Evaluation of short- and long-term results of Y-stent-assisted coiling with Leo stents in endovascular treatment of wide-necked intracranial bifurcation aneurysms.

PURPOSE: This study aimed to evaluate the feasibility, safety, and efficacy of Y-stent-assisted coiling (Y-SAC) using LEO Baby® stents in treating of bifurcation aneurysms. METHODS: Patients who underwent Y-SAC using a braided stent (LEO Baby®, Montmorency, France) for wide-necked intracranial aneurysms between 2009 and 2019 and whose radiological and clinical follow-up data for at least 6 months could be obtained were evaluated. Data were obtained from patient records and analyzed retrospectively. RESULTS: We evaluated 111 patients with a mean age of 56.0 ± 10.8 years (range, 25-88 years). Most of the aneurysms were detected incidentally. Three patients had ruptured aneurysms. LEO Baby deployment and coiling were successful in all patients. Immediate aneurysm occlusion rates were determined as modified Raymond-Roy classification (mRRC) I 95.5% (n = 106), mRRC II 3.6% (n = 4), mRRC IIIa 0.9% (n = 1). In the sixth month, aneurysm occlusion rates were found to be complete and nearly complete in all patients (mRRC I 94.6%, n = 105 and mRRC II 4.5%; n = 5, respectively). Follow-up data of 91 patients for > 2 years were obtained. Of these, 88 had MRRCI obstruction and 3 had MRRC II obstruction. The overall complication rate was 4.8%, and one patient died during the post-procedural follow-up. CONCLUSION: The long-term follow-up results of Y-stenting with LEO Baby revealed that it provides stable closure of the aneurysm sac while preserving the main arterial structures. Therefore, it is a safe, durable, and effective method for treating wide-necked and complex bifurcation aneurysms.

Safety and efficacy of flow diverter stents in the treatment of middle cerebral artery aneurysms: a single-center experience and follow-up data

PURPOSE: This study aims to evaluate the safety and efficacy of flow diverters (FDs) in the treatment of middle cerebral artery (MCA) aneurysms and share the follow-up (F/U) results. METHODS: The treatment and F/U results of 76 MCA aneurysms treated with the flow re-direction endoluminal device (FRED), FRED Jr., and pipeline embolization device (PED) FD stents were evaluated retrospectively. The aneurysm occlusion rates were compared between FDs, and the integrated and jailed branches were evaluated through follow-ups. The oversizing of the stent was compared between occluded/non-occluded aneurysms and integrated branches. RESULTS: The mean F/U duration was 32 ± 6.3 months, and the mean aneurysm diameter was 4.45 mm. A total of 61 (80.3%) aneurysms were wide-necked; 73 (96.1%) were saccular; 52 (68.4%) were located at the M1 segment; and 36 (45.6%) FREDs, 23 (29.1%) FRED Jr.s, and 19 (24.1%) PEDs were used for treatment. The overall occlusion rates for the 6-, 12-, 24-, 36-, and 60-month digital subtraction angiographies were 43.8%, 63.5%, 73.3%, 85.7%, and 87.5% respectively. The last F/U occlusion rates were 67.6% for FRED, 66.7% for PED, and 60.6% for FRED Jr. (P = 0.863). An integrated branch was covered with an FD during the treatment of 63 (82.8%) aneurysms. A total of six (10%) of the integrated branches were occluded without any symptoms at the last F/U appointment. The median oversizing was 0.45 (0-1.30) for occluded aneurysms, and 0.50 (0-1.40) for non-occluded aneurysms (P = 0.323). The median oversizing was 0.70 (0.45-1.10) in occluded integrated branches and 0.50 (0-1.40) in non-occluded branches (P = 0.131). In-stent stenosis was seen in 22 (30.1%) of the stents at the 6-month F/U and in only 2 (4.7%) at the 24-month F/U. Thus, none of the patients had any neurological deficits because of the in-stent stenosis. Severe in-stent stenosis was seen in two stents. CONCLUSION: MCA aneurysms tend to be complex, with integrated branches and potentially wide necks. FD stents are safe and effective in the treatment of MCA aneurysms, and the patency of the side and jailed branches is preserved in most cases. Higher occlusion and lower in-stent stenosis rates are seen with longer F/U durations.

Increased prevalence of blister aneurysm formation during the COVID-19 pandemic.

