable. These limitations are crucial to consider when interpreting the findings, and the authors' emphasis on the need for a large prospective study with standardized protocols and treatment regimens is well-placed. Such an approach would not only address potential biases but also provide a more robust foundation for clinical decision-making.
The study's exploration of the diverse clinical manifestations of NICE lesions, ranging from asymptomatic findings to seizures and focal neurological deficits, adds a layer of complexity to the clinical management of these lesions. The lack of standardized recommendations for treating asymptomatic cases raises important questions about the optimal approach to care and prompts consideration of long-term immunosuppression in symptomatic cases.
In conclusion, this study significantly advances our understanding of NICE lesions following flow diversion, highlighting the need for ongoing research, transparent disclosure of technical details, and a comprehensive prospective study to validate findings and guide clinical management. I commend the authors for their contribution to the field and look forward to future research endeavors that build upon these critical insights.
Dear Editor,
I am writing to provide a thorough assessment of the recently published study titled "Cost-effectiveness of Endovascular Therapy for Acute Stroke with a Large Ischemic Region in Japan: Impact of the Alberta Stroke Program Early CT Score on Cost-effectiveness" [1]. While the study addresses important aspects of the economic implications of endovascular therapy (EVT) for acute ischemic stroke (AIS) in Japan, my analysis aims to delve deeper into specific methodological considerations and discuss the applicability of the study's findings in a broader context.
The primary focus of the study is the cost-effectiveness of EVT based on the Alberta Stroke Program Early CT Score (ASPECTS) for patients with AIS involving a large ischemic region. The conclusion that EVT is cost-effective for individuals with ASPECTS of 3–5 as determined by treating neurologists using MRI raises questions about the reliability and consistency of ASPECTS as a determinant of cost-effectiveness. Furthermore, the study acknowledges the variability in incremental costs and quality-adjusted life years (QALYs) associated with EVT in Japan compared to other countries. The higher incremental costs in Japan, attributed to the specific stroke care system and the frequent use of combined techniques and MRI, present challenges when applying these findings to healthcare systems with different cost structures and resource allocations.
The study acknowledges the variabilit...
Dear Editor,
I am writing to provide a thorough assessment of the recently published study titled "Cost-effectiveness of Endovascular Therapy for Acute Stroke with a Large Ischemic Region in Japan: Impact of the Alberta Stroke Program Early CT Score on Cost-effectiveness" [1]. While the study addresses important aspects of the economic implications of endovascular therapy (EVT) for acute ischemic stroke (AIS) in Japan, my analysis aims to delve deeper into specific methodological considerations and discuss the applicability of the study's findings in a broader context.
The primary focus of the study is the cost-effectiveness of EVT based on the Alberta Stroke Program Early CT Score (ASPECTS) for patients with AIS involving a large ischemic region. The conclusion that EVT is cost-effective for individuals with ASPECTS of 3–5 as determined by treating neurologists using MRI raises questions about the reliability and consistency of ASPECTS as a determinant of cost-effectiveness. Furthermore, the study acknowledges the variability in incremental costs and quality-adjusted life years (QALYs) associated with EVT in Japan compared to other countries. The higher incremental costs in Japan, attributed to the specific stroke care system and the frequent use of combined techniques and MRI, present challenges when applying these findings to healthcare systems with different cost structures and resource allocations.
The study acknowledges the variability in incremental costs and quality-adjusted life years (QALYs) associated with EVT in Japan compared to other countries. The higher incremental costs in Japan, attributed to the specific stroke care system and the frequent use of combined techniques and MRI, pose challenges when applying these findings to healthcare systems with different cost structures and resource allocations.
The discussion on the impact of baseline ASPECTS on cost-effectiveness draws parallels with a study conducted in the United States, suggesting that EVT for ASPECTS of 3 may not be cost-effective. However, caution is warranted when extrapolating these results to other countries due to substantial differences in patient characteristics, imaging modalities, and device strategies.
The study appropriately emphasizes the increasing importance of considering economic aspects as medical technology becomes more sophisticated and expensive, especially in aging populations. The adoption of cost-effectiveness analyses by the Central Social Insurance Medical Council in Japan reflects a growing awareness of the need to align healthcare expenditures with the value provided by medical technologies.
Nevertheless, the study's limitation in not examining the impact of various patient characteristics, such as age, time from stroke onset, stroke severity, and the involvement of eloquent areas, on the cost-effectiveness of EVT is a notable gap. Future research in this direction is crucial for understanding the nuanced factors that contribute to the economic viability of EVT in different patient cohorts.
In conclusion, while the study contributes valuable insights into the cost-effectiveness of EVT for a specific subgroup of stroke patients in Japan, its findings should be interpreted with caution when considering their broader applicability. Further research is needed to explore the generalizability of these conclusions to diverse healthcare settings and patient populations.
Reference:
1. Egashira S, Shin J, Yoshimura S, et alCost-effectiveness of endovascular therapy for acute stroke with a large ischemic region in Japan: impact of the Alberta Stroke Program Early CT Score on cost-effectivenessJournal of NeuroInterventional Surgery Published Online First: 10 December 2023. doi: 10.1136/jnis-2023-021068
Dear Editor,
I would like to commend the authors for their insightful study titled "Liquid embolic surface area as a predictor of chronic subdural hematoma resolution in middle meningeal artery embolization" [1]. The investigation into the correlation between liquid embolic surface area (LEA SA) and chronic subdural hematoma (cSDH) resolution in the context of middle meningeal artery embolization (MMAE) presents valuable contributions to the field. The authors employed a meticulous approach, retrospectively collecting data from 74 patients who underwent first-line MMAE with ethylene vinyl alcohol (EVOH) and utilizing 3D segmentation to quantify LEA SA. The observed correlation between greater LEA SA and enhanced cSDH resolution rates at 3 months and 6 months post-embolization is a noteworthy contribution to the field.
