Approaching the Boundaries of Endovascular Treatment in Acute Ischemic Stroke : Multicenter Experience with Mechanical Thrombectomy in Vertebrobasilar Artery Branch Occlusions.

PURPOSE: Little is known about catheter-based endovascular treatment of vertebrobasilar artery branch occlusion (VEBABO) in acute ischemic stroke (AIS). Nonetheless, the experience of mechanical thrombectomy (MT) in distal small sized arteries of the anterior circulation seems promising in AIS. In this multicenter study, we report the feasibility, efficacy and safety of MT in VEBABO. METHODS: Retrospective analysis of consecutive AIS patients treated with MT due to VEBABO including posterior and anterior inferior cerebellar artery (PICA, AICA) and superior cerebellar artery (SCA) occlusions at seven tertiary care centers between January 2013 and May 2020. Baseline demographics and angiographic outcomes including recanalization success of the affected cerebellar arteries and procedural complications were recorded. Clinical outcomes were evaluated by the modified Rankin scale (mRS) at discharge and 90 days. RESULTS: Out of 668 endovascularly treated posterior circulation strokes we identified 16 (0.02%) cases with MT for VEBABO. Most frequently, MT of the SCA was done (13/16, 81%). Most VEBABOs occurred after MT of initial basilar/posterior cerebral artery occlusion (9/16, 56%). In 10/16 (63%) procedures, the affected VEBABO was successfully recanalized. Out of four patients three (75%) with isolated VEBABO had benefited from endovascular therapy. Subarachnoid hemorrhage was observed in 3/16 (19%) procedures. The rate of favorable outcome (mRS ≤2) was 40% at discharge and 47% at 90-day follow-up. Mortality was 13% (2/15). CONCLUSION: The use of MT for VEBABO is rare but appears to be feasible and effective; however, the comparatively high rate of procedure-related hemorrhage highlights that the indications for MT in these occlusion sites should be carefully weighed up.

Primary Multivessel Occlusions Treated With Mechanical Thrombectomy: A Multicenter Analysis and Systemic Literature Review.

BACKGROUND AND PURPOSE: Acute ischemic stroke caused by primary multivessel occlusions (pMVO) is a rare but devastating disease. Whether multi-target mechanical thrombectomy for pMVO is beneficial remains unknown. METHODS: Multicenter retrospective review of patients treated with multi-target mechanical thrombectomy. The following pMVO sites were included: basilar artery, internal carotid artery, and middle cerebral artery (M1 and M2). Baseline characteristics were reported together with interventional technique, technical efficacy, and safety parameters. Clinical outcomes were evaluated applying the National Institutes of Health Stroke Scale and modified Rankin Scale. A systematic literature review was performed to summarize previous reports on pMVO mechanical thrombectomy. RESULTS: Of 6081 patients screened, 21 patients met the inclusion criteria (0.35% [95% CI, 0.23%-0.53%]). In 70% (14/20) a cardioembolic cause was reported. A successful reperfusion of Thrombolysis in Cerebral Infarction scale score ≥2b was achieved in 95.2% (20/21) for the first and 76.1% (16/21) for the second target vessel. In those who survived the acute hospital stay (n=10/21), median admission National Institutes of Health Stroke Scale improved from 21 (interquartile range, 13-27) to 8 (interquartile range, 2-20) at discharge (P=0.006). Mortality was 60% (12/20) at 90 days and only 20% (4/20) of patients reached modified Rankin Scale score ≤2. Acceptable outcomes were almost exclusively observed in pMVO patients presenting with at least one M2 occlusion. CONCLUSIONS: Multi-target mechanical thrombectomy for pMVOs is rarely performed; however, the procedure appears to be feasible and safe with high reperfusion rates for both occlusion sites. More than half of all treated patients deceased early and favorable outcomes may only be expected for pMVO patients including at least one M2 occlusion.

Repeated mechanical thrombectomy in short-term large vessel occlusion recurrence: multicenter study and systematic review of the literature.

