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Ma Y, Ji Z, Yang W, Li L, Han L, Liu Y, Guo Y, Dmytriw AA, He C, Li G, Zhang H. Role of optical coherence tomography in pipeline embolization device for the treatment of vertebral-basilar artery dissecting aneurysms. J Neurointerv Surg 2024; 16:308-312. [PMID: 36882320 DOI: 10.1136/jnis-2022-019927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/28/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND Vertebral-basilar artery dissecting aneurysms (VADAs) are an uncommon phenomenon in all fields of cerebrovascular disease. The flow diverter (FD) can be used as an endoluminal reconstruction device that promotes neointima formation at the aneurysmal neck and preserves the parent artery. To date, imaging examinations such as CT angiography, MR angiography, and DSA are the main methods used to evaluate the vasculature of patients. However, none of these imaging methods can reveal the situation of neointima formation, which is of great importance in evaluating occlusion of VADAs, especially those treated with a FD. METHODS Three patients were included in the study from August 2018 to January 2019. All patients underwent preprocedural, postprocedural, and follow-up evaluations with high resolution MRI, DSA, and optical coherence tomography (OCT), as well as the formation of intima on the surface of the scaffold at the 6 month follow-up. RESULTS Preprocedural, postoperative, and follow-up high resolution MRI, DSA, and OCT of all three cases successfully evaluated occlusion of the VADAs and occurrence of in stent stenosis from different views of intravascular angiography and neointima formation. CONCLUSIONS OCT was feasible and useful to further evaluate VADAs treated with FD from a near pathological perspective, which may contribute toward guiding the duration of antiplatelet medication and early intervention of in stent stenosis.
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Affiliation(s)
- Yongjie Ma
- Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute, Beijing, China
| | - Zhe Ji
- Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute, Beijing, China
| | - Wanxin Yang
- Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute, Beijing, China
| | - Li Li
- Neurosurgery, Harbin Medical University Fourth Hospital, Harbin, China
| | - Liqiang Han
- Software Engineering, Dalian University of Technology, Dalian, Liaoning, China
| | - Yu Liu
- Software Engineering, Dalian University of Technology, Dalian, Liaoning, China
| | - Yuanhao Guo
- Institute of Automation, Chinese Academy of Sciences Institute of Automation, Beijing, China
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
- Neuroradiology and Neurointervention, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Chuan He
- Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute, Beijing, China
| | - Guilin Li
- Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute, Beijing, China
| | - Hongqi Zhang
- Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute, Beijing, China
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Charles JH, Desai S, Jean Paul A, Hassan A. Multimodal imaging approach for the diagnosis of intracranial atherosclerotic disease (ICAD): Basic principles, current and future perspectives. Interv Neuroradiol 2024; 30:105-119. [PMID: 36262087 PMCID: PMC10956456 DOI: 10.1177/15910199221133170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 09/29/2022] [Indexed: 02/05/2023] Open
Abstract
PURPOSE To review the different imaging modalities utilized in the diagnosis of Intracranial Atherosclerotic Disease (ICAD) including their latest development and relevance in management of ICAD. METHODS A review of the literature was conducted through a search in google scholar, PubMed/Medline, EMBASE, Scopus, clinical trials.gov and the Cochrane Library. Search terms included, "imaging modalities in ICAD," "ICAD diagnostic," "Neuroimaging of ICAD," "Evaluation of ICAD". A summary and comparison of each modality's basic principles, advantages and disadvantages were included. RESULTS A total of 144 articles were identified and reviewed. The most common imaging used in ICAD diagnoses were DSA, CTA, MRA and TCD. They all had proven accuracy, their own benefits, and limitations. Newer modalities such as VWI, IVUS, OCT, PWI and CFD provide more detailed information regarding the vessel walls, plaque characteristics, and flow dynamics, which play a tremendous role in treatment guidance. In certain clinical scenarios, using more than one modality has been shown to be helpful in ICAD identification. The rapidly evolving software related to imaging studies, such as virtual histology, are very promising for the diagnostic and management of ICAD. CONCLUSIONS ICAD is a common cause of recurrent ischemic stroke. Its management can be both medical and/or procedural. Many different imaging modalities are used in its diagnosis. In certain clinical scenario, a combination of two more modalities can be critical in the management of ICAD. We expect that continuous development of imaging technique will lead to individualized and less invasive management with adequate outcome.
