Acute isolated posterior cerebral artery stroke treated with mechanical thrombectomy: A single-center experience and review of the literature.

BACKGROUND: Acute isolated posterior cerebral artery (PCA) occlusions account for 5-10% of all ischemic events. Due to peculiar patient presentation, the potential benefit of mechanical thrombectomy (MT) remains controversial. We evaluated the safety, feasibility, and effectiveness of MT in our patients and compared our results with the literature review conducted. METHODS: Charts were reviewed retrospectively for consecutive patients diagnosed with acute PCA stroke who underwent MT. Demographics, procedural, and follow-up details were noted. For the literature review, a systematic search of PubMed, MEDLINE, and EMBASE databases was conducted for the keywords "posterior cerebral artery" and "thrombectomy" for articles published between January 1, 2010 and June 30, 2021. Estimated rates for recanalization, favorable outcomes (modified Rankin Scale [mRS] score 0-2), symptomatic intracerebral hemorrhage (sICH), and mortality were extracted. RESULTS: Our cohort included 21 patients. Mean age was 71.2 years (standard deviation [SD] ± 10.2). Median National Institutes of Health Stroke Scale (NIHSS) presentation score was 9 (interquartile range [IQR] 5-15), with visual symptoms reported in 12(57.1%) patients. Overall, final modified thrombolysis in cerebral infarction (mTICI) 2b-3 was achieved in 17 patients (80.9%) with first-pass mTICI 2b-3 attained in 8 (38.1%). Postprocedure sICH occurred in 1 (4.8%) patient. Fifteen (71.4%) patients had a 0-2 mRS score at 90 days. Visual symptoms resolved in 10 of 12(83.3%) patients. Mortality occurred in 2 (9.5%) patients. For the systematic review, cohorts from 4 articles plus ours were included, totaling 222 patients. The estimated rate of successful recanalization was 85.25% (95% confidence interval[CI], 73.05%-97.45%), sICH was 3.60% (95% CI, 1.11%-6.09%), and mortality was 10.51% (95% CI, 5.88%-15.15%). CONCLUSION: The results of our series and systematic review indicate MT as a potentially safe and effective treatment modality for acute PCA stroke. These results also indicate that patient selection and assessment may be the key in obtaining favorable outcomes.

Rist Guide Catheter for Endovascular Procedures: Initial Case Series from a Single Center.

BACKGROUND: The transradial approach (TRA) for endovascular procedures has become a frequent practice in neurointervention. Advantages of the TRA include less access-site complications, early ambulation, and less postprocedural pain. The Rist 079 radial access guide catheter (Medtronic) is the first device designed specifically for neurointerventions performed through the TRA. In this study, we report our initial experience with the Rist catheter in a variety of neurointerventional procedures, aiming to evaluate the performance of this device and discuss its limitations. METHODS: A prospectively maintained database was retrospectively searched to identify patients who underwent procedures using the Rist catheter. Information on demographics, procedural details, and complications was recorded. RESULTS: Seventy-eight patients were included in the study, with a mean age of 60.3 years (range, 25-92 years); 45 (57.7%) were men. The interventional or diagnostic procedure was successfully completed in 77 patients (98.7%). The radial artery was the primary access-site choice in 71 patients (91%). The most frequent type of procedures performed were coiling or stent-assisted coiling (16.7%) and angioplasty and stenting (16.7%), followed by middle meningeal artery embolization (14.1%). Crossover to femoral artery access while maintaining use of the Rist was done in 5 cases (6.4%). Reasons for access or procedural failure included anatomical anomaly of the target vessel, unfavorable geometry of the great vessels, and proximal tortuosity of the supra-aortic vessels. CONCLUSION: We demonstrated a high success rate with use of the Rist catheter system for a variety of procedures.

Carotid Artery Stenting Using the Walrus Balloon Guide Catheter With Flow Reversal for Proximal Embolic Protection: Technical Description and Single-Center Case Series.

