Patch Technique for Primary Treatment of Type A Carotid Cavernous Fistula: A Case Series and Technical Notes

BACKGROUND

The utilization of flow diverters (FDs) in the treatment of high-flow Type A carotid cavernous fistulas (CCFs) has been described before mainly as an adjunct to the traditional endovascular techniques and rarely as a stand-alone treatment. In this study, we retrospectively evaluated our experience with FDs as the solo nonadjunctive treatment of Type A CCF with severe cortical venous reflux (CVR).

METHODS

A retrospective review was performed of patients with Type A CCFs who were treated using FDs' patch technique (PT). Patients' demographics, clinical data, and preoperative and postoperative ocular examination were recorded. The procedure technique, pipeline embolization device (PED) diameters, and immediate and late procedure outcomes were described.

RESULTS

Three patients were included in this case series. All patients had history of trauma and presented with decreased visual acuity, cranial nerve II deficit, limited extraocular muscles' movement, and increased intraocular pressure (IOP). Diagnostic angiography was performed, which confirmed high-flow Type A CCF. Endovascular treatment was performed through distal radial access in 2 patients and femoral access in 1 patient by deploying 4 sequentially enlarging PEDs with immediate resolution of the ocular symptoms. Follow-up angiography confirmed complete resolution of CCF in 2 patients. One patient was lost to follow-up; however, angiogram at 4 months demonstrated residual small CCF with significant improvement from postprocedure angiogram.

CONCLUSIONS

The patch technique using sequentially enlarging FDs is a reasonable alternative solo technique for the treatment of direct CCF symptoms and results in immediate resolution of CVR while preserving the cavernous sinus anatomy.

Arterial Glyceryl Trinitrate in Acute Ischemic Stroke After Thrombectomy for Neuroprotection (AGAIN): A Pilot Randomized Controlled Trial

Although endovascular therapy demonstrates robust clinical efficacy in acute ischemic stroke (AIS), not all stroke patients benefit from successful reperfusion. This study aimed to evaluate the safety, feasibility, and preliminary efficacy of intra-arterial administration of glyceryl trinitrate (GTN) after endovascular recanalization for neuroprotection. This is a prospective randomized controlled study. Eligible patients were randomized to receive 800 μg GTN or the same volume of normal saline through the catheter after recanalization. The primary outcome was symptomatic intracranial hemorrhage (ICH), while secondary outcomes included mortality, functional outcome, infarction volume, complications, and blood nitrate index (NOx). A total of 40 patients were enrolled and randomized with no participants being lost to follow-up. There was no significant difference in the proportion of sICH between GTN and control groups. Additionally, no significant difference was observed in mortality or rates of neurological deterioration and other complications. Favorable trends, while non-significant, were noted in both outcome and imaging for functional independence at 90 days and reduction in final infarct volume (75.0% vs 65.0%; 33.2 vs 38.9 ml) for the GTN group. Moreover, the concentration of blood NOx in the GTN group was significantly higher than in the control group at 2 h after GTN administration (26.2 vs 18.0 μmol/l, p < 0.05). The AGAIN study suggests intra-arterial administration of GTN post-endovascular therapy is safe and feasible and GTN successfully raised NOx levels over controls at 2 h. A multi-center randomized controlled trial with a larger sample size is warranted to determine GTN neoadjuvant efficacy.

Vertebrobasilar artery cooling infusion in acute ischemic stroke for posterior circulation following thrombectomy: Rationale, design and protocol for a prospective randomized controlled trial

Background

Although endovascular mechanical thrombectomy demonstrates clinical efficacy in posterior circulation acute ischemic stroke (AIS), only one third of these patients attain functional independence with a third of patients' expiring despite vascular recanalization. Neuroprotection strategies, such as therapeutic hypothermia (TH) have been considered a promising adjunctive treatment in AIS. We propose the following rationale, design and protocol for a prospective randomized controlled trial (RCT) aimed to determine whether Vertebrobasilar Artery Cooling Infusion (VACI) improves functional outcomes in posterior circulation AIS patients post mechanical thrombectomy.

Methods

Subjects in the study will be assigned randomly to either the cooling infusion or the control group in a 1:1 ratio (n = 40). Patients allocated to the cooling infusion group will receive 300 ml cool saline at 4C through the catheter (30 ml/min) into vertebral artery after thrombectomy. The control group will receive the same volume of 37C saline. All patients enrolled will receive standard care according to current guidelines for stroke management. The primary outcome is symptomatic intracranial hemorrhage (ICH), whereas the secondary outcomes include functional outcome score, infarction volume, mortality, ICH, fatal ICH, cerebral vasospasm, coagulation abnormality, pneumonia and urinary infection.

Discussions

This study will determine the preliminary safety, feasibility, and neuroprotective benefits of VACI in posterior circulation AIS patients with reperfusion therapy. The results of this study may provide evidence for VACI as a new therapy in posterior circulation AIS.

Clinical Trial Registration

www.chictr.org.cn, ChiCTR2200065806, registered on November 15, 2022.

Imaging features of adult moyamoya disease patients with anterior intracerebral hemorrhage based on high-resolution magnetic resonance imaging

This study aimed to identify the high-resolution magnetic resonance imaging (HRMRI) features of moyamoya disease (MMD) patients with anterior intracerebral hemorrhage (ICH) and attempted to reveal potential mechanisms of anterior ICH. Eligible adult MMD patients were consecutively included, and the morphological features of lenticulostriate arteries (LSAs), vessel wall structure of terminal internal carotid artery (ICA) and periventricular anastomosis were evaluated by HRMRI. 78 MMD patients containing 21 patients with anterior ICH, 31 ischemic patients and 26 asymptomatic patients were included. The mean value of total length of LSAs in anterior ICH group (90.79 ± 37.00 mm) was distinctively lower (p < 0.001) compared with either ischemic group (138.04 ± 46.01 mm) or asymptomatic group (170.50 ± 39.18 mm). Lumen area of terminal ICA was significantly larger (p < 0.001) in hemorrhagic group (4.33 ± 2.02 mm²) compared with ischemic group (2.29 ± 1.17 mm²) or asymptomatic group (3.00 ± 1.34 mm²). Multivariate analysis revealed the total length of LSAs (OR 0.689, 95%CI, 0.565-0.840; p < 0.001) and lumen area of terminal ICA (OR 2.085, 95%, 1.214-3.582; p = 0.008) were significantly associated with anterior ICH. Coexistence of reduced LSAs and relatively preserved lumen area of terminal ICA with an AUC of 0.901 (95%CI, 0.812-0.990) could be a potential predictor of anterior ICH in MMD patients.

Arterial Glyceryl Trinitrate in Acute Ischemic Stroke after Thrombectomy for Neuroprotection (AGAIN): Rationale, design and protocol for a prospective randomized controlled trial

Background

Although endovascular recanalization therapy demonstrates robust clinical efficacy in acute ischemic stroke (AIS), not all victims of these cerebrovascular accidents can benefit from it and achieve a favorable prognosis after successful reperfusion. Therefore, alternative neuroprotective strategies are urgently needed for AIS patients after vessel recanalization. Nitric oxide (NO) levels are low after AIS and NO donor drugs may be neuroprotective against cerebral ischemia–reperfusion injury. Glyceryl trinitrate (GTN), often used in the clinic as a NO donor, may provide a novel neuroprotective strategy. This rationale, design, and protocol for a prospective pilot study plans to explore the preliminary safety, feasibility, and neuroprotective benefits of Arterial Glyceryl Trinitrate in Acute Ischemic Stroke after Thrombectomy for Neuroprotection (AGAIN).