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Affiliation(s)
| | - Sohum Desai
- Department of Endovascular Surgical Neuroradiology, Valley Baptist Medical Center, Harlingen, Texas, USA
| | - Axler Jean Paul
- School of Medicine, State University of Haiti, Port Au Prince, Haiti
| | - Ameer Hassan
- Department of Endovascular Surgical Neuroradiology, Valley Baptist Medical Center, Harlingen, Texas, USA
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Shi X, Tao T, Wang Y, Han Y, Xu X, Yin Q, Wang F, Liu R, Liu X. Heavy macrophage infiltration identified by optical coherence tomography relates to plaque rupture. Ann Clin Transl Neurol 2023; 10:2334-2346. [PMID: 37822283 PMCID: PMC10723231 DOI: 10.1002/acn3.51923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 08/31/2023] [Accepted: 10/02/2023] [Indexed: 10/13/2023] Open
Abstract
OBJECTIVE Risk stratification plays a critical role in patients with asymptomatic carotid atherosclerotic stenosis. Heavy macrophage infiltration (HMC) is an important factor of plaque destabilization. However, in vivo imaging technologies and screening criteria for HMC remain limited. We aimed to (i) introduce algorithms for in vivo detection of macrophage infiltrations using optical coherence tomography (OCT) and (ii) to investigate the threshold of HMC and its association with plaque vulnerability. METHODS Ex vivo OCT images were co-registered with histopathology in 282 cross-sectional pairs from 19 carotid endarterectomy specimens. Of these, 197 randomly selected pairs were employed to define the parameters, and the remaining 85 pairs were used to evaluate the accuracy of the OCT-based algorithm in detecting macrophage infiltrations. Clinical analysis included 93 patients receiving carotid OCT evaluation. The prevalence and burden of macrophage infiltration were analyzed. Multivariable and subgroup analysis were performed to investigate the association between HMC and plaque rupture. RESULTS The sensitivity and specificity of algorithm for detecting macrophage infiltration were 88.0% and 74.9%, respectively. Of 93 clinical patients, ruptured plaques exhibited higher prevalence of macrophage infiltration than nonruptured plaques (83.7% [36/43] vs 32.0% [16/50], p < 0.001). HMC was identified when the macrophage index was greater than 60.2 (sensitivity = 74.4%, specificity = 84.0%). Multivariable analysis showed that HMC and multiple calcification were independent risk factors for non-lipid-rich plaque rupture. INTERPRETATION This study provides a novel approach and screening criteria for HMC, which might be valuable for atherosclerotic risk stratification.
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Affiliation(s)
- Xuan Shi
- Department of Neurology, Nanjing Jinling Hospital, Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
| | - Tao Tao
- Department of Neurosurgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
| | - Yi Wang
- Department of Neurosurgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
| | - Yunfei Han
- Department of Neurology, Nanjing Jinling Hospital, Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
| | - Xiaohui Xu
- Department of Neurology, Nanjing Jinling Hospital, Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
| | - Qin Yin
- Department of Neurology, Nanjing Jinling Hospital, Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
| | - Fang Wang
- Department of Neurology, Nanjing Jinling Hospital, Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
| | - Rui Liu
- Department of Neurology, Nanjing Jinling Hospital, Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
| | - Xinfeng Liu
- Department of Neurology, Nanjing Jinling Hospital, Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
- Stroke Center and Department of Neurology, First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and MedicineUniversity of Science and Technology of ChinaHefeiChina
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Optical Coherence Tomography in Cerebrovascular Disease: Open up New Horizons. Transl Stroke Res 2023; 14:137-145. [PMID: 35445969 DOI: 10.1007/s12975-022-01023-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 04/12/2022] [Accepted: 04/13/2022] [Indexed: 10/18/2022]
Abstract
Optical coherence tomography (OCT), based on the backscattering or reflection of near-infrared light, enables an ultra-high resolution of up to 10 μm. The successful application of OCT in coronary artery diseases has sparked increasing interest in its implementation in cerebrovascular diseases. OCT has shown promising potential in the atherosclerotic plaque structure characterization, plaque rupture risk stratification, pre-stenting and post-stenting evaluation, and long-term follow-up in extracranial and intracranial atherosclerotic stenosis (ICAS). In hemorrhagic cerebrovascular diseases, OCT plays an important role in the structure evaluation, rupture risk stratification, and healing and occlusion evaluation following initial treatment in intracranial aneurysms (IAs). In this study, we summarized the applications of OCT in the diagnosis, treatment, and follow-up of cerebrovascular diseases, especially in ICAS and IAs. The current limitations and future directions of OCT in the endovascular treatment of cerebrovascular diseases were also discussed.
