A Systematic Review of Neuropsychological Outcomes After Treatment of Intracranial Aneurysms.

BACKGROUND: Aneurysmal subarachnoid hemorrhage is a cause of profound morbidity and mortality. Its effects extend beyond functional neurological status to neurocognitive and psychological functioning. Endovascular treatment is becoming more prevalent after increasing evidence for its safety and efficacy; however, there is a relative paucity of evidence specific to neurocognitive status after treatment. OBJECTIVE: To assess and compare neuropsychological outcomes after the treatment of ruptured and unruptured intracranial aneurysms. METHODS: A systematic review of the literature was conducted searching for articles assessing the neuropsychological and cognitive outcomes after the treatment of ruptured and unruptured intracranial aneurysms. Inclusion criteria were English language, publication between January 2000 and October 2020, and discussion of neuropsychological outcomes in adequate detail. Outcomes were categorized into 8 domains: 5 Neurocognitive (Language, Executive Function, Complex Attention, Memory and Learning, and Perceptual motor function), Intelligence Quotient, Affect, and Quality of Life. RESULTS: Twenty-four articles were included comprising 2236 patients (924 surgical clipping, 1095 endovascular coiling, and 217 controls). These studies reported that most tests revealed no significant difference [n = 356/421 (84.56%)] between treatment modalities. More studies reported significantly superior test scores in the fields of language, executive function, and memory and learning after coiling [n = 53/421 tests (12.59%)] compared with clipping [n = 12/421 tests (2.85%)]. CONCLUSION: The current available data and published studies demonstrate a trend toward improved neurocognitive and psychological outcomes after endovascular treatment. Although these findings should be considered when deciding on the optimal treatment method for each patient, drawing definitive conclusions is difficult because of heterogeneity between patients and studies.

Clipping versus coiling: A critical re-examination of a decades old controversy.

BACKGROUND: Two major studies, The International Subarachnoid Aneurysm Trial and the Barrow Ruptured Aneurysm Trial, compare the long-term outcomes of clipping and coiling. Although these demonstrated coiling's initial benefits, rebleeding and retreatment rates as well as converging patient outcomes sparked controversy regarding its durability. This article will critically examine the available evidence for and against clipping and coiling of intracranial aneurysms. Critics of endovascular treatment state that the initial benefit seen with endovascular coiling decreases over the duration of follow-up and eventually functional outcomes of both treatment modalities are similar. Combined with the increased rate of retreatment and rebleeding, these trials reveal that coiling is not as durable and not as effective as a long-term treatment compared to clipping. Also, due to the cost of devices following endovascular treatment and prolonged hospitalization following clipping, the financial burden has been considered controversial. SUMMARY/KEY MESSAGES: Short-term outcomes reveal better morbidity and mortality outcomes following coiling. Despite the higher rates of retreatment and rebleeding with coiling, there was no significant change in functional outcomes following retreatment. Furthermore, examining more recent trials reveals a decreased rate of recurrence and rebleeding with improved technology and expertise. Functional outcomes deteriorate for both cohorts over time while recent results revealed improved long-term cognitive outcomes and levels of health-related quality of life after coiling in comparison to clipping. The expense of longer hospital stays following clipping must be balanced against the expense of endovascular devices in coiling.

The Woven EndoBridge Device for the Treatment of Intracranial Aneurysms: Initial Clinical Experience within an Australian Population.