Methods

AGAIN, a prospective RCT, is proposed for AIS patients after mechanical thrombectomy. Subjects will be randomly assigned in a 1:1 fashion (n = 40) to either the control group or the intervention group. Participants assigned to the intervention group will be administered 800 μg GTN in the catheter immediately after recanalization, whereas those in the control group will be administered the same volume of normal saline. All participants from either group will be given concurrent treatment with standard of care therapies in accordance with the current guidelines for stroke management. The primary outcome is safety [symptomatic intracranial hemorrhage (ICH), hypotension, neurological deterioration, ICH, fatal ICH, as well as headache, tachycardia, emesis, and seizures], whereas secondary outcomes included changes in poststroke functional outcomes, infarction volumes, and blood nitrate index detection.

Discussions

This study is a prospective randomized controlled trial to test the safety and efficacy of intra-arterial GTN in AIS patients after endovascular therapy. The results from this study will give insight for future GTN studies and new neuroprotective strategies for future AIS treatment strategies.

Trial registration number

ChiCTR2100045254. Registered on March 21, 2021.

Daily Remote Ischemic Conditioning Can Improve Cerebral Perfusion and Slow Arterial Progression of Adult Moyamoya Disease—A Randomized Controlled Study

Background and Purpose

Moyamoya disease (MMD) is a complicated cerebrovascular disease with recurrent ischemic or hemorrhagic events. This study aimed to prove the safety and efficacy of remote ischemic conditioning (RIC) on MMD.

Methods

In total, 34 patients with MMD participated in this pilot, prospective randomized controlled study for 1 year. 18 patients were allocated into the RIC group, and 16 patients accepted routine medical treatment only. RIC-related adverse events were recorded. The primary outcome was the improvement ratio of mean cerebral blood flow (mCBF) in middle cerebral artery territory measured by multidelay pseudocontinuous arterial spin labeling, and the secondary outcomes were the cumulative incidence of major adverse cerebrovascular events (MACEs), the prevalence of stenotic-occlusive progression, and periventricular anastomosis at 1-year follow-up.

Results

In total, 30 of the 34 patients with MMD completed the final follow-up (17 in the RIC group and 13 in the control group). No adverse events of RIC were observed. The mCBF improvement ratio of the RIC group was distinctively higher compared with the control group (mCBF−whole-brain: 0.16 ± 0.15 vs. −0.03 ± 0.13, p = 0.001). Stenotic-occlusive progression occurred in 11.8% hemispheres in the RIC group and 38.5% in the control group (p = 0.021). The incidence of MACE was 5.9% in the RIC group and 30.8% in the control group (hazard ratio with RIC, 0.174; 95% CI, 0.019–1.557; p = 0.118). No statistical difference was documented in the periventricular anastomosis between the two groups after treatment.

Conclusions

Remote ischemic conditioning has the potential to be a safe and effective adjunctive therapy for patients with MMD largely due to improving cerebral blood flow and slowing the arterial progression of the stenotic-occlusive lesions. These findings warrant future studies in larger trials.

Passing Extracranial Artery Occlusion by Intermediate Catheter With Expanding Microballoon (PEACE): A Novel Endovascular Therapy in Acute Tandem Occlusion Stroke

PURPOSE

Endovascular treatment of atherosclerotic tandem occlusions in acute ischemic stroke (AIS) is a matter of debate. This article reports a single-center experience using an intermediate catheter with microballoon for treatment of tandem occlusions.

METHODS

A total of 151 AIS patients with large vessel occlusion received endovascular therapy and a consecutive series of patients (n = 26) who suffered from tandem cervical intracranial occlusions were treated using the Passing Extracranial Artery Occlusion by Intermediate Catheter with Expanding Microballoon (PEACE) technique. Intracranial recanalization was achieved by aspiration or stent retriever and then emergency stenting was performed for extracranial internal carotid artery (ICA) lesion. Demographic, clinical characteristics, procedural details of endovascular therapy, and prognosis outcome were assessed. The outcomes of tandem occlusion group were compared with isolated intracranial occlusion group (n = 122) and previous studies.

RESULTS

As compared to isolated intracranial occlusion groups, only a few patients suffered from atrial fibrillation (7.7% vs 38.5%, p<0.01) in tandem occlusions group. A larger proportion of patients (61.5% vs 29.5%) had tandem occlusions in which extracranial ICA occlusion was combined with intracranial terminus occlusion in ICA (p<0.01). 46.2% of tandem occlusions patients achieved intracranial recanalization by aspiration alone versus 15.6% in patients with isolated intracranial occlusion (p<0.01). In tandem occlusion patients treated with PEACE, 92.3% achieved successful reperfusion (thrombolysis in cerebral infarct [TICI] ≥2b). The median time from puncture to recanalization was 51 minutes (interquartile range [IQR], 41-66). 67.6% favorable functional prognosis (modified Rankin score [mRS], 0-2) was seen, with 11.5% mortality and 3.8% of symptomatic intracerebral hemorrhage (sICH) at 90 days. These outcomes are all consistent or better than previously reported studies performed for tandem occlusion.

CONCLUSIONS

Endovascular therapy using the PEACE technique with intermediate catheter and lined expanding microballoon is safe, efficient, and fast in the treatment of atherosclerotic tandem occlusion patients.

Learning curves for transradial access versus transfemoral access in diagnostic cerebral angiography: a case series

BACKGROUND

The perception of a steep learning curve associated with transradial access has resulted in its limited adoption in neurointervention despite the demonstrated benefits, including decreased access-site complications.

OBJECTIVE

To compare learning curves of transradial versus transfemoral diagnostic cerebral angiograms obtained by five neurovascular fellows as primary operator.

METHODS

The first 100-150 consecutive transradial and transfemoral angiographic scans performed by each fellow between July 2017 and March 2020 were identified. Mean fluoroscopy time per artery injected (angiographic efficiency) was calculated as a marker of technical proficiency and compared for every 25 consecutive procedures performed (eg, 1-25, 26-50, 51-75).

RESULTS

We identified 1242 diagnostic angiograms, 607 transradial and 635 transfemoral. The radial cohort was older (64.3 years vs 62.3 years, p=0.01) and demonstrated better angiographic efficiency (3.4 min/vessel vs 3.7 min/vessel, p=0.03). For three fellows without previous endovascular experience, proficiency was obtained between 25 and 50 transfemoral angiograms. One fellow achieved proficiency after performing 25-50 transradial angiograms; and the two other fellows, in <25 transradial angiograms. The two fellows with previous experience had flattened learning curves for both access types. Two patients experienced transient neurologic symptoms postprocedure. Transradial angiograms were associated with significantly fewer access-site complications (3/607, 0.5% vs 22/635, 3.5%, p<0.01). Radial-to-femoral conversion occurred in 1.2% (7/607); femoral-to-radial conversion occurred in 0.3% (2/635). Over time, the proportion of transradial angiographic procedures increased.

CONCLUSION

Technical proficiency improved significantly over time for both access types, typically requiring between 25 and 50 diagnostic angiograms to achieve asymptomatic improvement in efficiency. Reduced access-site complications and decreased fluoroscopy time were benefits associated with transradial angiography.