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Li W, Zhu W, Wang Y, Zhao Y, Wang Y, Liu X, Zhang Y. Stent-alone treatment of unruptured vertebral artery fusiform aneurysms: A comparison of flow diverter and conventional stents. Front Neurol 2022; 13:1012382. [DOI: 10.3389/fneur.2022.1012382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022] Open
Abstract
BackgroundTreatment of vertebral artery fusiform aneurysms (VAFAs) is complex and controversial. This study aimed to compare the safety and efficacy between flow diverter and conventional stents in patients with VAFAs undergoing endovascular stent-alone treatment (SAT).MethodsThirty-six patients with 36 VAFAs who underwent SAT between January 2014 and December 2018 were retrospectively analyzed. Patient and aneurysm characteristics, procedural details, complications, and angiographic and clinical outcomes were compared between flow diverter stent patients (n = 22) and conventional stent patients (n = 14).ResultsMore branches covered with stent were found in the conventional stent group (88.9 vs. 33.3%; p = 0.008). The number of stents placed was significantly higher in the conventional stent group (1.57 ± 0.76 vs. 1.09 ± 0.29; p = 0.016). The proportion of patients with significant or moderate stasis within the aneurysm immediately after stent placement was higher in the flow diverter stent group (95.5 vs. 57.1%; p = 0.004). The proportion of patients with complete obliteration or only a residual neck on follow-up angiography was significantly higher in the flow diverter stent group (86.3 vs 50.0%; p = 0.047). However, the incidence of parent artery stenosis or occlusion was also higher in the flow diverter stent group (27.3% vs. zero; p = 0.032). The rate of complications did not significantly differ between the groups.ConclusionsSAT was safe and effective in patients with VAFAs. Flow diverter stents are associated with a significantly better complete occlusion rate than conventional stents; however, they are also associated with an increased risk of parent artery stenosis.
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Gounis MJ, Steinman DA. Up around the bend: progress and promise of intravascular imaging in neurointerventional surgery. J Neurointerv Surg 2021; 13:495-496. [PMID: 33986130 DOI: 10.1136/neurintsurg-2021-017707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2021] [Indexed: 01/03/2023]
Affiliation(s)
- Matthew J Gounis
- Radiology, New England Center for Stroke Research, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - David A Steinman
- Mechanical & Industrial Engineering, University of Toronto, Toronto, Ontario, Canada
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Anagnostakou V, Ughi GJ, Puri AS, Gounis MJ. Optical Coherence Tomography for Neurovascular Disorders. Neuroscience 2021; 474:134-144. [PMID: 34126186 DOI: 10.1016/j.neuroscience.2021.06.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 06/03/2021] [Accepted: 06/06/2021] [Indexed: 11/26/2022]
Abstract
Diagnosis of cerebrovascular disease includes vascular neuroimaging techniques such as computed tomography (CT) angiography, magnetic resonance (MR) angiography (with or without use of contrast agents) and catheter digital subtraction angiography (DSA). These techniques provide mostly information about the vessel lumen. Vessel wall imaging with MR seeks to characterize cerebrovascular pathology, but with resolution that is often insufficient for small lesions. Intravascular imaging techniques such as ultrasound and optical coherence tomography (OCT), used for over a decade in the peripheral circulation, is not amendable to routine deployment in the intracranial circulation due to vessel caliber and tortuosity. However, advances in OCT technology including the probe profile, stiffness and unique distal rotation solution, holds the promise for eventual translation of OCT into the clinical arena. As such, it is apropos to review this technology and present the rationale for utilization of OCT in the cerebrovasculature.