PURPOSE: Advances in endovascular technology have expanded the treatment options for intracranial aneurysms. Intrasaccular flow diversion is a relatively new technique that aims to disrupt blood inflow at the neck of the aneurysm, hence promoting intrasaccular thrombosis. The Woven EndoBridge device (WEB; MicroVention, Aliso Viejo, CA, USA) is an US Food and Drug Administration approved intrasaccular flow diverter for wide-necked aneurysms. We report the early interim clinical and radiological outcomes of patients with both ruptured and unruptured intracranial aneurysms (IAs) treated using the WEB device in an Australian population. MATERIALS AND METHODS: A retrospective analysis was done of patients with ruptured or unruptured IAs who received treatment with WEB across 5 Australian neuroendovascular referral centers between May 2017 and November 2020. Angiographic occlusion was assessed with time-of-flight magnetic resonance angiography. Complications were recorded and clinical outcomes were assessed using the modified Rankin scale at follow-up. RESULTS: In total, 66 aneurysms were treated in 63 patients, with successful deployment of the WEB device in 98.5% (n=65). Eighteen (26.9%) ruptured aneurysms were included. Failure of deployment occurred in a single case. Adjunct coiling and/or stenting was performed in 20.9% (n=14) cases. Sixty-two patients with 65 aneurysms using a WEB device were followed up (mean=9.1 months), and 89.4% of these had complete aneurysm occlusion while 1.5% remained patent. Functional independence was achieved in 93.5% of cases. CONCLUSION: Early results following the use of WEB devices in Australia demonstrate safety and adequate aneurysm occlusion comparable to international literature.

STABILISE; treatment of aortic dissection, a single Centre experience.

PURPOSE: To outline the process of the STABILISE technique and its use; reporting patient outcomes and midterm follow up for complicated aortic dissection. MATERIALS AND METHODS: Single centre retrospective analysis from January 2011 to January 2021 using the STABILISE technique which utilises balloon assistance to facilitate intimal disruption and promote aortic relamination. RESULTS: Sixteen patients underwent endovascular aortic repair with the STABILISE technique for aortic dissection over the study period. Fourteen patients (14/16; 88%) had acute dissection. Two of 16 (12%) were chronic. The median age of the patient cohort was 61 years (range 32-80 years) and consisted of a male majority (n = 11; 69%). The median time from diagnosis to intervention was 5 days (1-115 days; IQR 1-17.3). More than half (56%) had surgical repair of a acute type A aortic dissection prior to radiological intervention. The procedure was technically successful with no procedural mortality. Two patients were lost to follow up and two died in the post-operative period. Twelve patients had ongoing follow up with an average number of 2.9 ± 1.6 scans performed. Follow up was available in thirteen patients (81%) with a median follow up period of 1097 days (IQR 707-1657). The rate of re-intervention (n = 2/16; 13%) requiring additional stenting was in line with published re-intervention data (15%). Follow up showed a reduction in false lumen size following treatment with total luminal dimensions remaining stable over the follow-up period. CONCLUSION: The STABILISE technique as a procedure for complicated aortic dissection, either acute or chronic, appears safe with stable mid-term aortic remodelling and patient outcomes. LEVEL OF EVIDENCE: Level 3, Retrospective cohort study.

CaRotid Artery Filtering Technique (CRAFT): A Technique for Carotid Artery Stenting with Intrinsic Embolic Protection.

PURPOSE: Carotid artery stenting (CAS) is an established treatment for symptomatic carotid artery stenosis as an alternative to carotid endarterectomy. A variety of techniques and devices have been devised to minimise periprocedural stroke risk using either proximal or distal embolic protection. This study presents a method of embolic protection during CAS-the CaRotid Artery Filtering Technique (CRAFT). MATERIALS AND METHODS: The CRAFT technique employs aspects of both proximal and distal embolic protection. The CASPER RX stent (MicroVention, Tustin, CA, USA), which is a double-layered, closed-cell, micromesh nitinol stent, is deployed across the carotid artery stenosis with the assistance of a FlowGate balloon guide catheter (Stryker Neurovascular, Fremont, CA, USA). The partially deployed stent acts as a distal filter while the balloon guide is deflated midway during stent deployment to prevent distal plaque embolisation, followed by completion of stent deployment and angioplasty. RESULTS: A total of 94 patients underwent CAS using the CRAFT technique between June 2016 and March 2021. Successful stent deployment was achieved in all patients. Preliminary results demonstrated acute stent occlusion in 6 patients (6.4%) and distal embolic stroke in 5 patients (5.3%). The median procedural fluoroscopy time was 34 minutes with an interquartile range of 22 to 55 minutes. CONCLUSION: The CRAFT technique of CAS presented by this study can be applied in the treatment of symptomatic carotid artery stenosis in both emergency and elective procedure settings with a high technical success and low distal embolic stroke risk.