Outcomes in Endovascular Therapy for Basilar Artery Occlusion: Intracranial Atherosclerotic Disease vs. Embolism

Acute ischemic stroke due to basilar artery occlusion (BAO) carries a very poor prognosis. Functional outcomes in BAO patients undergoing endovascular therapy (EVT) may differ according to the specific pathological mechanisms. We aimed to explore the impact of the underlying pathological mechanisms on prognosis at 90-days and long-term follow-up in BAO patients treated with EVT. We analyzed consecutive BAO patients undergoing EVT from December 2012 to December 2018 at a single center (Xuanwu Hospital). Patients were classified into either an intracranial atherosclerotic disease (ICAD) group or an embolic group according to the corresponding angiographic findings. The baseline characteristics and functional outcomes were compared between the two groups. Multivariable logistic regression analysis was performed. Among the 167 patients enrolled, 78 patients (46.7%) were in the ICAD group and 89 patients (53.3%) were assigned to the embolic group. Overall, 149 patients (89.2%) achieved successful reperfusion post-EVT. There were no significant differences in functional outcomes at 90-days and long-term follow-up between the two groups. Similarly, a Kaplan-Meier survival analysis showed similar long-term survival probabilities (P = 0.438). The pathological mechanism was not associated with functional independence (OR, 1.818; 95% CI, 0.694-4.761; P = 0.224), favorable outcome (OR, 1.476; 95% CI, 0.592-3.681; P = 0.403), or mortality (OR, 1.249; 95% CI, 0.483-3.226; P = 0.646). However, based on subgroup analysis, embolic BAO versus ICAD was significantly associated with better functional independence in those aged 60 years and younger (OR, 4.513; 95% CI, 1.138-17.902). In this study, no differences in either 90-days or long-term functional outcomes between ICAD-related BAO and embolic BAO patients undergoing EVT were observed. However, in BAO patients aged ≤ 60 years, the pathological mechanism of embolism was associated with better functional independence.

NIHSS Consciousness Score Combined with ASPECTS is a Favorable Predictor of Functional Outcome post Endovascular Recanalization in Stroke Patients

Although revascularization rates after endovascular thrombectomy for large vessel acute ischemic stroke (AIS) are high (71%), only 46% of patients achieve functional independence at 90 days. The present study was designed to explore a new method for predicting the functional prognosis of AIS patients after endovascular recanalization. A total of 200 anterior circulation stroke patients who received endovascular therapy were enrolled. Logistic regression analysis of clinical characteristics on functional independence were performed. The predictive power of sub-items in National Institute of Health stroke scale (NIHSS) and the combination of NIHSS consciousness and Alberta Stroke Program Early CT Score (ASPECTS) on functional independence were assessed by Receiver Operating Characteristic (ROC) curves and the latter was compared with 3 previously published prediction models by AUC (the area under ROC curve). The AUC for the NIHSS consciousness score to predict functional independence was higher than whole NIHSS and other sub-items (0.716 v 0.705, 0.586, 0.573, 0.552 and 0.559). Low NIHSS consciousness score, high ASPECTS score, short time from onset to recanalization, and high rate of successful recanalization were demonstrated to be significantly associated with the functional independence (OR 0.697, 2.226, 0.994 and 28.643). The prediction power of the combination was significantly better than NIHSS and ASPECTS alone (AUC 0.793 v 0.705 and 0.752). Compared with 3 other prediction models, the combination was found to be the strongest predictor for functional independence (AUC 0.793 v 0.791, 0.671 and 0.564). NIHSS which has been shown to be a strong predictor of functional outcomes after endovascular recanalization is largely dependent on the consciousness component. NIHSS consciousness score combined with ASPECTS appears to be a favorable predictor of functional independence. These findings may have broad reaching effects for isolated centers around the world without advanced imaging for triage and prognostication.

Adjuvant High-Flow Normobaric Oxygen After Mechanical Thrombectomy for Anterior Circulation Stroke: a Randomized Clinical Trial

Adjuvant neuroprotective therapies for acute ischemic stroke (AIS) have demonstrated benefit in animal studies, albeit without human translation. We investigated the safety and efficacy of high-flow normobaric oxygen (NBO) after endovascular recanalization in anterior circulation stroke. This is a prospective randomized controlled study. Eligible patients were randomized to receive high-flow NBO by a Venturi mask (FiO2 50%, flow 15 L/min) or routine low-flow oxygen supplementation by nasal cannula (flow 3 L/min) after vessel recanalization for 6 h. Patient demographics, procedural metrics, complications, functional outcomes, symptomatic intracranial hemorrhage (sICH), and infarct volume were assessed. A total of 91 patients were treated with high-flow NBO. NBO treatment revealed a common odds ratio of 2.2 (95% CI, 1.26 to 3.87) favoring the distribution of global disability scores on the mRS at 90 days. The mortality at 90 days was significantly lower in the NBO group than in the control group, with an absolute difference of 13.86% (rate ratio, 0.35; 95% CI, 0.13-0.93). A significant reduction of infarct volume as determined by MRI was noted in the NBO group. The median infarct volume was 9.4 ml versus 20.5 ml in the control group (beta coefficient, - 20.24; 95% CI, - 35.93 to - 4.55). No significant differences were seen in the rate of sICH, pneumonia, urinary infection, and seizures between the 2 groups. This study suggests that high-flow NBO therapy after endovascular recanalization is safe and effective in improving functional outcomes, decreasing mortality, and reducing infarct volumes in anterior circulation stroke patients within 6 h from stroke onset.

Rapid Intervention of Chlorpromazine and Promethazine for Hibernation-Like Effect in Stroke: Rationale, Design, and Protocol for a Prospective Randomized Controlled Trial

Background: Following an acute ischemic stroke (AIS), rapidly initiated reperfusion therapies [i. e., intravenous thrombolysis (IVT) and endovascular treatment (EVT)] demonstrate robust clinical efficacy. However, only a subset of these patients can benefit from these therapies due to their short treatment windows and potential complications. In addition, many patients despite successful reperfusion still have unfavorable outcomes. Thus, neuroprotection strategies are urgently needed for AIS patients. Chlorpromazine and promethazine (C+P) have been employed in clinical practice for antipsychotic and sedative purposes. A clinical study has also shown a neuroprotective effect of C+P on patients with cerebral hemorrhage and subarachnoid hemorrhage. The safety, feasibility, and preliminary efficacy of intravenous administration of C+P in AIS patients within 24 h of onset will be elucidated.

Methods: A prospective randomized controlled trial is proposed with AIS patients. Participants will be randomly allocated to an intervention group and a control group with a 1:1 ratio (n = 30) and will be treated with standard therapies according to the current stroke guidelines. Participants allocated to the intervention group will receive intravenous administration of C+P (chlorpromazine 50 mg and promethazine 50 mg) within 24 h of symptom onset. The primary outcome is safety (mainly hypotension), while the secondary outcomes include changes in functional outcome and infarction volume.

Discussions: This study on Rapid Intervention of Chlorpromazine and Promethazine for Hibernation-like Effect in Stroke (RICHES) will be the first prospective randomized controlled trial to ascertain the safety, feasibility, and preliminary efficacy of intravenous C+P as a neuroprotection strategy in AIS patients. These results will provide parameters for future studies, provide insights into treatment effects, and neuroprotection with phenothiazine in AIS.

Clinical Trial Registration:www.chictr.org.cn, identifier: ChiCTR2000038727.

Complete flow control using transient concurrent rapid ventricular pacing or intravenous adenosine and afferent arterial balloon occlusion during transvenous embolization of cerebral arteriovenous malformations: case series

BACKGROUND

There are no reports that describe complete flow control using concurrent transient rapid ventricular pacing or intravenous (IV) adenosine and afferent arterial balloon flow arrest to aid transvenous embolization of cerebral arteriovenous malformations (AVM). We describe our experience with the use of this technique in patients undergoing transvenous AVM embolization.