The study's strength lies in its unique focus on a patient group undergoing first-line MMAE for cSDH, a subset that has been relatively underrepresented in the existing literature. The authors rightly acknowledge the potential selection bias in this group, considering patients with greater midline shift or poor neurologic exams might be directed immediately to surgical treatment. Nonetheless, the results support the utilization of upfront MMAE in patients with riskier surgical profiles due to comorbidities or borderline radiographic and clinical features.
However, it is essential to scrutinize the limitations outlined by the a...
Dear Editor,
I would like to commend the authors for their insightful study titled "Liquid embolic surface area as a predictor of chronic subdural hematoma resolution in middle meningeal artery embolization" [1]. The investigation into the correlation between liquid embolic surface area (LEA SA) and chronic subdural hematoma (cSDH) resolution in the context of middle meningeal artery embolization (MMAE) presents valuable contributions to the field. The authors employed a meticulous approach, retrospectively collecting data from 74 patients who underwent first-line MMAE with ethylene vinyl alcohol (EVOH) and utilizing 3D segmentation to quantify LEA SA. The observed correlation between greater LEA SA and enhanced cSDH resolution rates at 3 months and 6 months post-embolization is a noteworthy contribution to the field.
The study's strength lies in its unique focus on a patient group undergoing first-line MMAE for cSDH, a subset that has been relatively underrepresented in the existing literature. The authors rightly acknowledge the potential selection bias in this group, considering patients with greater midline shift or poor neurologic exams might be directed immediately to surgical treatment. Nonetheless, the results support the utilization of upfront MMAE in patients with riskier surgical profiles due to comorbidities or borderline radiographic and clinical features.
However, it is essential to scrutinize the limitations outlined by the authors and contemplate potential strategies for addressing these constraints in future work. The retrospective nature of the study introduces inherent biases and limitations associated with patient selection. The inclusion of patients who underwent MMAE as a first-line therapy may skew the results, as this subgroup may not have as sizable hematomas as those managed with surgery initially. To overcome this limitation, future studies should be designed in a prospective manner with clinical equipoise, allowing for a more comprehensive and unbiased comparison between MMAE and surgical management. This would help in better understanding the relative efficacy of MMAE in different patient populations.
The study's focus on radiographic data is another limitation, as it did not include crucial clinical datapoints such as hematologic laboratory values, corticosteroid usage, antiplatelet or anticoagulation therapy, the etiology of cSDH, and comorbidities. Future research endeavors could benefit from incorporating a more comprehensive set of clinical parameters to provide a holistic understanding of the factors influencing cSDH resolution.
A notable limitation highlighted by the authors is the absence of pre-embolization DynaCT scans in the segmentation process, leading to potential artifacts from overlying bone. To enhance the accuracy of LEA SA calculation and verification, future studies should consider including both pre- and post-DynaCT scans. This approach would mitigate the impact of artifacts and provide a clearer understanding of LEA penetration into the microvasculature of the subdural membranes.
The authors' acknowledgment of these limitations demonstrates their commitment to transparency and scientific rigor. As we move forward, the field could benefit from collaborative efforts to standardize imaging protocols, ensuring consistency and comparability across studies. Additionally, exploring advanced imaging or reconstruction methods, such as dual-energy CT or secondary reconstructions with a smaller volume of interest, could further enhance the precision of LEA SA measurements.
In conclusion, while celebrating the significant insights derived from this study, it is crucial to recognize the outlined limitations as opportunities for improvement. Addressing these limitations in future research endeavors will not only strengthen the robustness of findings but also contribute to advancing the understanding of the intricate interplay between LEA SA and cSDH resolution in the context of MMAE.
Reference
1. John K, Syed S, Kaestner T, et alLiquid embolic surface area as a predictor of chronic subdural hematoma resolution in middle meningeal artery embolizationJournal of NeuroInterventional Surgery Published Online First: 28 November 2023.
I am writing to discuss the recent article titled "Incidence of intracranial hemorrhagic complications after anterior circulation endovascular thrombectomy in relation to occlusion site: a nationwide observational register study" (1). This study provides valuable insights into intracranial hemorrhage (ICH) as a potential complication of endovascular thrombectomy (EVT) in patients with anterior circulation vessel occlusion stroke. The authors conducted a comprehensive analysis, considering different occlusion sites and their associations with the incidence and severity of ICH, specifically symptomatic (sICH) and non-symptomatic (non-sICH) cases. While the study presents crucial findings, it is essential to discuss its implications and limitations.
The study's key finding of a 4.5% incidence of sICH after EVT for anterior circulation vessel occlusion stroke is consistent with previous research in this area. The recognition of differences in the frequency and severity of ICH across occlusion sites, particularly in the internal carotid artery (ICA), middle cerebral artery's first segment (M1), and the M2 and beyond, is a significant contribution to our understanding of EVT outcomes. The study suggests that ICA occlusions, despite their lower overall hemorrhage frequency, tend to result in more severe ICH, including intraventricular hemorrhages and space-occupying intracerebral hemorrhages. This observation aligns with prior stud...
I am writing to discuss the recent article titled "Incidence of intracranial hemorrhagic complications after anterior circulation endovascular thrombectomy in relation to occlusion site: a nationwide observational register study" (1). This study provides valuable insights into intracranial hemorrhage (ICH) as a potential complication of endovascular thrombectomy (EVT) in patients with anterior circulation vessel occlusion stroke. The authors conducted a comprehensive analysis, considering different occlusion sites and their associations with the incidence and severity of ICH, specifically symptomatic (sICH) and non-symptomatic (non-sICH) cases. While the study presents crucial findings, it is essential to discuss its implications and limitations.