BACKGROUND: Data on the frequency and outcome of repeated mechanical thrombectomy (MT) in patients with short-term re-occlusion of intracranial vessels is limited. Addressing this subject, we report our multicenter experience with a systematic review of the literature. METHODS: A retrospective analysis was conducted of consecutive acute stroke patients treated with MT repeatedly within 30 days at 10 tertiary care centers between January 2007 and January 2020. Baseline demographics, etiology of stroke, angiographic outcome and clinical outcome evaluated by the modified Rankin Scale (mRS) at 90 days were noted. Additionally, a systematic review of reports with repeated MT due to large vessel occlusion (LVO) recurrence was performed. RESULTS: We identified 30 out of 7844 (0.4%) patients who received two thrombectomy procedures within 30 days due to recurrent LVO. Through systematic review, three publications of 28 participants met the criteria for inclusion. Combined, a total of 58 participants were analyzed: cardioembolic events were the most common etiology for the first (65.5%) and second LVO (60.3%), respectively. Median baseline NIHSS (National Institutes of Health Stroke Scale) was 13 (IQR 8-16) before the first MT and 15 (IQR 11-19) before the second MT (p=0.031). Successful reperfusion was achieved in 91.4% after the first MT and in 86.2% patients after the second MT (p=0.377). The rate of functional independence (mRS 0-2) was 46% at 90 days after the second procedure. CONCLUSION: Repeated MT in short-term recurrent LVO is a rarity but appears to be safe and effective. The second thrombectomy should be pursued with the same extensive effort as the first procedure as these patients may achieve similar good outcomes.

Initial and mid-term results from 108 consecutive patients with cerebral aneurysms treated with the WEB device.

INTRODUCTION: The Woven EndoBridge (WEB) is a novel device for the treatment of wide-necked intracranial bifurcation aneurysms. The present series demonstrates our 'real-world experience' in the use of all iterations of WEB devices (available in Europe) in ruptured and unruptured aneurysms. METHODS: We analyzed our all-inclusive cerebrovascular database for patients treated with the WEB device between October 2010 and May 2015. Anatomic and clinical results are reported for all patients. RESULTS: One hundred and eight patients with 114 intracranial aneurysms were included in the series. Forty-seven aneurysms (41.2%) were ruptured. Eighty-six patients received angiographic and clinical follow-up after a mean of 13.4 months. One hundred and ten of 114 WEB devices (96.5%) were deployed successfully. Thromboembolic complications occurred in 11 of 110 interventions (10.0%), with a new permanent deficit in one patient. Re-rupture after WEB treatment was detected in two aneurysms (4.3%), which had both initially presented with subarachnoid hemorrhage. Angiographic follow-up revealed adequate occlusion in 68 of 90 aneurysms (75.6%). Fifteen aneurysms required retreatment. CONCLUSIONS: This series confirms a high level of safety and efficacy of the WEB device for the treatment of wide-necked intracranial aneurysms.

Female gender predisposes for cerebrospinal fluid overdrainage in ventriculoperitoneal shunting.

BACKGROUND: Gravitational valves (GVs) prevent overdrainage in ventriculoperitoneal shunting (VPS). However, there are no data available on the appropriate opening pressure in the shunt system when implementing a GV. We performed a retrospective analysis of hydrocephalic patients who were successfully treated with VPS which included one or more GV. METHOD: In this retrospective study in adult VPS patients with GVs, we analysed all available data, including the most recent computed tomography (CT) scans, to determine the best adjustments for alleviating any symptoms of overdrainage and underdrainage. Vertical effective opening pressure (VEOP) of the entire shunt system, including the differential pressure valve, was determined. RESULTS: One hundred and twenty-two patients were eligible for the study. Of these, female patients revealed a higher VEOP compared with males (mean, 35.6 cmH2O [SD ± 2.46] vs 28.9 cmH2O [SD ± 0.87], respectively, p = 0.0072, t-test). In patients older than 60 years, lower VEOPs, by a mean of 6.76 cmH2O ± 2.37 (p = 0.0051), were necessary. Mean VEOP was found to be high in idiopathic intracranial hypertension (IIH; 41.6 cmH2O) and malresorptive and congenital HC (35.9 and 36.3), but low in normal pressure HC (27.5, p = 0.0229; one-way ANOVA). In the total cohort, body mass index (BMI) and height did not correlate with VEOP. Twelve patients required a VEOP of more than 40 cmH2O, and in eight of these patients this was accomplished by using multiple GVs. All but one of these eight patients were of female gender, and none of the latter were treated for normal pressure hydrocephalus (NPH) (p = 0.0044 and p = 0.0032, Fisher's exact test). CONCLUSIONS: In adult VPS patients, female gender increases the risk of overdrainage requiring higher VEOPs. Initial implantation of adjustable GV should be considered in female patients treated with VP shunts for pathology other than NPH.

The intra- and postoperative management of accidental durotomy in lumbar spine surgery: results of a German survey.