METHODS

Consecutive patients in whom transvenous embolization was attempted at our institute between January 2017 and July 2019 were included. Anatomical AVM features, number of embolization stages, technique of concurrent transient rapid ventricular pacing and afferent arterial balloon flow arrest, complications, and clinical and radiological outcomes were recorded and tabulated.

RESULTS

Transvenous AVM embolization was attempted in 12 patients but abandoned in two patients for technical reasons. Complete embolization was achieved in 10 patients, five of whom had infratentorial AVMs. All 10 had a single primary draining vein. Rapid ventricular pacing was used in nine cases; IV adenosine injection was used in one case to achieve cardiac standstill. Complete AVM nidus obliteration was achieved with excellent neurologic outcome in nine cases, with transvenous embolization alone in two cases, and with staged transarterial followed by transvenous embolization in the others. Two patients developed hemorrhagic complications intraprocedurally. One patient was managed conservatively and the other operatively with AVM excision and hematoma evacuation; both made an excellent recovery without any neurologic deficits at 3 months.

CONCLUSION

Complete flow control using concurrent transient rapid ventricular pacing with afferent arterial balloon flow arrest technique is safe and feasible for transvenous embolization of select AVMs.

Use of expandable stent retriever for mechanical thrombectomy of the right internal carotid artery terminus occlusion

Background:

Tigertriever (Rapid Medical, Sunrise, FL) is an adjustable-diameter stent retriever that is being tested in an investigational device exemption clinical trial, Treatment with Intent to Generate Reperfusion (TIGER). The retriever is available in three lengths with corresponding adjustable diameters; however, a single device cannot be used for multiple thrombectomy attempts. A clicker-based expansion mechanism allows incremental expansion of the retriever and step-wise increase in radial force to the parent vessel diameter. The clicker mechanism is used to expand the stent retriever until it is apposed with the vessel walls. Rest of the procedure is similar to a mechanical thrombectomy performed with a conventional stent retriever and is demonstrated in the video.

Case Description:

We present a case of a 59-year-old woman who presented with left-upper extremity weakness, facial droop, and hemineglect. Perfusion imaging demonstrated increased time-to-peak. Angiography showed right internal carotid artery terminus occlusion. The patient underwent successful mechanical thrombectomy (Thrombolysis in Cerebral Infarction 2b reperfusion) using the Tigertriever and was discharged home without any perioperative complications.

Conclusion:

An adjustable, expandable stent retriever allows operator to size the stent retriever to match the target artery diameter. The expandable design of stent retriever has potential implications for distal vessel occlusion mechanical thrombectomy.

Coil Occlusion of Right M2 Fusiform Aneurysm After Balloon-Test Occlusion: 2-Dimensional Video

We present a 73-year-old man with an incidental right M2 fusiform aneurysm demonstrating growth on serial noninvasive imaging over 5 years (Video 1). After multidisciplinary conference review, the decision was to proceed with intracranial balloon-test occlusion (BTO) followed by coil occlusion if the patient passed this test or by trap and bypass if the patient failed this test. With the patient under moderate conscious sedation, a transfemoral 8F approach was used with positioning of a TracStar 95-cm 088 guide catheter (Imperative Care, Campbell, California, USA) into the distal right cervical ICA. We positioned a Scepter 4-mm × 10-mm compliant dual-lumen balloon microcatheter (MicroVention, Alisa Viejo, California, USA) into the proximal M2. The patient passed the 30-minute BTO including a 15-minute hypotensive challenge with nitroprusside infusion. Our goal was to occlude the aneurysm from distal to proximal for precise thrombosis. A Phenom 17 150-cm microcatheter (Medtronic, Dublin, Ireland) separate from the Scepter balloon microcatheter was positioned in the distal portion of the aneurysm. Coil occlusion was successfully performed with an assortment of complex and helical coils. Sluggish anterograde flow was seen distal to the aneurysm with prominent retrograde filling of the distal right MCA territory via pial collaterals from the right PCA. The patient tolerated the procedure well and was discharged the following day neurologically intact. Six-month follow-up diagnostic angiogram confirmed complete occlusion of the aneurysm. This is the first published video using the elegant approach of intracranial BTO followed by coil occlusion for an intracranial fusiform aneurysm using a dual-lumen balloon microcatheter.

Treatment of Carotid Ophthalmic Aneurysm With Woven EndoBridge (WEB SL): 2-Dimensional Operative Video

Wide-necked cerebral aneurysms often require complex treatment strategies for optimal treatment. As the surgeon's arsenal continues to expand, consideration of all potential applications of available devices is important. The Woven EndoBridge (WEB) device (MicroVention-Terumo, Aliso Viejo, California) capitalizes on flow disruption to promote thrombosis and is Food and Drug Administration (FDA) approved for saccular wide-necked bifurcation aneurysms located at the middle cerebral artery bifurcation, internal carotid artery (ICA) terminus, anterior communicating artery complex, and basilar apex. In this video, we demonstrate an off-label use of the WEB to treat a wide-necked type II1 ophthalmic artery aneurysm, highlighting the importance of correct device sizing. The patient is a 74-yr-old woman with a family history of aneurysms. Her aneurysm was found incidentally after a minor trauma. Observation and various treatment options were considered. The patient preferred to avoid open surgical intervention and dual antiplatelet therapy. Endoluminal flow diversion for types II and III ophthalmic artery aneurysms has relatively low occlusion rates and a higher incidence of visual field deficits.1 A WEB device can be an excellent alternative to treat these aneurysms. A biaxial system was used to selectively catheterize the supraclinoid internal carotid artery and then the aneurysm, and optimal flow diversion was achieved. The patient did well and was discharged home the next day on aspirin alone. Six-month angiography showed near-occlusion of the aneurysm and ophthalmic artery patency. The neck remnant will be followed up with repeat angiography in 6 mo. The patient gave informed consent for the procedure and video recording. Institutional review board approval was deemed unnecessary. Video ©University at Buffalo Neurosurgery, 2019. With permission.

Measurement of instant flow reserve to quantify functional flow limitation across stenosis in intracranial atherosclerotic disease

Angiographic stenosis may not be an accurate reflection of physiological flow limitation. Measurement of instant flow reserve (IFR) to quantify functional flow limitation across stenosis may be valuable in identifying lesions causing significant flow limitation. A case of left middle cerebral artery atherosclerotic disease is presented. Because medical therapy had failed, endovascular revascularization was chosen. In this video 1, IFR measurement to guide submaximal balloon angioplasty with a 1.5×9 mm non-compliant Mini-Trek balloon (Abbott) is demonstrated. Pressure gradient across the middle cerebral artery-M1 stenosis was measured with a Volcano pressure wire (Philips) before and after submaximal balloon angioplasty. An excellent radiographic result and flow improvement into the severely stenosed segment were achieved, with an IFR increase from 0.23 to 0.89. The degree of corresponding stenosis changed from 85% to 30%. No periprocedural complication was observed. IFR can help to identify lesions requiring treatment in select patients and prevent the tendency to overtreat a lesion that is not physiologically significant.

Safety and feasibility of ulnar artery access for neuroangiography and neurointervention: a case series

BACKGROUND

Radial access has become popular among neurointerventionalists because it has favorable risk profiles compared with femoral access. Difficulties in accessing or navigating the radial artery have been viewed as a reason to convert to femoral access, but ulnar artery access may prevent complications associated with transfemoral procedures.

OBJECTIVE

To evaluate the safety and feasibility of ulnar access for neurointerventions and diagnostic neuroangiographic procedures.

METHODS

Consecutive patients who underwent diagnostic angiography or neurointerventional procedures via ulnar access between July 1, 2019 and April 15, 2020 were included. Data recorded were demographics, procedure indication, devices, technique, and complications. Descriptive analysis was performed.