BACKGROUND: The use of modern transfemoral balloon guide catheters (BGC) for flow reversal during carotid artery stenting is scarcely described in the literature but represents a promising and efficient technique for embolic protection. OBJECTIVE: To describe a flow-reversal technique using the Walrus BGC (Q'Apel Medical Inc.) and report our center's experience. METHODS: We performed a retrospective analysis of data for consecutive patients aged 18 years or older who underwent elective carotid artery stenting with the use of flow reversal through the Walrus BGC between July 2020 and September 2021. Patient characteristics, procedural details, and clinical follow-up were evaluated. RESULTS: One hundred and five patients were included. Mean age was 69.8 ± 9.4 years, and 36 (34.3%) were women. The most common comorbidities were hyperlipidemia (76.2%) and hypertension (57.1%). Fifty-nine (56.2%) patients were symptomatic. Ninety-nine (94.3%) patients had stenosis ≥70%. Contralateral stenosis ≥50% was present in 44 patients (41.9%). Distal filters were used after flow reversal was established in 90 patients (85.7%). Angioplasty was performed in 85 patients (80.9%). Stenting was successful in 100% of cases. No periprocedural transient ischemic attacks (TIAs) or strokes occurred. Stroke occurred in 2 patients (1.9%) during the 30-day follow-up period, resulting in 1 (0.9%) death. CONCLUSION: In our experience, this technique was safe, feasible, and efficient, with 100% technical success and no periprocedural thromboembolic complications. More extensive studies are needed to establish the role of proximal protection with flow reversal using modern BGCs.

Mechanical thrombectomy with a balloon-guide catheter: sheathless transradial versus transfemoral approach.

BACKGROUND: The transradial approach (TRA) for mechanical thrombectomy (MT) for acute ischemic stroke has been limited by the size of catheters usable in the radial artery, with the smaller access site precluding balloon-guide catheter (BGC) use. However, promising results have been reported for a TRA with a sheathless BGC (sTRA). We sought to perform a comparative study of MT with a BGC via the sTRA versus the transfemoral approach (TFA). METHODS: A retrospective review of our MT database was conducted. Baseline, procedure-related, and outcome data were compared for patients aged ≥18 years with anterior circulation large vessel occlusion, Alberta Stroke Program Early CT Score ≥6, and prestroke modified Rankin Scale score ≤2 treated with either approach. RESULTS: Ninety-three consecutive patients (34 sTRA and 59 TFA) were included. Both groups had similar demographics, comorbidities, stroke severity, intravenous alteplase use, and occlusion location. Mean time from puncture to final recanalization was faster in the sTRA group (29 vs 36 min, p=0.059) despite a higher access site crossover rate in the sTRA group (11.8% vs 0%, p=0.016). There were no differences between groups regarding last modified Thombolysis in Cerebral Infarction score; first-pass or modified first-pass effect; time from last known well to puncture; use of stent-retriever, aspiration, or combination first approach; number of passes; symptomatic intracranial hemorrhage; hospital stay; 90-day functional independence; and mortality. National Institutes of Health Scale score and modified first-pass effect were the only independent predictors of poor outcomes. CONCLUSIONS: Comparable patients treated with MT via the sTRA or TFA had similar angiographic and clinical outcomes.

Left Ophthalmic Segment Internal Carotid Artery Aneurysm Treated with Flow Diversion in a Child with Apert Syndrome: Technical Note.

INTRODUCTION: Prevalence of intracranial aneurysms in children with Apert syndrome has not been described, and development of an aneurysm as a complication secondary to craniofacial surgery has never been reported. CASE PRESENTATION: We report the rare case of a 10-year-old boy with Apert syndrome who underwent craniofacial reconstruction surgery consisting of subcranial Le Fort III osteotomies, bilateral lateral canthopexies, and nasal nares dilations for midfacial hypoplasia and resultant obstructive sleep apnea, and on routine follow-up magnetic resonance imaging (MRI) 1 year later, he was found to have a large left ophthalmic internal carotid artery (ICA) aneurysm that was not seen on MRI obtained 2 years prior. Immediately after the craniofacial surgery, the patient experienced a severe headache behind his left eye and extraocular movement abnormalities that subsided over the next days to months. Given the new and rapid growth of the aneurysm on follow-up MRI, the patient underwent a diagnostic cerebral angiogram followed by successful flow diversion treatment of the aneurysm with the pipeline embolization device (Medtronic, Dublin, Ireland). CONCLUSION: Post-procedurally, over the next year, the patient developed word-finding difficulty and stuttering speech. He was found to have in-stent ICA stenosis and middle cerebral artery (MCA) stenosis at the first follow-up and underwent an initial angioplasty. After several weeks, ICA, MCA, and anterior cerebral artery stenoses were identified, and the patient underwent angioplasties for the ICA and MCA stenoses. On follow-up examination after the second procedure, the patient had tremendous improvement in his speech difficulties and was doing well clinically.