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Affiliation(s)
- Vania Anagnostakou
- University of Massachusetts Medical School, Radiology, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655, United States
| | - Giovanni J Ughi
- University of Massachusetts Medical School, Radiology, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655, United States
| | - Ajit S Puri
- University of Massachusetts Medical School, Radiology, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655, United States
| | - Matthew J Gounis
- University of Massachusetts Medical School, Radiology, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655, United States.
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Pasarikovski CR, Ku JC, Keith J, Ramjist J, Dobashi Y, Priola SM, da Costa L, Yang VXD. Endovascular Cerebral Venous Sinus Imaging with Optical Coherence Tomography. AJNR Am J Neuroradiol 2020; 41:2292-2297. [PMID: 33214185 DOI: 10.3174/ajnr.a6909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 07/28/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Imaging of the cerebral venous sinuses has evolved Substantially during the past 2 decades, and most recently intravascular sinus imaging with sonography has shed light on the pathophysiology of sinus thrombosis and intracranial hypertension. Optical coherence tomography is the highest resolution intravascular imaging technique available but has not been previously used in cerebral sinus imaging. The purpose of this study was to develop a preclinical animal model of endovascular optical coherence tomography cerebral venous sinus imaging and compare optical coherence tomography findings with histology. MATERIALS AND METHODS Four consecutive Yorkshire swine were selected. The superior sagittal sinus was first catheterized with a microwire, and the optical coherence tomography catheter was delivered via a monorail technique into the sinus. Luminal blood was cleared with a single arterial injection. After structural and Doppler optical coherence tomography imaging, a craniotomy was performed and the sinus and adjacent dura/veins were resected. Bland-Altman analysis was performed to compare optical coherence tomography and histology. RESULTS Technically successful optical coherence tomography images were obtained in 3 of 4 swine. The luminal environment and visualization of dural arteries and draining cortical veins were characterized. The average maximum diameters of the sinus, dural arteries, and cortical veins were 3.14 mm, 135 µm, and 260 µm, respectively. Bland-Altman analysis demonstrated good agreement between histology and optical coherence tomography images. CONCLUSIONS Endovascular optical coherence tomography imaging was feasible in this preclinical animal study. Adoption of this imaging technique in the human cerebral venous sinus could aid in the diagnosis, treatment, and understanding of the pathophysiology of various diseases of the sinus. Human safety and feasibility studies are needed.
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Affiliation(s)
- C R Pasarikovski
- From the Division of Neurosurgery (C.R.P., J.C.K.), Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - J C Ku
- From the Division of Neurosurgery (C.R.P., J.C.K.), Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - J Keith
- Department of Anatomic Pathology (J.K.), Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - J Ramjist
- Division of Neurosurgery (J.R., Y.D., L.d.C., V.X.D.Y.), Sunnybrook Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Y Dobashi
- Division of Neurosurgery (J.R., Y.D., L.d.C., V.X.D.Y.), Sunnybrook Hospital, University of Toronto, Toronto, Ontario, Canada
| | - S M Priola
- Division of Neurosurgery (S.M.P.), Department of Surgery, Health Sciences North, Sudbury, Ontario, Canada
| | - L da Costa
- Division of Neurosurgery (J.R., Y.D., L.d.C., V.X.D.Y.), Sunnybrook Hospital, University of Toronto, Toronto, Ontario, Canada
| | - V X D Yang
- Division of Neurosurgery (J.R., Y.D., L.d.C., V.X.D.Y.), Sunnybrook Hospital, University of Toronto, Toronto, Ontario, Canada
- Hurvitz Brain Sciences Research Program (V.X.D.Y.), Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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Feng Y, Wu T, Wang T, Li Y, Li M, Li L, Yang B, Bai X, Zhang X, Wang Y, Gao P, Chen Y, Ma Y, Jiao L. Correlation between intracranial vertebral artery stenosis diameter measured by digital subtraction angiography and cross-sectional area measured by optical coherence tomography. J Neurointerv Surg 2020; 13:1002-1006. [DOI: 10.1136/neurintsurg-2020-016835] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/30/2020] [Accepted: 10/30/2020] [Indexed: 11/04/2022]