Contemporary Treatment of Intracranial Blood Blister Aneurysms - A Systematic Review.

INTRODUCTION: Blood blister aneurysms (BBAs) are rare aneurysms affecting non-branched points of intracerebral arteries. Due to their small size and fragility, BBAs are prone to rupture, and can be challenging to diagnose and treat. Several treatment options have been suggested yet there is no consensus regarding the best modality to reduce morbidity and mortality. MATERIALS AND METHODS: A systematic review of the literature was conducted searching for articles discussing the treatment of BBAs. Inclusion criteria included: articles published between January 2010 and August 2020, English language, with each paper including at least 15 patients. Studies included required detailed reporting of patient demographics, treatment, and patient outcomes (including complications, recurrence, neurologic functional status, and mortality). RESULTS AND DISCUSSION: A total of 25 studies with 883 patients were included. Most were female (n = 594, 67.3%) and aneurysms were overwhelmingly located in the supraclinoid internal carotid artery (99%). Aneurysms were variable in size and mostly presented with subarachnoid haemorrhage. Endovascular treatment (n = 518, 58.7%) was more common than microsurgery (n = 365, 41.1%) while only 2 patients were managed conservatively. Complications were more common in patients treated microsurgically. Microsurgical procedures had an unfavorable outcome (mRS 4-6, GOS 1-3) rate of 27.8% (n = 100/360) while that of endovascular procedures was 14.7% (n = 70/477). Endovascular procedures had a lower mortality rate than microsurgical interventions (8.4% vs 11%). CONCLUSION: This review demonstrates that endovascular treatment of blood blister aneurysm has reduced morbidity and mortality when compared with microsurgical treatment. Small sample sizes and substantial study heterogeneity makes strong conclusions difficult.

The 100 most cited articles in the endovascular treatment of brain arteriovenous malformations.

BACKGROUND: The literature base for endovascular treatment of brain arteriovenous malformations (BAVMs) has grown exponentially in recent decades. Bibliometric analysis has been used to identify impactful articles in other medical specialties. The aim of this citation analysis was to identify and characterize the top 100 most cited articles in the field of endovascular BAVM treatment. METHODS: The top-cited papers were identified by searching selected keywords ("endovascular treatment," "interventional treatment," "brain arteriovenous malformation," "emboliz(s)ation") on the Web of Science platform. The top 100 articles were ranked according to their number of citations. Each article was further evaluated to obtain predefined characteristics including citation(s) per year, year of publication, authorship, journal-title and impact factor, article topics, article type, and level of evidence. RESULTS: The top 100 most cited articles for endovascular BAVM treatment were published between 1960 and 2014. The total number of citations for these articles ranged from 56 to 471 (median 85.5). Most articles (76%) were published between 1990 and 2009 in three journals (56%), originated in the USA (52%) followed by France (16%). The most common topic related to embolization agents and the majority of articles constituted level IV or V evidence. CONCLUSIONS: This study provides a comprehensive overview of the most cited articles in the field of endovascular BAVM treatment. Our analysis recognizes key contributions from authors and institutions in the field and leads to a better understanding of the evidentiary framework for BAVM treatment.

Endovascular balloon-assisted liquid embolisation of soft tissue vascular malformations: technical feasibility and safety.

PURPOSE: Arteriovenous malformations (AVMs) are abnormal communications between arteries and veins without an intervening capillary system. The best endovascular treatment option for these is unclear and may involve multiple staged procedures using a variety of embolic materials. We report our initial experience using a modified version of a previously published neurointerventional technique to treat soft tissue AVMs with single-stage curative intent. MATERIALS AND METHODS: Soft tissue AVMs treated endovascularly using either sole arterial or combined arterial and venous balloon-assisted techniques with liquid embolic agents were retrospectively identified over a 3.5 year period (January 2017 to June 2020)) at two centres. Clinical, pre-operative radiological, procedural technical and post treatment details were recorded. RESULTS: Seven patients were treated for symptomatic soft tissue arteriovenous malformations. These AVMs were located in the peripheral limbs (five), tongue (one) and uterus (one). Curative treatment was achieved in 6/7 patients with one patient requiring a second treatment approximately 1 year later. A variety of liquid embolisation agents (LEAs) including sclerosants and polymers were used. Clinical success rate was 100% following treatment. One patient experienced expected temporary post-operative tongue swelling requiring tracheostomy occurred following embolisation of the lingual AVM. A minor complication in a second patient was due to an access site haematoma developed following treatment of the hand AVM requiring surgical intervention. No long-term sequelae or additional complications were observed. CONCLUSION: Endovascular arterial and venous balloon assisted LEA embolization of soft tissue AVMs with curative intent is feasible. This technique may provide an alternative treatment option for achieving durable occlusion for complex soft tissue AVMs.