RESULTS

Ulnar artery access was obtained for 21 procedures in 18 patients (mean age 70.3±7.8 years; nine men). Procedures included 13 diagnostic angiograms and eight neurointerventions (3 left middle meningeal artery embolization, 1 of which was aborted; 2 carotid artery stenting; 2 angioplasty; 1 mechanical thrombectomy for in-stent thrombosis). A right-sided approach with ultrasound guidance was used for all cases except one. Indications included small caliber radial artery (n=9), radial artery occlusion (n=10), and radial artery preservation for potential bypass (n=2). A 5-French slender sheath was used for diagnostic angiography; a 6-French slender sheath was used for neurointerventions. No case required conversion to femoral access. Two patients had minor hematomas after the procedure; one other had ulnar artery occlusion on 30-day ultrasonography.

CONCLUSION

Ulnar access is safe and feasible for diagnostic and interventional neuroangiographic procedures. It provides a useful alternative to radial access, potentially avoiding complications associated with femoral access.

Arterial spin labeling-MR may be an alternative to SPECT for evaluating cerebral perfusion in patients with unilateral middle cerebral artery stenosis

OBJECTIVE

Cerebral blood flow (CBF) mapping of single-photon emission tomography (SPECT) is considered a gold standard for evaluating cerebral perfusion. However, invasiveness, high costs and strict technical requirements can limit its clinical use. We aimed to evaluate the concordance of CBF maps obtained from SPECT and pseudo-continuous arterial spin labeling magnetic resonance (PCASL-MR) imaging for evaluating cerebral perfusion.

METHODS

PCASL-MR/SPECT-CBF maps were obtained from 16 eligible patients with unilateral middle cerebral artery stenosis (MCAS). Three slices (basal ganglia, semi-oval center and cerebellum) on both PCASL-MR and SPECT maps were divided into different regions of interest (ROIs) according to the ASPECT criterion, arterial territories, and cerebral hemispheres, respectively. The concordance of the two types of CBF maps and the specificity and sensitivity of PCASL-MR imaging on predicting regional hypoperfusion were calculated.

RESULTS

A total of 448 ROIs were divided according to the ASPECT criterion, 192 ROIs partitioned in accordance with arterial territories, and 96 ROIs delineated based on cerebral hemispheres were analyzed. PCASL-MR imaging exhibited 83.78% to 100% sensitivity, 90.19% to 95.83% specificity for detection of hypoperfusion. Qualitative analyses revealed a strong concordance between PCASL-MR and SPECT on reflecting regional cerebral hypoperfusion (Kappa coefficient = 0.662-0.920, p < 0.01). Semi-quantitative analysis by ΔCBF revealed moderate consistency (Spearman correlation coefficient = 0.610-0.571).

CONCLUSIONS

Our findings suggest that PCASL-MR may be a promising non-invasive, inexpensive alternative to SPECT for evaluating cerebral perfusion accurately in patients with symptomatic MCAS.

Transradial access for flow diversion of intracranial aneurysms: Case series

BACKGROUND

Transradial access for neurointerventions offers advantages of fewer access-site complications, reduced procedure time, and greater patient comfort over transfemoral access. Data about transradial access for flow diversion are limited. We share our early experience with transradial access for flow diversion in a relatively large case series.

METHODS

Consecutive patients who underwent Pipeline embolization device (Medtronic) deployment via transradial access were included in the study, irrespective of location and laterality of the intracranial aneurysm. The cases were performed between July 2016 and October 2019. Demographics, aneurysm characteristics, and procedure-related details (including catheter systems used) were recorded and statistically evaluated.

RESULTS

Thirty-five transradial flow diversion procedures were attempted in 32 patients, of which 33 procedures were successful. In two cases involving left common carotid artery and internal carotid artery access, guide catheter herniation into the aortic arch led to abandonment of transradial access in favor of transfemoral access. The most common aneurysm locations in the transradial access procedures were the posterior communicating artery (n = 7), ophthalmic artery (n = 7), and superior hypophyseal artery (n = 7). Most transradial access procedures (66.7%) were performed using a biaxial catheter system. 6-French Benchmark (Penumbra) and Phenom 27 (Medtronic) were the most commonly utilized guide- and microcatheters, respectively. One patient had intraprocedural subarachnoid hemorrhage. No access-site complications occurred.

CONCLUSION

This study demonstrates safety and feasibility of transradial access for Pipeline embolization device deployment and shows the versatility of this approach for different catheter systems. Tortuosity and acute angulation of the left common carotid artery and internal carotid artery were associated with approach failure.

Transradial middle meningeal artery embolization for chronic subdural hematoma using Onyx: case series

Background

Middle meningeal artery (MMA) embolization is an emerging therapy for the resolution of subacute or chronic subdural hematoma (CSDH). CSDH patients are often elderly and have several comorbidities. We evaluated our experience with transradial access (TRA) for MMA embolization using predominantly Onyx under conscious sedation.

Methods

Data for consecutive patients who underwent transradial MMA embolization for CSDH during a 2-year period (2018–2019) were analyzed from a single-center, prospectively-maintained database. Patient demographics, comorbidities, ambulatory times, subdural hematoma resorption status, and guide catheter type were recorded. Conversion to femoral access and complication rates were also recorded. Univariate and multivariate analyses were performed.

Results

Forty-six patients (mean age, 71.7±14.4 years) were included in this study. Mean CSDH size was 14±5.5 mm. Most (91.3%) TRA embolizations were performed with 6-French 0.071-inch Benchmark guide catheters (Penumbra). MMA embolization was successful in 44 patients (95.7%) (including two cases of TRA conversion). Twenty-one (48%) patients had a severe Charlson Comorbidity Index (>5). Symptomatic improvement was noted in 39 of 44 patients (88.6%). Mean length of stay was 4±3 days. Patients were ambulated immediately postprocedure. At mean follow-up (8±4 weeks), 86.4% of patients had complete or partial CSDH resolution. Persistent use of antiplatelet agents after the procedure was associated with failed or minimal CSDH resorption (5 of 6, 83.3% vs 9 of 38 23.7% with complete or near-complete resolution; P=0.009).

Conclusion

Transradial Onyx MMA embolization under conscious sedation is safe and effective for CSDH treatment. TRA may be especially useful in elderly patients with numerous comorbidities.

Asymmetric lenticulostriate arteries in patients with moyamoya disease presenting with movement disorder: three new cases

OBJECTIVE

Unilateral movement disorder associated with moyamoya disease is a rare finding and the mechanism remains to be fully elucidated. Theories postulated include contralateral cerebral ischemic or hemorrhagic lesions, and/or hypoperfusion. However, few studies have reported such patients without contralateral lesions nor hypoperfusion. This study aimed to explore the potential mechanism of those who had neither contralateral cerebral lesions nor hypoperfusion.

METHODS

Neuroradiological features of lenticulostriate arteries in three cases with unilateral movement disorder associated with moyamoya disease who had neither contralateral lesions nor hypoperfusion were mainly analyzed.

RESULTS

Angiography and 3 T black-blood T1-weighted intracranial vessel wall imaging both demonstrated a significant asymmetry between bilateral lenticulostriate arteries qualitatively and quantitatively on admission. After one-year follow-up, two patients' vessel wall imaging indicated that the asymmetry diminished, and the symptoms spontaneously resolved.

CONCLUSION

This report demonstrated that patients with moyamoya disease with unilateral movement disorder who had neither contralateral lesions nor hypoperfusion may be related to the asymmetry between bilateral lenticulostriate arteries through basal ganglia.