BACKGROUND: Intracranial blister aneurysms are a rare and an historically difficult to treat subset of aneurysms. They are distinct from typical saccular aneurysms with different pathophysiology and treatment options. METHODS: A prospectively maintained database of subarachnoid hemorrhage patients was queried for those presenting prior to the pandemic (2017-2019), and those presenting during the height of the pandemic in our locality (2021). Aneurysm characteristics and patient demographics associated with rupture risk/formation were collected. RESULTS: 334 aneurysmal subarachnoid hemorrhage patients were reviewed. 86 of these patients presented in 2021, with a statistically significant increase in the proportion of ruptured ICA blister aneurysms as compared to 2017-2019 (7/86, 8% vs 5/248, p = .02). Mean patient age, presenting grade, other aneurysm location proportions, aneurysm size, and incidence of delayed cerebral ischemia were not different between the groups. CONCLUSIONS: Patients presenting with SAH during the height of the SARS-CoV-2 pandemic in 2021 were more likely to have ICA blister type aneurysms.

Brain dural arteriovenous fistulas in the COVID-19 Era: A warning and rationale for association.

OBJECTIVES: Brain dural arteriovenous fistulas(bDAVFs) are anomalous connections between dural arteries and cerebral veins or sinuses. Cerebral venous thrombosis(CVT) often precedes or coincides with bDAVFs and is considered a risk factor for these vascular malformations. Recently, vaccine-induced thrombotic thrombocytopenia causing CVTs has been associated with COVID-19 vaccines. Concurrently with the start of massive vaccination in our region, we have observed a fivefold increase in the average incidence of bDAVFs. Our objective is to raise awareness of the potential involvement of COVID-19 vaccines in the pathogenesis of bDAVF. METHODS: A retrospective review of demographic, clinical, radiological, COVID-19 infection and vaccination data of patients diagnosed with bDAVFs between 2011 and 2021 was conducted. Patients were divided into two cohorts according to their belonging to pre- or post-COVID-19 vaccination times. Cohorts were compared for bDAVFs incidences and demographic and clinical features. RESULTS: Twenty-one bDAVFs were diagnosed between 2011 and 2021, 7 of which in 2021. The mean age was 57.7 years, and 62 % were males. All cases except one were treated; of them, 85 % exclusively managed with surgery. All treated cases were successfully occluded. The incidence in 2021 was significantly higher than that in the prevaccination period (1.72 vs 0.35/100,000/year;p = 0.036; 95 %Confidence Interval=0.09-2.66). Cohorts were not different in age, sex, hemorrhagic presentation, dural sinus thrombosis or presence of prothrombotic or cardiovascular risk factors. CONCLUSION: The significant increase in the incidence of bDAVF following general vaccination policies against COVID-19 observed in our region suggests a potential correlation between these two facts. Our findings need confirmation from larger cohorts and further pathogenic research.

Robotics in neurointerventional surgery: a systematic review of the literature.

BACKGROUND: Robotically performed neurointerventional surgery has the potential to reduce occupational hazards to staff, perform intervention with greater precision, and could be a viable solution for teleoperated neurointerventional procedures. OBJECTIVE: To determine the indication, robotic systems used, efficacy, safety, and the degree of manual assistance required for robotically performed neurointervention. METHODS: We conducted a systematic review of the literature up to, and including, articles published on April 12, 2021. Medline, PubMed, Embase, and Cochrane register databases were searched using medical subject heading terms to identify reports of robotically performed neurointervention, including diagnostic cerebral angiography and carotid artery intervention. RESULTS: A total of 8 articles treating 81 patients were included. Only one case report used a robotic system for intracranial intervention, the remaining indications being cerebral angiography and carotid artery intervention. Only one study performed a comparison of robotic and manual procedures. Across all studies, the technical success rate was 96% and the clinical success rate was 100%. All cases required a degree of manual assistance. No studies had clearly defined patient selection criteria, reference standards, or index tests, preventing meaningful statistical analysis. CONCLUSIONS: Given the clinical success, it is plausible that robotically performed neurointerventional procedures will eventually benefit patients and reduce occupational hazards for staff; however, there is no high-level efficacy and safety evidence to support this assertion. Limitations of current robotic systems and the challenges that must be overcome to realize the potential for remote teleoperated neurointervention require further investigation.

Hemodynamic differences by increasing low profile visualized intraluminal support (LVIS) stent local compaction across intracranial aneurysm orifice.