The study's key finding of a 4.5% incidence of sICH after EVT for anterior circulation vessel occlusion stroke is consistent with previous research in this area. The recognition of differences in the frequency and severity of ICH across occlusion sites, particularly in the internal carotid artery (ICA), middle cerebral artery's first segment (M1), and the M2 and beyond, is a significant contribution to our understanding of EVT outcomes. The study suggests that ICA occlusions, despite their lower overall hemorrhage frequency, tend to result in more severe ICH, including intraventricular hemorrhages and space-occupying intracerebral hemorrhages. This observation aligns with prior studies and may be attributed to various factors, including the larger affected brain area and differences in vascular supply.
The study emphasizes the complexity of managing blood pressure following EVT, as it plays a critical role in achieving optimal reperfusion while minimizing the risk of adverse events, particularly in cases involving proximal vessel occlusions. Furthermore, the authors shed light on the administration of antithrombotic medication during EVT for ICA occlusions and its potential impact on sICH. This is particularly relevant given the rising concern regarding the risk of hemorrhagic complications associated with procedural antithrombotic medication.
The findings regarding EVT for occlusions in the M2 and beyond are promising, with a relatively lower incidence of sICH. The study suggests room for improvement in revascularization efficacy for these distal vessels. This is a significant consideration as it indicates that EVT should not be discouraged for the treatment of more distal vascular domains within the middle cerebral artery territory.
However, it is crucial to acknowledge the study's limitations. The definition of sICH in this study differs from the Heidelberg Bleeding Classification, which may affect the frequency of sICH cases. The categorization of sICH and δ-NIHSS was not complete in the registry, which might result in an underestimation of sICH. Additionally, the use of a modified ASPECT score for the estimation of the affected brain area is subject to inherent limitations, and further research may benefit from a more precise approach.
In conclusion, this study provides valuable insights into the incidence and severity of ICH following EVT for anterior circulation vessel occlusion stroke, with a particular focus on different occlusion sites. The findings have important implications for clinical practice, especially in managing blood pressure and antithrombotic medication during and after EVT. While the study's limitations should be considered, its contributions to our understanding of EVT outcomes are noteworthy and may guide future research in this area.
References:
1. Hall E, Ullberg T, Andsberg G, et alIncidence of intracranial hemorrhagic complications after anterior circulation endovascular thrombectomy in relation to occlusion site: a nationwide observational register studyJournal of NeuroInterventional Surgery Published Online First: 05 October 2023. doi: 10.1136/jnis-2023-020768
We have read with great interest the article entitled “Efficacy and mid-term outcome of middle meningeal artery embolization with or without burr hole evacuation for chronic subdural hematoma compared with burr hole evacuation alone” by Onyinzo, C., et al, published in Journal of NeuroInterventional Surgery (2021).
The article has compared the Surgical and Endovascular management of (CSDH) in the elderly population who are at high risk to developing (CSDH) due to their co-morbidities and the use of anti-thrombotic agents.
It is noted that the anti-thrombotic agents were stopped to both management arms. Upfront Middle meningeal artery embolization without stopping the anti-thrombotics, might be a strategy to mitigate the risk of cardio-embolic events.
In regards to the evaluation of the patients outcome, clinical parameters did not include motor assessment, which is a significant factor to favor a rapid surgical evacuation in these delicate patients.
As to the radiological follow up, cured (CSDH) were defined in the article with a thickness less than 10 mm. This is debatable as there are a lot of variations exists for this population in regards to brain volume and brain elasticity.
Finally, we would like to point out the timing of the follow up was not defines for all patients. This need to be harmonized better to a well-defined follow up timeline. Joyce, MD, et al,2 a suggested a time frame of 6 weeks after the treatment...
We have read with great interest the article entitled “Efficacy and mid-term outcome of middle meningeal artery embolization with or without burr hole evacuation for chronic subdural hematoma compared with burr hole evacuation alone” by Onyinzo, C., et al, published in Journal of NeuroInterventional Surgery (2021).
The article has compared the Surgical and Endovascular management of (CSDH) in the elderly population who are at high risk to developing (CSDH) due to their co-morbidities and the use of anti-thrombotic agents.
It is noted that the anti-thrombotic agents were stopped to both management arms. Upfront Middle meningeal artery embolization without stopping the anti-thrombotics, might be a strategy to mitigate the risk of cardio-embolic events.
In regards to the evaluation of the patients outcome, clinical parameters did not include motor assessment, which is a significant factor to favor a rapid surgical evacuation in these delicate patients.
As to the radiological follow up, cured (CSDH) were defined in the article with a thickness less than 10 mm. This is debatable as there are a lot of variations exists for this population in regards to brain volume and brain elasticity.
Finally, we would like to point out the timing of the follow up was not defines for all patients. This need to be harmonized better to a well-defined follow up timeline. Joyce, MD, et al,2 a suggested a time frame of 6 weeks after the treatment and then at 90 days
We believe these points will bridge the findings of the authors to the real-world practice, by accounting for more clinical and radiological parameters to consolidate recommendations of practice.