Mechanical thrombectomy of right internal carotid artery terminus occlusion using the ADAPT technique: impact of aspiration on parent vessel

The impact of ADAPT—“a direct aspiration first pass technique”—on intracranial vasculature is not well understood, since the change of arterial diameter is often not visible during aspiration. We present a unique case in which the impact of aspiration on the parent vessel was visualized due to a previously deployed Neuroform Atlas stent and a Pipeline embolization device. The patient presented with right internal carotid artery occlusion. An aspiration catheter was advanced over the microcatheter system and corked into the clot, located within the stents in proximal M1. The stents were seen to collapse both during electronic pump and hand aspiration with no evidence of stent migration. This demonstrates that it is crucial to engage the clot interface with the tip of the aspiration catheter while performing ADAPT. Placing the aspiration catheter remote from the clot may result in collapse of the artery proximal to the clot with subsequent ADAPT failure.(video 1)

video 1.

Clinical manifestation of non-ketotic hyperglycemia chorea: A case report and literature review

INTRODUCTION

Chorea is considered a special complication of diabetes mellitus. Here we report a case of chorea associated with non-ketotic hyperglycemia (NKH).

PATIENT CONCERNS

The patient was a 79-year-old Asian woman. She had a history of type 2 diabetes mellitus more than 30 years, but with a poor control of blood sugar. She complained of acute onset of right limb involuntary activities, and being admitted to neurology department.

DIAGNOSIS

The patient was then diagnosed with NKH chorea.

INTERVENTIONS

Intravenous infusion of insulin was given to reduce blood glucose. Haloperidol was used to control motor symptoms.

OUTCOMES

Her symptoms improved quickly after treatment. In the past year, the patient's blood sugar was well controlled and her chorea did not recur.

LESSONS

If there are sudden abnormal movements in patients, in addition to thinking of chorea, hepatolenticular degeneration and other diseases, we should also pay attention to blood sugar, especially in diabetic patients with poor blood sugar control and negative ketone, we should consider the possibility of NKK chorea.

CONCLUSIONS

NKH chorea is a special complication of diabetes.

Navigating a proximal loop in the radial artery and avoiding the recurrent radial artery

Several anatomical variations of the radial artery have been described in the literature. Common variations include radial artery loop, recurrent branch, and anastomotic channels connecting the radial and brachial arteries. These variations can pose significant technical challenges to safe radial artery catheterization. Because radial access for neurointervention is becoming popular, appreciation of these variations and mastery of techniques for safe radial artery catheterization are of paramount importance. In this operative video,(video 1) we present a case of a 75-year-old man who underwent middle meningeal artery embolization for treatment of chronic subdural hematoma using a transradial approach. The patient was found to have a radial artery loop and a recurrent branch off the radial artery. The loop could not be negotiated with the conventional technique. We therefore used a microcatheter system with a stiff microwire to navigate and straighten the radial loop under road map guidance. The remaining procedure was performed successfully.

Therapeutic occlusion of the vertebral artery using a new penumbra occlusion device system and ruby coils (penumbra): A technical note

There are several methods to achieve the therapeutic sacrifice of the vessel, coiling brings the most commonly used. Penumbra occlusion device (POD) system is a newer modality for therapeutic large vessel occlusion, and it is the Food and Drug Administration approved only for peripheral vessels. We report a case where therapeutic vertebral artery (VA) occlusion was achieved with the POD system and Ruby coils for the first time. A patient was diagnosed with a new malignant-appearing tumor of the cervical spine. A conventional angiogram showed multiple tiny arterial feeders from the VA beyond scope of coil/onyx embolization, so we performed a balloon occlusion test followed by therapeutic sacrifice of the VA. A successful VA occlusion was achieved with significant reduction in the tumor blush, followed by open resection of the tumor. The patient had favorable postoperative course and without any neurological symptoms attributed to the VA occlusion.

Distal transradial access in the anatomical snuffbox for balloon guide-assisted stentriever mechanical thrombectomy: Technical note and case report

Recent trends in neuroendovascular surgery have seen a rise in alternative access utilization. Social media feeds such as #RadialFirst or #RadialForNeuro are the beacons of a growing movement among more and more endovascular neurosurgeons, as they venture away from the traditional femoral access gravitating toward radial access. We have previously shown our distal radial access technique utilizing the snuffbox to be a reliable means of endovascular access and in addition to traditional ventral radial access provides access to the entire cerebrum. Stroke thrombectomy often encounters reticence from those who prefer transfemoral access over the radial access. Thrombectomy has been performed radially in a few series and only once previously in a case report of distal radial access for thrombectomy. Hesitance to adopt radial access for mechanical thrombectomy is often related to perceived increased access times and a lack of suitable balloon guide catheters for radial techniques. Here, we present one of the first descriptions of a distal transradial access with balloon guide flow arrest for stentriever thrombectomy.

Transradial embolization of the left middle meningeal artery and accessory middle meningeal artery for treatment of subacute-chronic subdural hematoma

This 52-year-old man with no remarkable medical history, no anticoagulation use, and no history of trauma was noted to have a subacute–chronic left subdural hematoma during outpatient headache evaluation. No occult vascular lesion or cross-calvarial supply of the right middle meningeal artery (MMA) to the left side was identified on bilateral selective external carotid injections. Because the patient preferred non-surgical management, we performed a left MMA embolization with Onyx 18 (Medtronic), utilizing a Headway Duo microcatheter (MicroVention) via the transradial route. A 6 French Benchmark (Penumbra) was utilized for transradial support into the left external carotid. The patient was discharged home the same day. Repeat scans from 2 to 6 weeks revealed complete resolution of the subdural hematoma. The patient’s headaches resolved. Transradial MMA embolization for subacute–chronic subdural hematoma represents a minimally invasive treatment option for mass effect and hemorrhage-related symptoms. Tailored embolizations are necessary when >1 meningeal vessel supplies the subdural hematoma.

Blood-brain Barrier Disruption May Contribute to White Matter Lesions in the Setting of Internal Jugular Venous Stenosis

BACKGROUND AND PURPOSE

Cloudy white matter lesions are associated imaging features of internal jugular venous stenosis (IJVS). However, the mechanism of the IJVS associated cloudy white matter lesions is still unclear. This study aims to evaluate blood-brain barrier integrity of the patients with IJVS.

MATERIALS AND METHODS

A total of 45 eligible patients with IJVS confirmed by computed tomography venography (CTV) and 45 healthy controls were enrolled into this study. The levels of serum MMP-9 and the markers of tight junctions, including occludin and ZO-1 obtained from IJVS patients and control group were tested by enzyme-linked immune-sorbent assay and compared.

RESULTS

Both the levels of serum MMP-9 (0.2ng/ml) and occludin (0.05ng/ml) in IJVS group were higher than in the control group (0.01ng/ml vs. 0 ng/ml, all p<0.001). While, the levels of serum ZO-1 showed no statistical significance between the two groups (0.55ng/ml vs 0.735ng/ml, P=0.34). The levels of serum MMP-9 between the subset with or without white matter lesions in IJVS group showed a significant difference (0.22 [0.06, 0.43] vs. 0.01 [0.01, 0.06], P =0.019).

CONCLUSION

BBB disruption may participate in the formation of IJVS-associated white matter lesions; the mechanism of BBB disruption may involve MMP-9 and occludin.

Clinical trials of neurointervention : 2007-2018

BACKGROUND

ClinicalTrials.gov is one of the largest trials' registries in the world.

OBJECTIVE

To leverage the ClinicalTrials.gov database to define the portfolio of clinical trials of neurointervention.