BACKGROUND: The Low-profile Visualized Intraluminal Support device (LVIS) has been successfully used to treat cerebral aneurysm, and the push-pull technique has been used clinically to compact the stent across aneurysm orifice. Our aim was to exhibit the hemodynamic effect of the compacted LVIS stent. METHODS: Two patient-specific aneurysm models were constructed from three-dimensional angiographic images. The uniform LVIS stent, compacted LVIS and Pipeline Embolization Device (PED) with or without coil embolization were virtually deployed into aneurysm models to perform hemodynamic analysis. Intra-aneurysmal flow parameters were calculated to assess hemodynamic differences among different models. RESULTS: The compacted LVIS had the highest metal coverage across the aneurysm orifice (case 1, 46.37%; case 2, 67.01%). However, the PED achieved the highest pore density (case 1, 19.56 pores/mm2; case 2, 18.07 pores/mm2). The compacted LVIS produced a much higher intra-aneurysmal flow reduction than the uniform LVIS. The PED showed a higher intra-aneurysmal flow reduction than the compacted LVIS in case 1, but the results were comparable in case 2. After stent placement, the intra-aneurysmal flow was further reduced as subsequent coil embolization. The compacted LVIS stent with coils produced a similar reduction in intra-aneurysmal flow to that of the PED. CONCLUSIONS: The combined characteristics of stent metal coverage and pore density should be considered when assessing the flow diversion effects of stents. More intra-aneurysmal flow reductions could be introduced by compacted LVIS stent than the uniform one. Compared with PED, compacted LVIS stent may exhibit a flow-diverting effect comparable to that of the PED.

Hypoplastic internal carotid artery ending as an ophthalmic artery with multiple cerebral aneurysms, fenestrated Acom and triple A2.

A rare case of a hypoplastic internal carotid artery (ICA) terminating in the ophthalmic artery with multiple intracranial saccular aneurysms in the contralateral ICA, anterior communicating artery fenestration and triple A2 was identified. The aetiology and pathogenesis of ICA hypoplasia are subjected to certain hypotheses. Developing several collaterals to preserve the blood supply of the ipsilateral cerebral hemisphere could result in aneurysm formation due to flow overload on the contralateral vasculature, but it could also result in hemicranial hypoplasia, cerebral atrophy and deep watershed infarcts, as in our case.

Focal Cerebral Arteriopathy in a Young Adult Following SARS-CoV2 Reinfection.

Ten days after SARS-Cov2 reinfection with mild gastrointestinal symptoms and headache that occurred 2 months after an initial infection, a previously healthy 37-year-old woman developed fluctuating facial and upper limb paresthesia and weakness. Diffusion-weighted magnetic resonance imaging revealed ischemic lesions in the right parietal region of different stages within the same vascular territory. A cerebral angiography demonstrated an isolated focal arteriopathy with no other arterial involvement. Focal cerebral arteriopathy is exceedingly rare among adults and most commonly triggered by varicella-zoster virus reactivation. We present a case of focal cerebral arteriopathy in a patient with a recent reinfection with SARS-CoV-2.

Contained Rupture of a Posterior Communicating Artery Aneurysm in a Patient With a Third Nerve Palsy.

ABSTRACT: It is recommended that every patient with a new third nerve palsy undergo urgent neuroimaging (computed tomography angiography or magnetic resonance angiography) to exclude a posterior communicating artery aneurysm. Because of the novel coronavirus (COVID-19) pandemic, our institution noted a significant decline in the number of patients with aneurysmal subarachnoid hemorrhage presenting to the hospital. We report one such example of a patient who developed new-onset severe headache and vomiting and did not seek medical attention because of COVID-19. Two months later, she was noted to have ptosis during a routine follow-up and was found to have a complete, pupil-involving third nerve palsy. Computed tomography angiography was performed and revealed an irregular bilobed saccular aneurysm (7 × 9 × 5 mm) of the right posterior communicating (PComm) artery, but no acute hemorrhage was visible on CT. On MRI, immediately adjacent to the aneurysm, there was a small subacute hematoma in the right medial temporal lobe with surrounding vasogenic edema. This case had a fortunate and unique outcome as she had a contained hematoma adjacent to the ruptured PComm aneurysm and did not experience severe morbidity from the subarachnoid hemorrhage nor did she rebleed in the interval in which she did not seek care. This case highlights the importance of providing neuro-ophthalmic care even during a pandemic.

Utility of Apical Lung Assessment on Computed Tomography Angiography as a COVID-19 Screen in Acute Stroke.