Application of a computational model in simulating an endovascular clot retrieval service system within regional Australia.

INTRODUCTION: The global demand for endovascular clot retrieval (ECR) has grown rapidly in recent years creating challenges to healthcare system planning and resource allocation. This study aims to apply our established computational model to predict and optimise the performance and resource allocation of ECR services within regional Australia, and applying data from the state of South Australia as a modelling exercise. METHOD: Local geographic information obtained using the Google Maps application program interface and real-world data was input into the discrete event simulation model we previously developed. The results were obtained after the simulation was run over 5 years. We modelled and compared a single-centre and two-centre ECR service delivery system. RESULTS: Based on the input data, this model was able to simulate the ECR delivery system in the state of South Australia from the moment when emergency services were notified of a potential stroke patient to potential delivery of ECR treatment. In the model, ECR delivery improved using a two-centre system compared to a one-centre system, as the percentage of stroke patients requiring ECR was increased. When 15% of patients required ECR, the proportion of 'failure to receive ECR' cases for a single-centre system was 17.35%, compared to 3.71% for a two-centre system. CONCLUSIONS: Geolocation and resource utilisation within the ECR delivery system are crucial in optimising service delivery and patient outcome. Under the model assumptions, as the number of stroke cases requiring ECR increased, a two-centre ECR system resulted in increased timely ECR delivery, compared to a single-centre system. This study demonstrated the flexibility and the potential application of our DES model in simulating the stroke service within any location worldwide.

Combined interventional radiology and surgical management of a complex caesarean scar ectopic pregnancy.

Caesarean scar ectopic pregnancies are rare but growing in incidence due to increasing rates of caesarean deliveries. These cases have historically been treated with either medical or surgical management which both have significant limitations. More recently, uterine artery embolisation (UAE) has shown significant promise in the treatment of this condition. We present the case of a complex patient with a caesarean scar ectopic successfully managed with combined UAE and surgery.

COILUMICA: coil embolization of a coronary artery to pulmonary artery fistula via novel dual lumen micro catheter technique.

BACKGROUND: Management of coronary artery fistula (CAF) is based on obliterating the fistula communication between the cardiac arteries and other thoracic vessels. CASE PRESENTATION: We describe the presentation of an 85-year-old female with progressive exertional dyspnea on a background of a long standing left anterior descending diagonal to pulmonary artery fistula. We utilized neuro-interventional techniques to perform coil embolization via use of a Scepter XC dual lumen micro catheter. CONCLUSIONS: Dual lumen balloon catheters allow for super-selective artery interrogation, stability of balloon positioning, with less trauma to vessel architecture and accurate embolization. There were no complications and the patient reported improvement of symptoms on review.

Single Level Percutaneous Vertebroplasty for Vertebral Hemangiomata - A Review of Outcomes.