References
Catapano, J. S., Nguyen, C., Wakim, A., Albuquerque, F., & Ducruet, A. (2020). Joshua S. Catapano. Frontiers in Neurology , 11. https://doi.org/10.3389/fneur.2020.557233
Joyce, E., Bounajem, M. T., Scoville, J., Thomas, A. J., Ogilvy, C. S., Riina, H. A., Tanweer, O., Levy, E. I., Spiotta, A. M., Gross, B. A., Jankowitz, B. T., Cawley, C. M., Khalessi, A. A., Pandey, A. S., Ringer, A. J., Hanel, R., Ortiz, R. A., Langer, D., Levitt, M. R., … Grandhi, R. (2020). Middle meningeal artery embolization treatment of nonacute subdural hematomas in the elderly: a multiinstitutional experience of 151 cases. Neurosurgical Focus, 49(4). https://doi.org/10.3171/2020.7.focus20518
Jumah, F., Osama, M., Islim, A. I., Jumah, A., Patra, D. P., Kosty, J., Narayan, V., Nanda, A., Gupta, G., & Dossani, R. H. (2020). Efficacy and safety of middle meningeal artery embolization in the management of refractory or chronic subdural hematomas: a systematic review and meta-analysis. Acta Neurochirurgica, 162(3), 499–507. https://doi.org/10.1007/s00701-019-04161-3
Srivatsan, A., Mohanty, A., Nascimento, F. A., Hafeez, M. U., Srinivasan, V. M., Thomas, A., Chen, S. R., Johnson, J. N., & Kan, P. (2019). Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: Meta-Analysis and Systematic Review. World Neurosurgery, 122, 613–619. https://doi.org/10.1016/j.wneu.2018.11.167
I read with interest the paper by Pierot et al [1]. They conducted a prospective study to examine factors of delayed thromboembolic events in 335 patients after coiling of unruptured intracranial aneurysms. The number of delayed TEEs was 8. The adjusted odds ratios (95% confidence intervals) of autosomal dominant polycystic kidney disease and post-procedure aneurysm remnant at procedure completion for delayed TEEs were 27.3 (3.9 to 190.2) and 9.9 (1.0 to 51.3), respectively. They understand the lack of statistical power in the multivariate analysis and did not intend to examine the causal association. I present a comment regarding the number of events in logistic regression analysis.
The limitation in the total number of events for logistic regression analysis was simulated to improve statistical power [2]. In addition, Peduzzi et al. evaluated the effect of the number of events per variable (EPV) on the outcome in logistic regression analysis [3], concluding that the number of EPV less than 10 has some problems for the prediction of dependent variable. There is an opinion that EPV value less than 10 is also acceptable to evaluate the association by logistic regression analysis [4]. Pierot et al. observed 8 events, which was not appropriate for multivariate analysis even for examining the association instead of prediction in a prospective study. I think that wide ranges of 95% confidence intervals may reflect unstable estimates in a logistic regr...
I read with interest the paper by Pierot et al [1]. They conducted a prospective study to examine factors of delayed thromboembolic events in 335 patients after coiling of unruptured intracranial aneurysms. The number of delayed TEEs was 8. The adjusted odds ratios (95% confidence intervals) of autosomal dominant polycystic kidney disease and post-procedure aneurysm remnant at procedure completion for delayed TEEs were 27.3 (3.9 to 190.2) and 9.9 (1.0 to 51.3), respectively. They understand the lack of statistical power in the multivariate analysis and did not intend to examine the causal association. I present a comment regarding the number of events in logistic regression analysis.
The limitation in the total number of events for logistic regression analysis was simulated to improve statistical power [2]. In addition, Peduzzi et al. evaluated the effect of the number of events per variable (EPV) on the outcome in logistic regression analysis [3], concluding that the number of EPV less than 10 has some problems for the prediction of dependent variable. There is an opinion that EPV value less than 10 is also acceptable to evaluate the association by logistic regression analysis [4]. Pierot et al. observed 8 events, which was not appropriate for multivariate analysis even for examining the association instead of prediction in a prospective study. I think that wide ranges of 95% confidence intervals may reflect unstable estimates in a logistic regression analysis.
Their study is important for clarifying risk factors of delayed thromboembolic events even though the prevalence of adverse effect is low. I recommend that EPV should be kept higher by making larger sample sizes for keeping stable risk estimation.
REFERENCES
[1] Pierot L, Barbe C, Herbreteau D, et al. Delayed thromboembolic events after coiling of unruptured intracranial aneurysms in a prospective cohort of 335 patients. J Neurointerv Surg 2021;13(6):534-540.
[2] Novikov I, Fund N, Freedman LS. A modified approach to estimating sample size for simple logistic regression with one continuous covariate. Stat Med 2010;29(1):97-107.
[3] Peduzzi P, Concato J, Kemper E, et al. A simulation study of the number of events per variable in logistic regression analysis. J Clin Epidemiol 1996;49(12):1373-1379.
[4] Vittinghoff E, McCulloch CE. Relaxing the rule of ten events per variable in logistic and Cox regression. Am J Epidemiol 2007;165(6):710-718.
We read with great interest the recent paper by Vargas, et al. describing a novel beveled tip aspiration catheter with improved recanalization and patient outcome compared to conventional non-beveled tip catheters in a single-center retrospective study.[1] We want to express our sincere congratulations to the authors on this finding but also want to respectively present our disagreement on the mechanisms explaining the improved performance of the beveled tip catheter as compared to standard catheters.
The authors conclude that a primary reason for higher rate of complete clot ingestion for the beveled tip catheter relates to the area of the catheter tip. It is widely accepted that ingestion force predicts recanalization efficacy, and this force is proportional to tip area (A) and pressure drop (P). The authors note that the beveled tip leads to an ovalized tip area with a total tip area that is approximately 15% larger than a catheter with an equivalent inner diameter but standard non-beveled tip. They then propose that this 15% increase in tip area leads to a corresponding increase of ingestion force, using the standard F=A*P equation. However, this proposition is flawed. While it is true the total force is larger for the beveled tip catheter than a standard catheter, this total force includes two separate force components that are orthogonal to each other, including the ingestion force component (along the catheter’s length) that corks or ingests the clot and...