METHODS

We restricted our extraction to interventional clinical trials submitted between 2007 and 2018, and included MeSH terms that are part of the nervous system (n=19 344) or cardiovascular disease (n=19 234) categories and included a list of neurointerventional terms. The characteristics of trials, geographic distribution, dissemination, and funding sources were explored using descriptive and regression models.

RESULTS

A total of 206 neurointerventional clinical trials across 1691 medical centers were identified. Acute stroke was the most studied conditions (68, 33%), followed by aneurysms (63, 31%), carotid stenosis (48, 24%), intracranial atherosclerotic disease (7, 3.5%), cerebral venous thrombosis (6, 3%), arteriovenous malformation (4, 2%), idiopathic intracranial hypertension (3, 1.5%), and others (6, 3%). Overall, 59 (29%) trials were completed, 79 (37%) were active trials (28% recruiting), and 22 (11%) were terminated or suspended. Academic centers and industry were the most common primary funding source (63% and 29%, respectively), with no funding source reported in 16 (7.7%) trials. Among 77 completed or terminated trials, only 9 (11.7%) trials reported findings within 12 months. Median time to publication for trials funded by academia was 1.66 years (interquartile range (IQR) 0.7-2.1) versus 2.1 years (IQR 1.2-3.25) for industry-funded studies.

CONCLUSIONS

A low dissemination rate for results and a high rate of study non-completion, as well as lack of geographic dispersion of trials appear to be major challenges in the field.

Cervical spondylodiscitis caused by Candida albicans in a non-immunocompromised patient: A case report and review of literature

Background:

Fungal cervical spondylodiscitis is rare and accounts for less than 1% of all cervical, thoracic, and lumbar vertebral osteomyelitis and discitis.

Case Description:

A 32-year-old non-immunocompromised male presented with persistent neck pain and paresthesias. The magnetic resonance imaging of the cervical spine demonstrated a contrast-enhancing erosive lesion involving the cervical C6 and C7 vertebral bodies accompanied by epidural phlegmon. Blood culture was negative. The patient underwent a C6 and C7 anterior corpectomy with instrumented fusion (e.g., expandable cage C5 to T1). Intraoperatively, frank pus was noted within the C6-C7 disc space and was accompanied by thick prevertebral and epidural phlegmon extending from C5 to T1. Intraoperative cultures grew Candida albicans. Three days later, a C6-C7 laminectomy with C4-T2 posterior instrumented fusion was performed; the cultures again grew C. albicans. The patient was treated with intravenous micafungin for 14 days followed by 6–12 months of 400 mg oral fluconazole daily.

Conclusion:

There are few cases in literature where non-immunocompromised patients developed fungal cervical spondylodiscitis. Prompt diagnosis and appropriate management are critical to effectively treat these patients. Surgical intervention may warrant corpectomy, discectomy, and operative debridement followed by long-term targeted antifungal therapy.

Styloidectomy and Venous Stenting for Treatment of Styloid-Induced Internal Jugular Vein Stenosis: A Case Report and Literature Review

BACKGROUND

Internal jugular vein stenosis (IJVS) results in poor venous outflow and can result in intracranial hypertension. Venous stenting has become a debated topic for correction of this pathology.

CASE DESCRIPTION

A 49-year-old male merchant with bilateral IJVS presented with headache, dizziness, and pulsatile tinnitus. He was found to have intracranial hypertension and left IJVS caused by styloid process compression and right IJVS caused by damage of the venous intima. His symptoms improved after undergoing styloidectomy followed by left intra-internal jugular vein (IJV) balloon. However, 1 year later, the prior symptoms reoccurred. At this time, the patient underwent right intra-IJV stenting. After treatment of the contralateral side, the symptoms resolved during the following 3 months.

CONCLUSIONS

The clinical practice in this case indicated that in patients with bilateral IJVS, a 2-side intervention may be necessary when unilateral correction fails. We advise a staged approach to correction of bilateral IJVS. Styloid compression-induced IJVS should be corrected by styloidectomy in combination with balloon and/or stenting, whereas IJVS induced by venous wall issues needs only stenting.

Long-term Outcomes of Cerebral Venous Sinus Stenosis Corrected by Stenting

Background and Purpose:

Cerebral Venous Sinus Stenosis (CVSS) usually results in severe Intracranial Hypertension (IH), which can be corrected by stenting immediately. However, there is a lack of evidence of the long-term good outcomes in patients with CVSS who underwent stenting.

Methods:

A total of 62 patients with imaging confirmed non-thrombotic and non-external compression CVSS were enrolled into this single center real-world cohort study after undergoing stenting, and were continuously followed up for more than 12 years. The symptoms and signs of IH prior to stenting and post-stenting and the incidence of restenosis after stenting were analyzed.

Results:

The mean age of the 62 patients (range, 13 to 62) was 40 years old, and the mean body mass index was 26 (range 23 to 40). Females accounted for 67.7% (42/62). Headache was the most common symptom (79%). Transient visual obscurations occurred in 69% of the patients. 42% of the patients suffered from visual loss, 11.3% pulsatile tinnitus, and 96.8% Papilledema before stenting. The mean trans-stenotic pressure gradients were 6~43 mmHg prior to stenting and returned to 0~4 mmHg after stent placement. During the following 12~126 months (the median was 62) after stenting of the follow-up, 91.9% (57/62) of the patients obtained good outcomes. Headaches disappeared in 96% (47/49) of the patients and papilledema was attenuated in 98.3% (59/60). However, There were still 8.0 % (5/62) of the patients with poor outcomes, including optic disc atrophy in 3 patients and stent-interior thrombosis in 2 patients, which occurred 6.3 months after stenting.

Conclusion:

Our data suggest that stenting may be a promising therapy for CVSS correcting. Patients with CVSS may get long-term benefit from stenting, especially when they are accompanied with severe IH

Predictive analytics and machine learning in stroke and neurovascular medicine

Advances in predictive analytics and machine learning supported by an ever-increasing wealth of data and processing power are transforming almost every industry. Accuracy and precision of predictive analytics have significantly increased over the past few years and are evolving at an exponential pace. There have been significant breakthroughs in using Predictive Analytics in healthcare where it is held as the foundation of precision medicine. Yet, although the research in the field is expanding with the profuse volume of papers applying machine learning algorithms to medical data, very few have contributed meaningfully to clinical care. This lack of impact stands in stark contrast to the enormous relevance of machine learning to many other industries. Regardless of the status of its current contribution, the field of predictive analytics is expected to fundamentally change the way we diagnose and treat diseases, as well as the conduct of biomedical science research. In this review, we describe the main tools and techniques in predictive analytics and will analyze the trends in application of these techniques over the recent years. We will also provide examples of its application in medicine and more specifically in stroke and neurovascular research and outline current limitations.

Clinical potential of pre-reperfusion hypothermia in ischemic injury

The damage caused by ischemic stroke is mostly refractory to medical therapies and amounts to a substantial degree of mortality and morbidity in the world. The core tenet of treatment for acute ischemic stroke (AIS) is to save 'reversible' ischemic tissue (ischemic penumbra) as quickly as possible within a limited therapeutic time window. The neuroprotective effect of hypothermia has been proven previously in a large number of animal experiments and clinical trials. Some of these animal and human studies have shown that pre-reperfusion hypothermia can reduce myocardial infarction and improve clinical outcomes. However, to date, there is little research about hypothermia before reperfusion in the animal model and human study of AIS. This review will explore possible benefits of the application of pre-reperfusion hypothermia in the setting of AIS.