BACKGROUND: Percutaneous vertebroplasty is a minimally invasive technique to treat patients with symptomatic vertebral hermangiomata. OBJECTIVES: We present a single-operator series of cases to demonstrate the clinical outcomes and complication profiles for this technique. STUDY DESIGN: This is a retrospective multi-center cohort study. SETTING: Procedures were performed across multiple hospitals in Italy by a single proceduralist. METHODS: All patients with symptomatic vertebral hermangiomata that had percutaneous vertebroplasty over a 14-year period (March 1999 to April 2013) by a single proceduralist were included in this study. Information collected included demographic data, vertebral level of intervention, cement volume used, and the Visual Analogue Score for pain that was assessed pre- and post-intervention. Patients were followed up for a minimum of one year. RESULTS: Percutaneous vertebroplasty was performed for 50 patients. All patients had an improvement in pain, with 39 patients (78%) reporting complete pain relief. A unipedicular approach was undertaken in 41 cases (82%), and bipedicular approach in 8 patients (16%), while a transoral approach was used in one patient. The mean cement volume per vertebral level was 6.8 mL (1 - 18 mL). Recurrent symptoms occurred in 2 patients (4%) requiring repeat vertebroplasty. There were no cases of symptomatic cement leak, and no cases of procedural morbidity or mortality. LIMITATIONS: As a multicenter study conducted over a 14-year time period, there may be heterogeneity in procedural technique and rehabilitation protocols. There were no cases of cement leakage in our study, which could be an underreporting of cases. This is could be due to none of our patients receiving a post procedural computerized tomography scan, which is more sensitive in detecting cement leakage when compared to procedural fluoroscopy. CONCLUSION: Percutaneous vertebroplasty is associated with good post-procedural outcomes in patients with vertebral hermangiomata. Complications such as neurological injury and cement leakages are rare.

Endovascular flow-diversion of visceral and renal artery aneurysms using dual-layer braided nitinol carotid stents.

BACKGROUND: Visceral and renal artery aneurysms (VRAAs) are uncommon but are associated with a high mortality rate in the event of rupture. Endovascular treatment is now first line in many centres, but preservation of arterial flow may be difficult in unfavourable anatomy including wide necked aneurysms, parent artery tortuosity and proximity to arterial bifurcations. Endovascular stenting, and in particular flow-diversion, is used in neurovascular intervention to treat intracranial aneurysms but is less often utilised in the treatment of VRAAs. The CASPER stent is a low profile dual-layer braided nitinol stent designed for carotid stenting with embolic protection and flow-diversion properties. We report the novel use of the CASPER stent for the treatment of VRAAs. We present a case series describing the treatment of six patients with VRAAs using the CASPER stent. RESULTS: Six patients with unruptured VRAAs were treated electively. There were three splenic artery aneurysms and three renalartery aneurysms. Aneurysms were treated with the CASPER stent, with or without loose aneurysm coil packing or liquid embolic depending on size and morphology. All stents were successfully deployed with no immediate or periprocedural complications. Four aneurysms completely occluded after serial imaging follow up with one case requiring repeat CASPER stenting for complete occlusion. In one patient a single aneurysm remained patent at last follow up, A single case was complicated by delated splenic infarction and surgical splenectomy. CONCLUSION: Preliminary experience with the CASPER stent suggests it is technically feasible and effective for use in the treatment of VRAAs.

Geographic Service Delivery for Endovascular Clot Retrieval: Using Discrete Event Simulation to Optimize Resources.

BACKGROUND: Endovascular clot retrieval (ECR) is the standard of care for acute ischemic stroke caused by large vessel occlusion. Reducing stroke symptom onset to reperfusion time is associated with improved functional outcomes. This study aims to develop a computational model to predict and identify time-related outcomes of community stroke calls within a geographic area based on variable parameters to support planning and coordination of ECR services. METHODS: A discrete event simulation (DES) model to simulate and predict ECR service was designed using SimPy, a process-based DES framework written in Python. Geolocation data defined by the user, as well as that used by the model, were sourced using the Google Maps application programming interface. Variables were customized by the user on the basis of their local environment to provide more accurate prediction. RESULTS: A DES model can estimate the delay between the time that emergency services are notified of a potential stroke and potential cerebral reperfusion using ECR at a capable hospital. Variables can be adjusted to observe the effect of modifying each parameter input. By varying the percentage of stroke patients receiving ECR, we were able to define the levels at which our existing service begins to fail in service delivery and assess the effect of adding centers. CONCLUSIONS: This novel computational DES model can aid the optimization of delivery of a stroke service within a city, state, or country. By varying geographic, population, and other user-defined inputs, the model can be applied to any location worldwide.