We read with great interest the recent paper by Vargas, et al. describing a novel beveled tip aspiration catheter with improved recanalization and patient outcome compared to conventional non-beveled tip catheters in a single-center retrospective study.[1] We want to express our sincere congratulations to the authors on this finding but also want to respectively present our disagreement on the mechanisms explaining the improved performance of the beveled tip catheter as compared to standard catheters.
The authors conclude that a primary reason for higher rate of complete clot ingestion for the beveled tip catheter relates to the area of the catheter tip. It is widely accepted that ingestion force predicts recanalization efficacy, and this force is proportional to tip area (A) and pressure drop (P). The authors note that the beveled tip leads to an ovalized tip area with a total tip area that is approximately 15% larger than a catheter with an equivalent inner diameter but standard non-beveled tip. They then propose that this 15% increase in tip area leads to a corresponding increase of ingestion force, using the standard F=A*P equation. However, this proposition is flawed. While it is true the total force is larger for the beveled tip catheter than a standard catheter, this total force includes two separate force components that are orthogonal to each other, including the ingestion force component (along the catheter’s length) that corks or ingests the clot and a perpendicular force directed against the catheter wall, which does not affect ingestion. In fact, the ingestion force is exactly the same between the beveled catheter and standard tip catheters, and is calculated as A*P, where A is simply the area of the ID of the catheter, as with standard catheters.
We think several other possible mechanisms underlie the improved recanalization outcome with the beveled tip catheter as compared to standard catheters. First, as the authors addressed in the discussion, the beveled tip enables better alignment of the catheter’s main axis and the ingestion force to the clot’s main axis , which allows a larger force transmitted to the clot than those with standard catheters.[2] Second, the bevel could partially separate the clot from the vessel wall, reducing the friction and enabling easier clot ingestion. Third, in the cases of the beveled tip advanced to be flush with the clot face, the space between the bevel tip and the bevel base can enable non-contact aspiration,[3] where the clot ingestion is enhanced by the retrograde aspiration blood flow. In comparison, for contact aspiration with standard catheters, the clot blocks the entire catheter tip and no retrograde flow will be created to facilitate clot ingestion.
Overall, the clinical results are very encouraging, and we hope our comments can benefit our community to achieve a more comprehensive understanding of the action mechanism of the beveled tip catheter in our community. Additional mechanistic study is warranted.
References
1. Vargas J, Blalock J, Venkatraman A, et al. Efficacy of beveled tip aspiration catheter in mechanical thrombectomy for acute ischemic stroke. J Neurointerv Surg. Published online 2020:1-5.
2. Bernava G, Rosi A, Boto J, et al. Direct thromboaspiration efficacy for mechanical thrombectomy is related to the angle of interaction between the aspiration catheter and the clot. J Neurointerv Surg. 2020;12(4):396-400.
3. Haussen DC, Bouslama M, Grossberg JA, Nogueira RG. Remote aspiration thrombectomy in large vessel acute ischemic stroke. J Neurointerv Surg. 2017;9(3):250-252.
We congratulate Drs. Srivatsan and colleagues on their paper examining the effects of endovascular coiling of unruptured intracranial aneurysms (UIAs) on cognition using the Montreal Cognitive Assessment (MoCA).1 In particular, we appreciate the efforts made to sample the patients at multiple time points including pre-intervention and at 1-month and 6-months post-intervention. The study found that coiling did not diminish neurocognitive function per the MoCA, with there also being no correlation between follow-up MoCA scores and imaging findings, the overall results being comparable to the authors’ previous paper on MoCA scores following flow diversion for UIAs.2 Intriguingly, the MoCA scores at baseline were on average below the typical cut-off of 26 points, especially given the relatively young population (mean age 55.5 years).
However, as acknowledged by the authors, the ability of the study to discern post-coiling imaging changes was limited by both the small subset of the population that received follow-up imaging (17 of 33 patients, 51.5%) and the smaller subset that underwent MRI (9 patients, 27.3%).1 Diffusion-weighted imaging (DWI) sequences of MRI are most sensitive to identifying post-procedural ischemic injury following neuro-interventional procedures like coiling.3 DWI lesions occur quite frequently; for example, in the ENACT trial (Evaluating Neuroprotection in Aneurysm Coiling Therapy), 68% of patients had new lesions post-procedure, with an average o...
We congratulate Drs. Srivatsan and colleagues on their paper examining the effects of endovascular coiling of unruptured intracranial aneurysms (UIAs) on cognition using the Montreal Cognitive Assessment (MoCA).1 In particular, we appreciate the efforts made to sample the patients at multiple time points including pre-intervention and at 1-month and 6-months post-intervention. The study found that coiling did not diminish neurocognitive function per the MoCA, with there also being no correlation between follow-up MoCA scores and imaging findings, the overall results being comparable to the authors’ previous paper on MoCA scores following flow diversion for UIAs.2 Intriguingly, the MoCA scores at baseline were on average below the typical cut-off of 26 points, especially given the relatively young population (mean age 55.5 years).
However, as acknowledged by the authors, the ability of the study to discern post-coiling imaging changes was limited by both the small subset of the population that received follow-up imaging (17 of 33 patients, 51.5%) and the smaller subset that underwent MRI (9 patients, 27.3%).1 Diffusion-weighted imaging (DWI) sequences of MRI are most sensitive to identifying post-procedural ischemic injury following neuro-interventional procedures like coiling.3 DWI lesions occur quite frequently; for example, in the ENACT trial (Evaluating Neuroprotection in Aneurysm Coiling Therapy), 68% of patients had new lesions post-procedure, with an average of 4.3 new lesions in the NA-1 arm and 6.7 lesions in the placebo arm when considering just the 147 patients with UIAs.4 Future studies will need to examine the relationship between the burden of such DWI lesions and post-procedural cognitive outcomes in further detail.