High Intensity Physical Rehabilitation Later Than 24 h Post Stroke Is Beneficial in Patients: A Pilot Randomized Controlled Trial (RCT) Study in Mild to Moderate Ischemic Stroke

Objective: Very early mobilization was thought to contribute to beneficial outcomes in stroke-unit care, but the optimal intervention strategy including initiation time and intensity of mobilization are unclear. In this study, we sought to confirm the rehabilitative effects of different initiation times (24 vs. 48 h) with different mobilization intensities (routine or intensive) in ischemic stroke patients within three groups.

Materials and Methods: We conducted a randomized and controlled trial with a blinded follow-up assessment. Patients with ischemic stroke, first or recurrent, admitted to stroke unit within 24 h after stroke onset were recruited. Eligible subjects were randomly assigned (1:1:1) to 3 groups: Early Routine Mobilization in which patients received < 1.5 h/d out-of-bed mobilization within 24–48 h after stroke onset, Early Intensive Mobilization in which patients initiated ≥3 h/d mobilization at 24–48 h after the stroke onset, and Very Early Intensive Mobilization in which patients received≥3 h/d mobilization within 24 h. The modified Rankin Scale score of 0–2 was used as the primary favorable outcome.

Results: We analyzed 248 of the 300 patients (80 in Early Routine Mobilization, 82 in Very Early Intensive Mobilization and 86 in Early Intensive Mobilization), with 52 dropping out (20 in Early Routine Mobilization, 18 in Very Early Intensive Mobilization and 14 in Early Intensive Mobilization). Among the three groups, the Early Intensive Mobilization group had the most favorable outcomes at 3-month follow-up, followed by patients in the Early Routine Mobilization group. Patients in Very Early Intensive Mobilization received the least odds of favorable outcomes. At 3 month follow up, 53.5%, (n = 46) of patients with Early Intensive Mobilization showed a favorable outcome (modified Rankin Scale 0–2) (p = 0.041) as compared to 37.8% (n = 31) of patients in the Very Early Intensive Mobilization.

Conclusions: Post-stroke rehabilitation with high intensity physical exercise at 48 h may be beneficial. Very Early Intensive Mobilization did not lead to a favorable outcome at 3 months.

Clinical Trial Registration:www.chictr.org.cn, identifier ChiCTR-ICR-15005992.

Concordance between the interictal focal EEG pattern and MRI lesions as a predictor of a favorable surgical outcome in patients with epileptic spasms: a Chinese study

OBJECTIVE

The aim of this study was to evaluate the electro-clinical features, etiology, treatment, and postsurgical seizure outcomes in patients with intractable epileptic spasms (ESs).

METHODS

The authors retrospectively studied the medical records of all patients who had presented with medically intractable ESs and had undergone surgery in the period between October 2009 and August 2015. The interictal electroencephalography (EEG) pattern, MRI studies, magnetoencephalography findings, and postsurgical seizure outcomes were compared.

RESULTS

Twenty-six patients, 12 boys and 14 girls (age range 3-22 years), were eligible for study inclusion. Of these 26 patients, 84.6% (22) presented with multiple seizure types including partial seizures (PSs) independent of the ESs (30.8%); ESs followed by tonic seizures (30.8%); myoclonic seizures (19.2%); tonic seizures (19.2%); ESs followed by PSs (19.2%); focal seizures with secondary generalization (15.4%); atypical absence (11.5%); PSs followed by ESs (7.7%); and myoclonic followed by tonic seizures (7.7%). Seventeen patients underwent multilobar resection and 9 underwent unilobar resection. At the last follow-up (mean 36.6 months), 42.3% of patients were seizure free (outcome classification [OC] 1), 23.1% had > 50% reduction in seizure frequency (OC2-OC4), and 34.6% had < 50% reduction in seizure frequency or no improvement (OC5 and OC6). Predictors of favorable outcomes included an interictal focal EEG pattern and concordance between interictal EEG and MRI-demonstrated lesions (p = 0.001 and 0.004, respectively).

CONCLUSIONS

A favorable surgical outcome is achievable in a highly select group of patients with ESs secondary to structural lesions. Interictal EEG can help in identifying patients with the potential for favorable resective outcomes.

Batroxobin in combination with anticoagulation may promote venous sinus recanalization in cerebral venous thrombosis: A real-world experience

Aims

The objective of this study was to evaluate cerebral venous recanalization with magnetic resonance black‐blood thrombus imaging (MRBTI) in patients with cerebral venous thrombosis (CVT) who underwent batroxobin treatment in combination with anticoagulation.

Methods

A total of 31 CVT patients were enrolled in this real‐world registry study. The patients were divided into batroxobin (n = 21) and control groups (n = 10). In addition to the same standard anticoagulation as in the control group, patients in the batroxobin group underwent intravenous batroxobin for a total of three times.

Results

In the batroxobin group compared with the control group, we found better odds of recanalization degree [adjusted OR (95%CI) of 8.10 (1.61‐40.7)] and segment‐stenosis attenuation [adjusted OR (95%CI) of 4.48 (1.69‐11.9)] with batroxobin treatment. We further noted a higher ratio of patients with the attenuation of stenosis [adjusted OR (95%CI) of 26.4 (1.10‐635)]; as well as a higher ratio of segments with stenosis reversion [adjusted OR (95%CI) of 4.52 (1.48‐13.8)]. However, neurological deficits between the two groups showed no statistical difference at 90‐day follow‐up (P > 0.05).

Conclusions

Batroxobin may promote venous sinus recanalization and attenuate CVT‐induced stenosis. Further randomized study of this promising drug may be warranted to better delineate the amount of benefit.

Retained Solitaire FR device after mechanical thrombectomy: Case review and management strategies

Solitaire FR device is a Food and Drug Administration-approved device for mechanical thrombectomy. It has been tested in various clinical trials for its safety and efficacy. We report a case of inadvertent detachment of the Solitaire FR device at stent-stent wire interface while performing mechanical thrombectomy. We review a rare phenomenon of retained Solitaire FR stent retriever in situ and discuss technique of avoidance and its management.

Efficacy of stenting in patients with cerebral venous sinus thrombosis-related cerebral venous sinus stenosis

BACKGROUND

Venous stenting has been proven to be a safe and effective therapeutic option for patients with idiopathic intracranial hypertension (IIH) and cerebral venous sinus stenosis (CVSS). However, its use in patients with cerebral venous sinus thrombosis-related CVSS has been less reported.

PURPOSE

To explore the safety and efficacy of stenting for patients with cerebral venous sinus thrombosis (CVST)-related CVSS.

METHODS

The clinical presentation, treatment, and outcome of patients with CVST-related CVSS received venous stenting in the chronic stage after failed medical treatment were retrospectively evaluated.

RESULTS

A total of 17 patients with CVST-related CVSS were included. Mean pressure gradient across the CVSS decreased from 11.5±4.2 mmHg prior to stenting to 2.1±1.1 mmHg post- stenting. Mean CSF opening pressure decreased from 33.1±5.5 cmH₂O to 18.7±1.7 cmH₂O. Both headache and visual disturbance improved or resolved in 78% and 92% of the patients, respectively. Complications included lethal cerebellar hematoma in one case and bilateral occipital epidural hematoma in another case. One of the patients received retreatment with ventriculo-peritoneal shunting due to recurrent headache.

CONCLUSION

Restoring the patency of stenotic sinuses with stents in patients of CVST-related CVSS unresponsive to medical therapy in the chronic stage may improve symptoms in the majority of the patients. However, a relatively higher cerebral hemorrhage rate was observed and may be related to this pathology. Stenting in this subgroup of CVSS patients may require further evaluation with a larger and long-term study, and should be used with caution at this time.