Endovascular treatment of a hepatic artery pseudoaneurysm using a novel pericardium covered stent.

Visceral and renal artery aneurysms (VRAAs) and pseudoaneurysms are rare. Their increasing incidence is largely thought to be due to advances in medical imaging. Twenty percent of VRAAs occur in hepatic arteries, with approximately fifty percent of these represented by pseudoaneurysms, which are prone to spontaneous rupture. Many treatments for VRAAs exist, with the endovascular approach being favoured. Treatment aims to preserve visceral perfusion and exclude the aneurysm; however, complex aneurysms may require parent artery or end-organ sacrifice. Covered stents allow rapid aneurysm exclusion while preserving parent artery patency, a favourable outcome when parent artery or end-organ sacrifice is undesirable. The AneuGraft pericardium covered stent (PCS) combines the benefits of a low-profile covered stent with those of a low immunogenic material. We describe the endovascular treatment of a patient with a hepatic artery pseudoaneurysm, where parent artery sacrifice was considered unacceptable. The AneuGraft PCS was used to provide immediate and complete exclusion, with dual antiplatelet therapy for 1 week, followed by single antiplatelet use. The procedure was a technical success, with preservation of the hepatic arteries and complete exclusion of the pseudoaneurysm. There were no complications immediately following the procedure or on post-procedural follow-up. The pseudoaneurysm remained excluded at 6-week CT angiogram (CTA) follow-up. This case describes a safe and effective method for completely excluding a complex pseudoaneurysm, utilising the AneuGraft PCS, allowing for the potential management of a wider range of aneurysms with unfavourable morphology.

CODE STROKE ALERT-Concept and Development of a Novel Open-Source Platform to Streamline Acute Stroke Management.

Introduction: Effective, time-critical intervention in acute stroke is crucial to mitigate mortality rate and morbidity, but delivery of reperfusion treatments is often hampered by pre-, in-, or inter-hospital system level delays. Disjointed, repetitive, and inefficient communication is a consistent contributor to avoidable treatment delay. In the era of rapid reperfusion therapy for ischemic stroke, there is a need for a communication system to synchronize the flow of clinical information across the entire stroke journey. Material/Methods: A multi-disciplinary development team designed an electronic communications platform, integrated between web browsers and a mobile application, to link all relevant members of the stroke treatment pathway. The platform uses tiered notifications, geotagging, incorporates multiple clinical score calculators, and is compliant with security regulations. The system safely saves relevant information for audit and research. Results: Code Stroke Alert is a platform that can be accessed by emergency medical services (EMS) and hospital staff, coordinating the flow of information during acute stroke care, reducing duplication, and error in clinical information handover. Electronic data logs provide an auditable trail of relevant quality improvement metrics, facilitating quality improvement, and research. Discussion: Code Stroke Alert will be freely available to health networks globally. The open-source nature of the software offers valuable potential for future development of plug-ins and add-ons, based on individual institutional needs. Prospective, multi-site implementation, and measurement of clinical impact are underway.

Optimizing Resources for Endovascular Clot Retrieval for Acute Ischemic Stroke, a Discrete Event Simulation.

Objective: Endovascular clot retrieval (ECR) is the standard of care for acute ischemic stroke due to large vessel occlusion. Performing ECR is a time critical and complex process involving many specialized care providers and resources. Maximizing patient benefit while minimizing service cost requires optimization of human and physical assets. The aim of this study is to develop a general computational model of an ECR service, which can be used to optimize resource allocation. Methods: Using a discrete event simulation approach, we examined ECR performance under a range of possible scenarios and resource use configurations. Results: The model demonstrated the impact of competing emergency interventional cases upon ECR treatment times and time impact of allocating more physical (more angiographic suites) or staff resources (extending work hours). Conclusion: Our DES model can be used to optimize resources for interventional treatment of acute ischemic stroke and large vessel occlusion. This proof-of-concept study of computational simulation of resource allocation for ECR can be easily extended. For example, center-specific cost data may be incorporated to optimize resource allocation and overall health care value.