Furthermore, although the MoCA is a useful global assessment of cognitive impairment, we suspect that it may have more limited sensitivity in identifying mild post-procedural cognitive changes. As the studies by Drs. Strivatsan and colleagues with post-coiling and post-flow-diversion outcomes have shown, any potential changes are likely to be subtle. As we seek to uncover the phenotype of potential cognitive deficits after endovascular procedures for UIAs, we may seek guidance from the existing literature on vascular cognitive impairment (VCI), which is known to have a preponderance of executive dysfunction, including slowed information processing, impaired set-/task-shifting, and deficits in working memory.5 6 To help assess such domains with greater granularity, the National Institute of Neurological Disorders and Stroke (NINDS) and the Canadian Stroke Network (CSN) have proposed cognitive testing protocols as part of the NINDS-CSN VCI Harmonization Standards.7 Of the 5-minute, 30-minute, and 60-minute protocols proposed, the 30-minute test protocol (applied in the ENACT trial)4 appears to offer a helpful balance of length and granularity, with specific measures of the aforementioned domains like the Controlled Oral Word Association Test (COWAT – phonemic fluency), semantic fluency, Digit Symbol-Coding, the Hopkins Verbal Learning Test (HVLT), the Trail Making Test, as well as brief assessments of neuropsychiatric symptoms through the Center for Epidemiologic Studies – Depression (CES-D) scale and the Neuropsychiatric Inventory, Questionnaire Version (NPI-Q).7 Future studies of post-procedural cognitive changes should seek to incorporate some or all of these additional tests into their follow-up testing protocols.
References
1. Srivatsan A, Mohanty A, Saleem Y, et al. Cognitive outcomes after unruptured intracranial aneurysm treatment with endovascular coiling. J Neurointerv Surg 2020 doi: 10.1136/neurintsurg-2020-016362 [published Online First: 2020/07/24]
2. Wagner K, Srivatsan A, Mohanty A, et al. Cognitive outcomes after unruptured intracranial aneurysm treatment with flow diversion. J Neurosurg 2019:1-6. doi: 10.3171/2019.9.JNS191910 [published Online First: 2019/11/30]
3. Iosif C, Camilleri Y, Saleme S, et al. Diffusion-weighted imaging-detected ischemic lesions associated with flow-diverting stents in intracranial aneurysms: safety, potential mechanisms, clinical outcome, and concerns. J Neurosurg 2015;122(3):627-36. doi: 10.3171/2014.10.JNS132566 [published Online First: 2015/01/07]
4. Hill MD, Martin RH, Mikulis D, et al. Safety and efficacy of NA-1 in patients with iatrogenic stroke after endovascular aneurysm repair (ENACT): a phase 2, randomised, double-blind, placebo-controlled trial. Lancet Neurol 2012;11(11):942-50. doi: 10.1016/S1474-4422(12)70225-9
5. Garrett KD, Browndyke JN, Whelihan W, et al. The neuropsychological profile of vascular cognitive impairment--no dementia: comparisons to patients at risk for cerebrovascular disease and vascular dementia. Arch Clin Neuropsychol 2004;19(6):745-57. doi: 10.1016/j.acn.2003.09.008 [published Online First: 2004/08/04]
6. Nyenhuis DL, Gorelick PB, Geenen EJ, et al. The pattern of neuropsychological deficits in Vascular Cognitive Impairment-No Dementia (Vascular CIND). Clin Neuropsychol 2004;18(1):41-9. doi: 10.1080/13854040490507145 [published Online First: 2004/12/15]
7. Hachinski V, Iadecola C, Petersen RC, et al. National Institute of Neurological Disorders and Stroke-Canadian Stroke Network vascular cognitive impairment harmonization standards. Stroke 2006;37(9):2220-41. doi: 10.1161/01.STR.0000237236.88823.47
After reading the interesting article by Jeon et al, indeed, the first series of cases of revascularization in cerebral infarction, it is important to point out several aspects related to the cancer patient. Cancer is a heterogeneous group of diseases with some points in common related to cellular behavior in the face of cell division controls and their local and systemic effects. Its incidence and prevalence are increasing, and the borders of treatment are changing, as is the disease itself. Patients with active cancer, therefore, should be approached in a multidisciplinary strategy, for the management of their oncological pathology or associated patient comorbidities. Stroke does not escape this strategy, because it does not have the same clinical impact to treat a patient with an oncological disease in early staging compared to one in advanced staging or in disease progression in palliative care and short calculated survival. It is not possible to establish a general rule of treatment in stroke with active cancer for these reasons, and a careful analysis of which primary tumors, their staging or clinical evolution of response to treatment, are necessary to clarify the clinical picture of stroke treatment in the oncological disease context.
Dear Editor,
Show MoreI am writing to address the significant findings presented in the article "Short- versus long-term Dual AntiPlatelet Therapy for Stent-Assisted treatment of CErebral aneurysm (DAPTS ACE)." This research, a randomized clinical trial aimed at unraveling the ideal duration of Dual AntiPlatelet Therapy (DAPT) after stent-assisted coil embolization (SACE) for cerebral aneurysms, raises crucial questions regarding the management of these delicate cases.