BACKGROUND: The intra- and postoperative management of accidental durotomy in operations of the lumbar spine is not standardized. It is the aim of our survey to obtain an overview on the current practice in neurosurgical departments in Germany. METHODS: The used questionnaire consisted of three questions and could be answered within a few minutes by checking boxes. In September 2012, the questionnaire was sent to 149 German neurosurgical departments. In the following 4 weeks 109 replies (73.2 %) were received. RESULTS: Seventy-one neurosurgical departments (65.1 %) treat dural tears by a combination of methods, 28 (25.7 %) with suture alone, 7 (6.4 %) with fibrin-coated fleeces alone, 2 (1.8 %) with muscle patch alone and 1 (0.9 %) with fibrin glue alone. Sixty-six neurosurgical departments (60.5 %) decide on postoperative bed rest depending on the quality of the dural closure. Forty-three (39.5 %) neurosurgical departments do not rely on the quality of the dural closure for their postoperative management. In total, 72.5 % of the neurosurgical departments prescribe bed rest for 1-3 days, 1.8 % for more than 3 days, whereas 25.7 % allow immediate mobilization. CONCLUSIONS: Among German neurosurgeons, no consensus exists concerning the intra- and postoperative management of accidental durotomies in lumbar spine surgery. Despite not being proved to reduce the rate of cerebrospinal fluid fistulas, bed rest is frequently used. As bed rest prolongs the hospital stay with additional costs and has the potential of a higher rate of medical complications, a prospective multicenter trial is warranted.

Stent-assisted coil embolization of intracranial aneurysms using the Solitaire™ AB Neurovascular Remodeling Device: initial and midterm follow-up results.

INTRODUCTION: The purpose of this retrospective review was to present our experience in using the Solitaire™ AB Neurovascular Remodeling Device in the stent-assisted treatment of intracranial aneurysms, focusing on midterm results. To date, this is the largest series using the Solitaire™ AB Neurovascular Remodeling Device. METHODS: From February 2008 to December 2010, 102 patients harboring 104 wide-necked or complex intracranial aneurysms were consecutively enrolled. Forty-five patients presented with an acute subarachnoid hemorrhage. Stent implantation was combined with a standard coiling procedure in 100 patients; in 13 of them, by bailout stenting. On average, at least one clinical and angiographic follow-up was available in 63 patients after 6.3 months. Forty-nine patients were followed for up to 13.6 months. RESULTS: Of the stents, 98.4 % could be deployed successfully. A Raymond class 1 occlusion was obtained in 51 % of the aneurysms, a Raymond class 2 occlusion in 44 %, and in the remaining 5 % a Raymond class 3 occlusion was obtained. Procedure-related morbidity was 3.9 % (n = 4) and procedure-related mortality was 2.9 % (n = 3). During the follow-up period, 39.2 % of the aneurysms showed further thrombosis, 45.1 % remained unchanged, and 15.7 % recanalized. In the follow-up clinical examination according to the modified Rankin Scale, 16.3 % of all patients presented with clinical improvement, 73.5 % were unchanged, and 10.2 % of patients deteriorated. CONCLUSION: Considering that stent-assisted coiling is indicated in unfavorable aneurysms, which are not amenable to standard coiling procedures, the Solitaire AB stent proved to be an efficient and safe device in midterm angiographic and clinical follow-up results.

Coil embolization of anterior circulation aneurysms supported by the Solitaire AB Neurovascular Remodeling Device.

INTRODUCTION: The purpose of the study is to evaluate patients with wide-necked or complex aneurysms of the anterior circulation who underwent Solitaire AB Neurovascular Remodeling Device-assisted coil embolization. METHODS: From February 2008 to March 2009, consecutive data were collected from 45 patients with anterior circulation aneurysms. Eighteen of the patients presented with acute subarachnoid hemorrhage. Forty-six aneurysms were treated with the aid of different applications (n = 49) of the Solitaire AB Remodeling Device followed by standard coiling procedure (n = 43) using bioactive coils or/and bare coils. RESULTS: Successful positioning of the remodeling device was obtained in 95.9% of the cases. There were two thromboembolic complications (4.1%) and one severe vasospasm requiring retrieval of the device. Permanent procedural morbidity was observed in one patient (2%). The proportion of patients in whom Raymond class 1 occlusion was obtained was 53.5% (n = 23). Raymond class 2 occlusion was achieved in 42% (n = 18) and Raymond class 3 occlusion in 4.7% (n = 2). Thirty-nine patients left the hospital with a good clinical status. CONCLUSION: The initial technical and clinical results of Solitaire AB device-assisted coiling of aneurysms in the anterior circulation are highly encouraging. This technique may enhance the possibilities of the endovascular treatment of these aneurysms in clinical routine.