Transarterial and transvenous pial arteriovenous Fistula embolization: A video case report.

Cerebral pial arteriovenous fistulas (pAVFs) are rare and complex high-flow vascular malformations found in pediatric and adolescent populations.1 They are often divided into two groups based on the pattern of venous drainage, galenic or nongalenic. Nongalenic pAVFs are typically supratentorial and carry a high risk of rupture. Their angioarchitecture is very complex with various patterns of feeding arteries and draining veins not originating from dural vessels or the vein of Galen.2 The natural history has not been well established; however, mortality estimates range as high 63%.1 Presentations include hemorrhage, seizure, congestive heart failure, and elevated intracranial pressure.3 We describe the case of an adolescent girl with acute onset of headaches that led to the discovery of an occipital, nongalenic pAVF. Transarterial and transvenous embolizations performed during a single procedure resulted in complete obliteration of the fistula. No complications arose, and the patient remained at her neurological baseline.

Technical nuances of flow-diverting stent-assisted coiling of a ruptured carotid wall aneurysm.

The management of ruptured, large and giant wide-necked aneurysms of the anterior circulation is challenging. Treatment options include balloon-assisted coiling versus flow-diverter-assisted coiling. In this technical video, https://drive.google.com/file/d/1EtyrJv3e5Z0XM2pYBNNBHVUdYwavlTFh/view?usp = sharing we demonstrate a case of a right-sided paraclinoid aneurysm in a young man who presented with post-coital sudden-onset headache. The computed tomography scan showed a Fisher grade IV subarachnoid hemorrhage. An external ventricular drain was placed, and the patient was intubated for prompt treatment. Balloon-assisted coiling of the aneurysm was attempted but abandoned because the balloon failed to provide adequate coverage of the aneurysm neck. A loading dose of aspirin and ticagrelor (Brilinta, Astra Zeneca, Cambridge, United Kingdom) was administered, and Pipeline embolization device (Medtronic, Dublin, Ireland)-assisted coiling was then performed for adequate occlusion of the aneurysm sac. The 6-month follow-up angiogram showed complete obliteration of the aneurysm. The technical video succinctly demonstrates the technical nuances of the procedure.

Use of a sheathless 8-French balloon guide catheter (Walrus) through the radial artery for mechanical thrombectomy: technique and case series.

BACKGROUND: The effectiveness of transradial stroke thrombectomy has been limited by guide catheter size and lack of good balloon options. In this study we describe our technique for the use of a sheathless 8-French balloon guide catheter (Walrus) through radial access and present our initial clinical experience. METHODS: This was a retrospective case series of consecutive patients who underwent mechanical thrombectomy for large vessel occlusion using the sheathless catheter over a period of 3 months. Clinical characteristics, procedural details, reperfusion success (modified Thrombolysis in Cerebral Infarction (mTICI) 2b-3 grade), first-pass effect (FPE; mTICI reperfusion grade 2c or 3 with a single pass), access site complications and clinical improvement at discharge were recorded. A descriptive analysis was performed. RESULTS: Among the 10 patients in the series, median age was 77 years (IQR 75-79) and three were women. All patients had a baseline modified Rankin Scale score ≤2. Median admission National Institutes of Health Stroke Scale (NIHSS) score was 12.5 (IQR 9-16). Four patients received intravenous alteplase before mechanical thrombectomy. Eight patients had M1 occlusion and two had proximal M2 occlusion. The median radial artery diameter was 2.5 mm (IQR 2.5-2.7). Successful reperfusion was achieved in all patients. FPE was achieved in six patients. No access site-related complications or post-procedural intracranial hemorrhages occurred. All patients had improvement in NIHSS score at discharge. CONCLUSIONS: The use of this sheathless catheter for transradial access was safe and feasible. The technique can potentially improve the outcomes of transradial access for stroke intervention.

Use of Walrus balloon-guide catheter through sheathless radial approach for mechanical thrombectomy of right middle cerebral artery occlusion.