The article reports that the trial, DAPTS ACE, investigated whether extending DAPT for 12 months could effectively reduce the risk of ischemic stroke in comparison to a shorter 3-month DAPT regimen for patients who underwent SACE for cerebral aneurysms. The study, conducted in 17 hospitals in Japan, enrolled 142 patients between November 4, 2016, and January 7, 2019, and assigned them randomly to either the long-term or short-term DAPT group. The primary outcome was the occurrence of ischemic stroke events during the period of 3 to 12 months after SACE.
The results are undeniably important, as they indicate that there was no statistically significant difference in the rate of ischemic strokes between the long-term and short-term DAPT groups. In fact, ischemic stroke was a rare occurrence in both groups, and the data show that the extended duration of DAPT did not offer a significant advantage in preventing ischemic events. This is the first randomized controlled trial to tackle the duratio...
Dear Editor,
I am writing to express my appreciation for the recent publication of the multicenter study entitled "Non-ischemic cerebral enhancing (NICE) lesions after flow diversion for intracranial aneurysms: a multicenter study." The investigation sheds light on a relatively underexplored aspect of neuroendovascular procedures and provides valuable insights into the incidence, clinical presentation, and potential device-related factors associated with NICE lesions.
The study, conducted across eight centers, presents a meticulous analysis of 15 patients with NICE lesions following flow diversion. Notably, the reported incidence of 1% raises concerns given its contrast with rates observed in previous studies on various neuroendovascular procedures. This finding underscores the need for a closer examination of the potential risks and implications of flow diversion in the context of NICE lesions.
One of the notable contributions of this study is the identification of a concerning accumulation of NICE lesion cases associated with specific product lines—Pipeline devices and Derivo devices. While the study rules out the device material itself as the exclusive culprit, the hypotheses put forth regarding mechanical properties, vendor-specific catheters, and the call for further bench testing and transparent disclosure of technical details add depth to the discussion. This nuanced exploration of potential contributing factors sets the stage for more...
Show MoreDear Editor,
Show MoreI am writing to provide a thorough assessment of the recently published study titled "Cost-effectiveness of Endovascular Therapy for Acute Stroke with a Large Ischemic Region in Japan: Impact of the Alberta Stroke Program Early CT Score on Cost-effectiveness" [1]. While the study addresses important aspects of the economic implications of endovascular therapy (EVT) for acute ischemic stroke (AIS) in Japan, my analysis aims to delve deeper into specific methodological considerations and discuss the applicability of the study's findings in a broader context.
The primary focus of the study is the cost-effectiveness of EVT based on the Alberta Stroke Program Early CT Score (ASPECTS) for patients with AIS involving a large ischemic region. The conclusion that EVT is cost-effective for individuals with ASPECTS of 3–5 as determined by treating neurologists using MRI raises questions about the reliability and consistency of ASPECTS as a determinant of cost-effectiveness. Furthermore, the study acknowledges the variability in incremental costs and quality-adjusted life years (QALYs) associated with EVT in Japan compared to other countries. The higher incremental costs in Japan, attributed to the specific stroke care system and the frequent use of combined techniques and MRI, present challenges when applying these findings to healthcare systems with different cost structures and resource allocations.
The study acknowledges the variabilit...
Dear Editor,
Show MoreI would like to commend the authors for their insightful study titled "Liquid embolic surface area as a predictor of chronic subdural hematoma resolution in middle meningeal artery embolization" [1]. The investigation into the correlation between liquid embolic surface area (LEA SA) and chronic subdural hematoma (cSDH) resolution in the context of middle meningeal artery embolization (MMAE) presents valuable contributions to the field. The authors employed a meticulous approach, retrospectively collecting data from 74 patients who underwent first-line MMAE with ethylene vinyl alcohol (EVOH) and utilizing 3D segmentation to quantify LEA SA. The observed correlation between greater LEA SA and enhanced cSDH resolution rates at 3 months and 6 months post-embolization is a noteworthy contribution to the field.
The study's strength lies in its unique focus on a patient group undergoing first-line MMAE for cSDH, a subset that has been relatively underrepresented in the existing literature. The authors rightly acknowledge the potential selection bias in this group, considering patients with greater midline shift or poor neurologic exams might be directed immediately to surgical treatment. Nonetheless, the results support the utilization of upfront MMAE in patients with riskier surgical profiles due to comorbidities or borderline radiographic and clinical features.
However, it is essential to scrutinize the limitations outlined by the a...
To the Editor,
I am writing to discuss the recent article titled "Incidence of intracranial hemorrhagic complications after anterior circulation endovascular thrombectomy in relation to occlusion site: a nationwide observational register study" (1). This study provides valuable insights into intracranial hemorrhage (ICH) as a potential complication of endovascular thrombectomy (EVT) in patients with anterior circulation vessel occlusion stroke. The authors conducted a comprehensive analysis, considering different occlusion sites and their associations with the incidence and severity of ICH, specifically symptomatic (sICH) and non-symptomatic (non-sICH) cases. While the study presents crucial findings, it is essential to discuss its implications and limitations.
The study's key finding of a 4.5% incidence of sICH after EVT for anterior circulation vessel occlusion stroke is consistent with previous research in this area. The recognition of differences in the frequency and severity of ICH across occlusion sites, particularly in the internal carotid artery (ICA), middle cerebral artery's first segment (M1), and the M2 and beyond, is a significant contribution to our understanding of EVT outcomes. The study suggests that ICA occlusions, despite their lower overall hemorrhage frequency, tend to result in more severe ICH, including intraventricular hemorrhages and space-occupying intracerebral hemorrhages. This observation aligns with prior stud...
Show MoreDear Editor,
We have read with great interest the article entitled “Efficacy and mid-term outcome of middle meningeal artery embolization with or without burr hole evacuation for chronic subdural hematoma compared with burr hole evacuation alone” by Onyinzo, C., et al, published in Journal of NeuroInterventional Surgery (2021).