BACKGROUND AND PURPOSE: Evaluation of the lung apices using computed tomography angiography of the head and neck during acute ischemic stroke (AIS) can provide the first objective opportunity to screen for coronavirus disease 2019 (COVID-19). METHODS: We performed an analysis assessing the utility of apical lung exam on computed tomography angiography for COVID-19-specific lung findings in 57 patients presenting with AIS. We measured the diagnostic accuracy of apical lung assessment alone and in combination with patient-reported symptoms and incorporate both to propose a COVID-19 era AIS algorithm. RESULTS: Apical lung assessment when used in isolation, yielded a sensitivity of 0.67, specificity of 0.93, positive predictive value of 0.19, negative predictive value of 0.99, and accuracy of 0.92 for the diagnosis of COVID-19, in patients presenting to the hospital for AIS. When combined with self-reported clinical symptoms of cough or shortness of breath, sensitivity of apical lung assessment improved to 0.83. CONCLUSIONS: Apical lung assessment on computed tomography angiography is an accurate screening tool for COVID-19 and can serve as part of a combined screening approach in AIS.

Transcranial Doppler Ultrasound Evidence of Active Cerebral Embolization in COVID-19.

OBJECTIVE: To report six consecutive patients with confirmed coronavirus disease-2019 (COVID-19) who underwent Transcranial Doppler (TCD) ultrasonography evaluation for cerebral microemboli in the setting of suspected or confirmed acute ischemic stroke. METHODS: Patient data were obtained from medical records from Northwestern Memorial Hospital, Chicago, IL between May and June 2020. All patients with confirmed COVID-19 who underwent clinical TCD ultrasonography for microemboli detection were included. RESULTS: A total of eight TCD studies were performed in six patients with COVID-19 (4 men and 2 women, median age 65±5), four with confirmed ischemic stroke and two with refractory encephalopathy. Microemboli were detected in three male patients, two patients had suffered a confirmed ischemic stroke and one who developed prolonged encephalopathy. Microemboli of varying intensity were identified in multiple vascular territories in two patients, and microemboli persisted despite therapeutic anticoagulation in a third patient. Of the three patients without evidence of microemboli on TCD ultrasonography, two patients had suffered a confirmed ischemic stroke, while one remained with refractory encephalopathy. CONCLUSIONS: TCD ultrasonography for microemboli detection identified three patients with confirmed COVID-19 with evidence of cerebral arterial microemboli, including one who was therapeutically anticoagulated. TCD ultrasonography provides a non-invasive method for evaluating cerebral microemboli in patients with COVID-19 and may be useful in assessing response to treatment in cases with suspected or confirmed disorders of hypercoagulability. Further studies investigating the prevalence of cerebral microemboli and associated risk factors are needed to characterize their pathogenic mechanism and guide therapeutic interventions in hospitalized COVID-19 patients.

Cerebral Venous Sinus Thrombosis in the COVID-19 Pandemic.

BACKGROUND: Recent studies have noted concern for increased thromboembolic events in the setting of Coronavirus Disease 2019 (COVID-19). Cerebral venous sinus thrombosis (CVST) is a form of thromboembolism that has been observed as a neuro-ophthalmologic complication of COVID-19. METHODS: Review of the scientific literature. RESULTS: In this article, we report an overview of CVST epidemiology, clinical presentation, diagnostics, disease pathophysiology, and management in the setting of COVID-19. CONCLUSION: CVST is an uncommon thromboembolic event with variable phenotypes and multiple etiologies. Neurologic complications can be severe, including significant visual deficits and death. Current observations suggest that the risk of CVST may be profoundly impacted by this novel COVID-19 pandemic, thus prompting increased attention to disease presentation, pathogenesis, and management.

Mechanical Thrombectomy of COVID-19 positive acute ischemic stroke patient: a case report and call for preparedness.

BACKGROUND: The novel coronavirus (COVID-19) global pandemic is associated with an increased incidence of acute ischemic stroke (AIS) secondary to large vessel occlusion (LVO). The treatment of these patients poses unique and significant challenges to health care providers requiring changes in existing protocols. CASE PRESENTATION: A 54-year-old COVID-19 positive patient developed sudden onset left hemiparesis secondary to an acute right middle cerebral artery occlusion (National Institutes of Health Stroke Scale (NIHSS) score = 11). Mechanical thrombectomy (MT) was performed under a new protocol specifically designed to maximize protective measures for the team involved in the care of the patient. Mechanical Thrombectomy was performed successfully under general anesthesia resulting in TICI 3 recanalization. With regards to time metrics, time from door to reperfusion was 60 mins. The 24-h NIHSS score decreased to 2. Patient was discharged after 19 days after improvement of her pulmonary status with modified Rankin Scale = 1. CONCLUSION: Patients infected by COVID-19 can develop LVO that is multifactorial in etiology. Mechanical thrombectomy in a COVID-19 confirmed patient presenting with AIS due to LVO is feasible with current mechanical thrombectomy devices. A change in stroke workflow and protocols is now necessary in order to deliver the appropriate life-saving therapy for COVID-19 positive patients while protecting medical providers.