The literature demonstrates a favorable first pass effect with balloon-guide catheter (BGC) for mechanical thrombectomy. An 8F BGC is routinely used with femoral access. We present the first video report of 8F BGC advanced through the radial artery using a sheathless technique (video 1). An approximately 70-year-old patient presented with left-sided hemiplegia, neglect, and dysarthria. A CT angiogram demonstrated right M1 occlusion, and the patient underwent urgent mechanical thrombectomy. Radial approach was preferred owing to patient history of anticoagulation. A 6F Sim Select intermediate catheter was used to minimize the step off as the 8F BGC was advanced into the radial artery over an 035 exchange-length Advantage Glidewire. A skin nick over the Glidewire Advantage facilitated the introduction of the 8F BGC into the radial artery. Standard mechanical thrombectomy using a combination of stent retriever and aspiration catheter (Solumbra technique) was performed, and thrombolysis in cerebral infarction 3 recanalization was achieved after a single pass. The National Institutes of Health Scale score improved from 12 to 4, with mild left facial droop, dysarthria, and decreased speech fluency. The patient was discharged from the hospital on postoperative day 2. Ultrasound should be used for immediate assessment of radial artery size and conversion to femoral access without delay if the radial artery is less than 2.5 mm. neurintsurg;14/5/neurintsurg-2021-017985/V1F1V1Video 1.

First U.S. Experience Using the Pipeline Flex Embolization Device with Shield Technology for Treatment of Intracranial Aneurysms.

BACKGROUND: The Pipeline Flex Embolization Device with Shield technology (PED-Shield [Medtronic, Dublin, Ireland]) is a third-generation flow diverter. Surface modification of the mesh with phosphorylcholine covalently bound to the metal struts aims to reduce thrombogenicity. In the present study, we report the results from the first U.S. series of patients with intracranial aneurysms treated with the PED-Shield and a comprehensive systematic literature review. METHODS: We retrospectively collected the patient demographics, aneurysm characteristics, procedural details, and periprocedural complications from our prospectively maintained endovascular database (April 2021 to July 2021). Our literature review encompassed 3 databases (PubMed, Embase, and MEDLINE). RESULTS: Ten patients with 11 anterior circulation unruptured wide-necked aneurysms (10 saccular, 1 fusiform) were included. The average patient age was 64.7 years (range, 45-86 years), and 9 were women. One device demonstrated insufficient distal opening. No other technical issues or intraprocedural complications had occurred. After the procedure, 1 patient had developed a groin hematoma and 1 had experienced a small intracranial hemorrhage, with no clinical repercussions. All patients were discharged with dual-antiplatelet therapy. In the review, we identified 15 studies. Most had been conducted in Europe and South America and 3 were U.S. case reports of compassionate use of the device. CONCLUSIONS: In our initial periprocedural experience with the PED-Shield for intracranial aneurysm treatment, the device demonstrated an excellent performance and no major complications. Further studies are required to evaluate the long-term follow-up results and the safety of different antiplatelet regimens.

Ulnar Artery Access: A Nontraditional Access Site for Diagnostic Cerebral Angiography and Neurointervention: 2-Dimensional Operative Video.

Transfemoral access has long been the main access site for cerebral angiography and neurointerventional procedures. Radial access is accepted as an alternative to the traditional transfemoral approach. Ulnar access may be undertaken if the radial artery is occluded or small caliber, or when radial artery preservation is needed. The safety and feasibility of ulnar access for neuroangiographic procedures has been demonstrated.1-3 In this operative video, we demonstrate ulnar artery access in a patient in whom radial artery preservation was desired. We further elaborate on the technical nuances of this access. This nontraditional access site offers the same advantages as radial access, avoiding the need to switch to femoral artery access. A preoperative Allen's test is not necessary. Ultrasound imaging is used to aid in the identification and successful puncture of the ulnar artery. A medial to lateral approach for ulnar artery puncture is advised to avoid injury to the ulnar nerve. Careful application of wrist closure bands avoids hematoma accumulation. The patient gave informed consent for the procedure and video recording. Institutional review board approval was deemed unnecessary. Video. © University at Buffalo, May 2021. Used with permission.