Vertebroplasty for acute painful osteoporotic vertebral compression fractures: An update.

Vertebral compression fractures (VCFs) are a common cause of back pain and disability and are usually osteoporotic in nature. Therapy aims to adequately control pain and allow early mobilisation and return of function while preventing additional fractures. A proportion of patients do not achieve adequate pain relief using conservative measures alone. Unwanted adverse effects from medications may also ensue. Vertebroplasty represents an alternative treatment option for VCFs. Patients with acute VCFs (≤6 weeks old) may gain the most benefit from vertebroplasty as healed fractures are not as amenable to cement injection. High-quality studies have reported conflicting results regarding the use of vertebroplasty in the treatment of acute VCFs. Despite high-quality evidence, varying study designs and heterogenous patient cohorts make interpretation of this data difficult. Only one sham-controlled randomised controlled trial (RCT) has evaluated vertebroplasty exclusively in patients with acute VCFs, reporting favourable results. Pooled data from RCTs also suggest vertebroplasty to be safe. This article provides a concise and critical review of the current literature regarding vertebroplasty for the treatment of acute VCFs.

Carotid Artery Stenting in Acute Stroke Using a Microporous Stent Device: A Single-Center Experience.

BACKGROUND: Carotid artery stenting (CAS) is an established treatment for carotid artery stenosis, typically in a semielective or elective setting. The growth of mechanical thrombectomy for acute stroke has led to an increased use of emergent carotid artery stenting (eCAS). This single-center retrospective case series evaluates the safety and efficacy of eCAS using a dual-layer micromesh nitinol stent to treat carotid artery stenosis in the acute stroke setting. METHODS: Ethics approval was granted by the institutional review board. Clinical data of all patients who underwent CAS using the Casper dual-layer micromesh nitinol stent system (MicroVention, Terumo, Tustin, California, USA) at a tertiary level 24-hour endovascular thrombectomy service over a 2-year period (June 2016-June 2018) were retrospectively obtained and reviewed. RESULTS: Twenty eCAS procedures were performed in 19 patients over the study period. Most patients had tandem lesions (12/20; 60%). Median National Institute of Health Stroke Scale score on admission was 17 (interquartile range 9-22). Stent deployment was technically successful in all patients. Recanalization rate was 95%. Symptomatic intracranial hemorrhage occurred in 2 patients (10%), both resulting in death. No other procedure-related deaths occurred. Stent thrombosis occurred in 2 patients. One delayed embolic stroke occurred. No other stent-related complications occurred. Median National Institute of Health Stroke Scale score at 24 hours postprocedure was 3 (interquartile range 1-12). Six patients had a good clinical outcome (modified Rankin Scale score between 0 and 2) at 3- to 6-month follow-up (38%). CONCLUSIONS: eCAS using the Casper stenting system is effective and technically feasible in the acute stroke setting, although the ideal antiplatelet and anticoagulation regime is not clearly established.

Carotid artery stenting: Current state of evidence and future directions.

Both carotid endarterectomy (CEA) and carotid artery stenting (CAS) are common treatments for carotid artery stenosis. Several randomized controlled trials (RCTs) have compared CEA to CAS in the treatment of carotid artery stenosis. These studies have suggested that CAS is more strongly associated with periprocedural stroke; however, CEA is more strongly associated with myocardial infarction. Published long-term outcomes report that CAS and CEA are similar. A reduction in complications associated with CAS has also been demonstrated over time. The symptomatic status of the patient and history of previous CEA or cervical radiotherapy are significant factors when deciding between CEA or CAS. Numerous carotid artery stents are available, varying in material, shape and design but with minimal evidence comparing stent types. The role of cerebral protection devices is unclear. Dual antiplatelet therapy is typically prescribed to prevent in-stent thrombosis, and however, evidence comparing periprocedural and postprocedural antiplatelet therapy is scarce, resulting in inconsistent guidelines. Several RCTs are underway that will aim to clarify some of these uncertainties. In this review, we summarize the development of varying techniques of CAS and studies comparing CAS to CEA as treatment options for carotid artery stenosis.