The article has compared the Surgical and Endovascular management of (CSDH) in the elderly population who are at high risk to developing (CSDH) due to their co-morbidities and the use of anti-thrombotic agents.
Show MoreIt is noted that the anti-thrombotic agents were stopped to both management arms. Upfront Middle meningeal artery embolization without stopping the anti-thrombotics, might be a strategy to mitigate the risk of cardio-embolic events.
In regards to the evaluation of the patients outcome, clinical parameters did not include motor assessment, which is a significant factor to favor a rapid surgical evacuation in these delicate patients.
As to the radiological follow up, cured (CSDH) were defined in the article with a thickness less than 10 mm. This is debatable as there are a lot of variations exists for this population in regards to brain volume and brain elasticity.
Finally, we would like to point out the timing of the follow up was not defines for all patients. This need to be harmonized better to a well-defined follow up timeline. Joyce, MD, et al,2 a suggested a time frame of 6 weeks after the treatment...
Dear Editor,
I read with interest the paper by Pierot et al [1]. They conducted a prospective study to examine factors of delayed thromboembolic events in 335 patients after coiling of unruptured intracranial aneurysms. The number of delayed TEEs was 8. The adjusted odds ratios (95% confidence intervals) of autosomal dominant polycystic kidney disease and post-procedure aneurysm remnant at procedure completion for delayed TEEs were 27.3 (3.9 to 190.2) and 9.9 (1.0 to 51.3), respectively. They understand the lack of statistical power in the multivariate analysis and did not intend to examine the causal association. I present a comment regarding the number of events in logistic regression analysis.
The limitation in the total number of events for logistic regression analysis was simulated to improve statistical power [2]. In addition, Peduzzi et al. evaluated the effect of the number of events per variable (EPV) on the outcome in logistic regression analysis [3], concluding that the number of EPV less than 10 has some problems for the prediction of dependent variable. There is an opinion that EPV value less than 10 is also acceptable to evaluate the association by logistic regression analysis [4]. Pierot et al. observed 8 events, which was not appropriate for multivariate analysis even for examining the association instead of prediction in a prospective study. I think that wide ranges of 95% confidence intervals may reflect unstable estimates in a logistic regr...
Show MoreWe read with great interest the recent paper by Vargas, et al. describing a novel beveled tip aspiration catheter with improved recanalization and patient outcome compared to conventional non-beveled tip catheters in a single-center retrospective study.[1] We want to express our sincere congratulations to the authors on this finding but also want to respectively present our disagreement on the mechanisms explaining the improved performance of the beveled tip catheter as compared to standard catheters.
The authors conclude that a primary reason for higher rate of complete clot ingestion for the beveled tip catheter relates to the area of the catheter tip. It is widely accepted that ingestion force predicts recanalization efficacy, and this force is proportional to tip area (A) and pressure drop (P). The authors note that the beveled tip leads to an ovalized tip area with a total tip area that is approximately 15% larger than a catheter with an equivalent inner diameter but standard non-beveled tip. They then propose that this 15% increase in tip area leads to a corresponding increase of ingestion force, using the standard F=A*P equation. However, this proposition is flawed. While it is true the total force is larger for the beveled tip catheter than a standard catheter, this total force includes two separate force components that are orthogonal to each other, including the ingestion force component (along the catheter’s length) that corks or ingests the clot and...
Show MoreWe congratulate Drs. Srivatsan and colleagues on their paper examining the effects of endovascular coiling of unruptured intracranial aneurysms (UIAs) on cognition using the Montreal Cognitive Assessment (MoCA).1 In particular, we appreciate the efforts made to sample the patients at multiple time points including pre-intervention and at 1-month and 6-months post-intervention. The study found that coiling did not diminish neurocognitive function per the MoCA, with there also being no correlation between follow-up MoCA scores and imaging findings, the overall results being comparable to the authors’ previous paper on MoCA scores following flow diversion for UIAs.2 Intriguingly, the MoCA scores at baseline were on average below the typical cut-off of 26 points, especially given the relatively young population (mean age 55.5 years).
However, as acknowledged by the authors, the ability of the study to discern post-coiling imaging changes was limited by both the small subset of the population that received follow-up imaging (17 of 33 patients, 51.5%) and the smaller subset that underwent MRI (9 patients, 27.3%).1 Diffusion-weighted imaging (DWI) sequences of MRI are most sensitive to identifying post-procedural ischemic injury following neuro-interventional procedures like coiling.3 DWI lesions occur quite frequently; for example, in the ENACT trial (Evaluating Neuroprotection in Aneurysm Coiling Therapy), 68% of patients had new lesions post-procedure, with an average o...
Show MoreAfter reading the interesting article by Jeon et al, indeed, the first series of cases of revascularization in cerebral infarction, it is important to point out several aspects related to the cancer patient. Cancer is a heterogeneous group of diseases with some points in common related to cellular behavior in the face of cell division controls and their local and systemic effects. Its incidence and prevalence are increasing, and the borders of treatment are changing, as is the disease itself. Patients with active cancer, therefore, should be approached in a multidisciplinary strategy, for the management of their oncological pathology or associated patient comorbidities. Stroke does not escape this strategy, because it does not have the same clinical impact to treat a patient with an oncological disease in early staging compared to one in advanced staging or in disease progression in palliative care and short calculated survival. It is not possible to establish a general rule of treatment in stroke with active cancer for these reasons, and a careful analysis of which primary tumors, their staging or clinical evolution of response to treatment, are necessary to clarify the clinical picture of stroke treatment in the oncological disease context.
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