Comparison of effectiveness and outcomes among different thrombectomy techniques in acute basilar artery occlusion: a dual-center experience.

OBJECTIVE: Acute basilar artery occlusion (BAO) is a rare large-vessel occlusion associated with high morbidity and mortality. Modern thrombectomy with stent retrievers and large-bore aspiration catheters is highly effective in achieving recanalization, but a direct comparison of different techniques for acute BAO has not been performed. Therefore, the authors sought to compare the technical effectiveness and clinical outcomes of stent retriever-assisted aspiration (SRA), aspiration alone (AA), and a stent retriever with or without manual aspiration (SR) for treatment of patients presenting with acute BAO and to evaluate predictors of clinical outcome in their cohort. METHODS: A retrospective analysis of databases of large-vessel occlusion treated with endovascular intervention at two US endovascular neurosurgery centers was conducted. Patients ≥ 18 years of age with acute BAO treated between January 2013 and December 2020 with stent retrievers or large-bore aspiration catheters were included in the study. Demographic information, procedural details, angiographic results, and clinical outcomes were extracted for analysis. RESULTS: Eighty-three patients (median age 67 years [IQR 58-76 years]) were included in the study; 33 patients (39.8%) were female. The median admission National Institutes of Health Stroke Scale (NIHSS) score was 16 (IQR 10-21). Intravenous alteplase was administered to 26 patients (31.3%). The median time from symptom onset to groin or wrist puncture was 256 minutes (IQR 157.5-363.0 minutes). Overall, successful recanalization was achieved in 74 patients (89.2%). The SRA technique had a significantly higher rate of modified first-pass effect (mFPE; 55% vs 31.8%, p = 0.032) but not true first-pass effect (FPE; 45% vs 34.9%, p = 0.346) than non-SRA techniques. Good outcome (modified Rankin Scale [mRS] score 0-2) was not significantly different among the three techniques. Poor outcome (mRS score 3-6) was associated with a higher median admission NIHSS score (12.5 vs 19, p = 0.007), a higher rate of adjunctive therapy usage (9% vs 0%, p < 0.001), and a higher rate of intraprocedural complications (10.7% vs 14.5%, p = 0.006). The admission NIHSS score significantly predicted good outcome (OR 0.98, 95% CI 0.97-0.099; p = 0.032). Incomplete recanalization after thrombectomy significantly predicted mortality (OR 1.68, 95% CI 1.18-2.39; p = 0.005). CONCLUSIONS: The evaluated techniques resulted in high recanalization rates. The SRA technique was associated with a higher rate of mFPE than AA and SR, but the clinical outcomes were similar. A lower admission NIHSS score predicted a better prognosis for patients, whereas incomplete recanalization after thrombectomy predicted mortality.

Is Endovascular Therapy for Stroke Cost-Effective Globally? A Systematic Review of the Literature.

OBJECTIVES: Cost-effectiveness of endovascular therapy (EVT) is a key consideration for broad use of this approach for emergent large vessel occlusion stroke. We evaluated the evidence on cost-effectiveness of EVT in comparison with best medical management from a global perspective. MATERIALS AND METHODS: This systematic review of studies published between January 2010 and May 2020 evaluated the cost effectiveness of EVT for patients with large vessel occlusion acute ischemic stroke. The gain in quality adjusted life year (QALY) and incremental cost-effectiveness ratio (ICER), expressed as cost per QALY resulting from EVT, were recorded. The study setting (country, economic perspective), decision model, and data sources used in economic models of EVT cost-effectiveness were recorded. RESULTS: Twenty-five original studies from 12 different countries were included in our review. Five of these studies were reported from a societal perspective; 18 were reported from a healthcare system perspective. Two studies used real-world data. The time horizon varied from 1 year to a lifetime; however, 18 studies reported a time horizon of >10 years. Twenty studies reported using outcome data from randomized, controlled clinical trials for their models. Nineteen studies reported using a Markov model. Incremental QALYs ranged from 0.09-3.5. All studies but 1 reported that EVT was cost-effective. CONCLUSIONS: Evidence from different countries and economic perspectives suggests that EVT for stroke treatment is cost-effective. Most cost-effectiveness studies are based on outcome data from randomized clinical trials. However, there is a need to study the cost-effectiveness of EVT based solely on real-world outcome data.