Abstract
BackgroundIntracranial vertebral artery (V4 segment) stenosis quantification traditionally uses the narrowest stenosis diameter. However, the stenotic V4 lumen is commonly irregularly shaped. Optical coherence tomography (OCT) allows a more precise calculation of V4 geometry. We compared the narrowest diameter stenosis (DS), measured by digital subtraction angiography (DSA), with the area stenosis (AS), measured by OCT. We hypothesized that DS is the gold standard for measuring the degree of stenosis.MethodsFive neuroradiologists evaluated 49 stenosed V4 segments in a blinded protocol. V4 stenosis was measured in millimeters on DSA at its narrowest diameter. OCT was used to estimate the cross-sectional luminal area. We also used automated software to measure DS. Three different angles (anterior, lateral, and oblique views) were used for calculations, and the North American Symptomatic Carotid Endarterectomy Trial (NASCET) and Warfarin–Aspirin Symptomatic Intracranial Disease (WASID) methods were used in all measurements. Spearman’s R values were calculated. Non-linear regression analysis was performed between the DS and AS, with statistically different correlations.ResultsA high correlation was observed between the WASID and NASCET methods to measure DS with observer measurement and automated software. A good correlation was found between DS measured by observers and AS measured by OCT. Non-linear regression analysis showed that only observer measurement using the oblique view and the WASID method could attain statistically significant differences, but it was weak (r=0.389).ConclusionMeasurement of the narrowest diameter was not a reliable predictor of the cross-sectional area of V4 stenosis. Larger studies are therefore needed to develop a new evaluation system based on V4 stenosis.
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Pasarikovski CR, Ku JC, Priola SM, da Costa L, Yang VXD. Endovascular optical coherence tomography imaging in cerebrovascular disease. J Clin Neurosci 2020; 80:30-37. [PMID: 33099363 DOI: 10.1016/j.jocn.2020.07.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/18/2020] [Accepted: 07/27/2020] [Indexed: 10/23/2022]
Abstract
Endovascular optical coherence tomography (OCT) is the highest resolution imaging modality currently available with spatial resolution of 10 µm. Although originally developed for interventional cardiology, the ability to visualize the luminal environment and anatomy, along with the stent-vessel interaction could be of great utility for various cerebrovascular diseases, and the adoption of endovascular OCT imaging in the evolving field of interventional neuroradiology seems instinctive. The purpose of this study is to conduct a systematic review of the literature regarding applications of endovascular OCT in the diagnosis and treatment of cerebrovascular diseases. In addition, the authors report their institutional experience with the use of OCT in carotid atherosclerotic disease, cerebral aneurysms, and acute ischemic stroke. A systematic review of the literature was undertaken. Peer-reviewed articles were collected through MEDLINE, Embase, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) searches through March 2020. A total of 34 studies with 598 patients were included in the qualitative synthesis. These include 23 studies of carotid atherosclerotic disease, 7 studies of cerebral aneurysms, and 4 studies of non-aneurysmal posterior circulation pathology. OCT imaging was feasible in 94% of patients with 0.6% complication rate. Endovascular OCT appears to be safe and feasible, allowing clinicians to visualize stent-vessel interactions, aneurysmal healing, and vulnerable atherosclerotic plaque features. OCT carries great promise, however additional investigations are needed before any imposing statement can be made about the role of OCT in cerebrovascular imaging.
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Affiliation(s)
| | - Jerry C Ku
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Stefano M Priola
- Division of Neurosurgery, Department of Surgery, Health Sciences North, Sudbury, Ontario, Canada; Norther Ontario School of Medicine, Sudbury, Ontario, Canada
| | - Leodante da Costa
- Division of Neurosurgery, Sunnybrook Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Victor X D Yang
- Division of Neurosurgery, Sunnybrook Hospital, University of Toronto, Toronto, Ontario, Canada; Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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