Evaluation of Pipeline Flex delivery system for the treatment of unruptured aneurysms.

INTRODUCTION: Refinements in endovascular technology have revolutionized the treatment of intracranial aneurysms (IAs) with the development of flow-diversion technology. The first generation of the Pipelin Embolization Device (PED) has demonstrated its safety and efficacy. However, the deployment technique was a difficult task that often led to complex maneuvers. The Pipeline Flex Embolization Device (PED Flex) is the second generation and its introduction has arrived with high expectations due to a completely redesigned delivery system that intends to overcome deployment difficulties seen in the previous generation. Areas covered: Preclinical studies, mechanism of action of flow-diverters, technical aspects and deployment system of the PED Flex, and clinical outcomes with both PED generations. Expert commentary: Flow diversion has allowed us to treat lesions that would be otherwise challenging for surgical clipping or unsuitable for other endosaccular strategies. Although the experience with PED Flex is limited, initial results suggest its safety and short-term efficacy.

Endovascular Therapy for Large Vessel Stroke in the Elderly: Hope in the New Stroke Era.

BACKGROUND AND PURPOSE: Acute ischemic stroke (AIS) in the elderly encompasses approximately one-third of all AIS cases. Outcome data have been for the most part discouraging in this population. We aim to evaluate the outcomes in a large contemporary series of elderly patients treated with thrombectomy. METHODS: Retrospective analysis of a single-center endovascular database for consecutive elderly (≥80 years) patients treated for anterior circulation large vessel occlusion AIS between September 2010 and April 2015. Univariate- and multivariate analyses were performed to identify the predictors of good clinical outcome (90-day modified Ranking Scale [mRS] ≤2). Receiver operating characteristic curves were used to calculate the optimal final infarct volume (FIV) threshold to predict good outcomes. RESULTS: A total of 111 patients met our inclusion criteria (mean age 84.8 ± 4.2 years; National Institutes of Health Stroke Scale [NIHSS] score 19.1 ± 5.6; time from last-known normal to puncture, 349.6 ± 246.6 min; 33% male; 68% Alberta Stroke Program Early CT Score [ASPECTS] ≥8). The rates of successful reperfusion (modified treatment in cerebral ischemia ≥2b), symptomatic intracranial hemorrhage and 90-day mortality were 80%, 7% and 41%, respectively. The overall rate of good outcome was 29% (n = 32/111) but was 52% (n = 13/25) in patients with baseline mRS score of 0-2 who were selected based on CT perfusion and treated with stent retrievers. On multivariate analysis, only ASPECTS (OR 2.17; 95% CI 1.28-3.67.7; p = 0.004) and baseline NIHSS score (OR 0.87; 95% CI 0.77-0.97; p = 0.013) were independently associated with good outcome. A FIV ≤16 ml demonstrated the greatest accuracy for identifying good outcomes (sensitivity 75.0%, specificity 82.6%). CONCLUSIONS: Our results are encouraging demonstrating nearly one-third of elderly patients achieving full independence at 90 days. Contemporary treatment paradigms employing optimized patient selection and modern thrombectomy technology may result in even better outcomes.

Early Endovascular Treatment in Intravenous Tissue Plasminogen Activator-Ineligible Patients.

BACKGROUND AND PURPOSE: Intravenous tissue-type plasminogen activator (tPA) treatment in acute stroke has many exclusion criteria. We aimed to assess the safety and efficacy of endovascular therapy (ET) in intravenous (IV) tPA-ineligible patients. METHODS: Retrospective analysis of a prospectively collected database of consecutive patients treated with ET within 6 hours of stroke onset between September 2010 and April 2015. Patients treated with IV-tPA followed by ET were compared with those treated with ET alone because of IV-tPA ineligibility. Efficacy and safety end points included the rates of good outcome (90-day modified Rankin scale score ≤2), successful reperfusion (modified Treatment in Cerebral Ischemia 2b-3), parenchymal hematoma (PH-1 and PH-2), and 90-day mortality. Univariate and logistic regression were performed to identify the predictors of outcomes. RESULTS: A total of 422 patients were included. Two hundred and fifty-three (59%) patients received IV-tPA+ET, and 169 (41%), ET alone. Combined IV-tPA+ET patients were slightly younger (64.9±15.2 versus 67.9±14.9 years; P=0.05), more often males (56% versus 44%; P=0.01), and had less hypertension (70% versus 81%; P=0.02) and vertebrobasilar occlusions (3% versus 8%; P=0.02). The remaining baseline characteristics, including National Institutes of Health Stroke Scale score (20 [15-23] versus 19 [15-24]; P=0.85), Alberta Stroke Program Early CT Score (ASPECTS; 8 [7-9] versus 8 [7-9]; P=0.24), and stroke onset to puncture times (235±70 versus 240±81 minutes; P=0.27), were similar across both groups. There were no significant differences in the rates of modified Treatment in Cerebral Ischemia 2b-3 (83% versus 80%; P=0.52), 90-day modified Rankin scale score ≤2 (45% versus 38%; P=0.21), or any PH (3% versus 5%; P=0.21). Unadjusted 90-day mortality was higher with ET alone (21% versus 34%; P<0.01); however, IV-tPA ineligibility was not associated with modified Treatment in Cerebral Ischemia 2b-3, any PH, good outcome, or 90-day mortality on logistic regression. CONCLUSIONS: IV-tPA-eligible and -ineligible patients seem to have similar outcomes after early ET.

Endovascular Treatment of Acute Ischemic Stroke Due to Tandem Occlusions: Large Multicenter Series and Systematic Review.

BACKGROUND: Ischemic strokes due to tandem occlusions (TOs) have poor outcomes if they have been treated with only medical interventions. Recent trials demonstrated the effectiveness of endovascular treatment of acute ischemic stroke due to intracranial occlusions; however, most studies excluded patients with TOs. METHODS: Retrospective review of prospectively collected thrombectomy databases from 3 stroke centers between 2011 and 2015. Consecutive patients with tandem extracranial steno-occlusive carotid disease and intracranial occlusions who underwent emergent thrombectomy were selected. Angiographic and clinical outcomes were analyzed; baseline and procedural variables were included in univariate and multivariate analyses to define the independent predictors of good outcomes (90-day modified Rankin Scale ≤2). RESULTS: A total of 100 patients met the study inclusion criteria. The mean age was 64.4 ± 12.5, baseline National Institutes of Health Stroke Scale (NIHSS) 17.6 ± 5.0, time from last known well to puncture 7.3 ± 5.8 h, and Alberta Stroke Program Early CT Score (ASPECTS) 7.5 ± 1.6. Forty percent received intravenous tissue plasminogen activator. Intracranial occlusion sites included: internal carotid artery thrombus, 31%; middle cerebral artery (MCA)-M1, 53%; MCA-M2, 10%; and anterior cerebral artery, 6%. Good outcome was achieved in 42% and successful reperfusion modified thrombolysis in cerebral infarction (mTICI ≥2B) in 88% of the cases, including complete (mTICI 3) reperfusion in 40%. Severe parenchymal hematoma (PH)-2 occurred in 6% of the patients and 90-day mortality was 20%. In the multivariate analysis, younger age (OR 0.93; 95% CI 0.88-0.98; p = 0.004), lower baseline NIHSS (OR 0.84; 95% CI 0.74-0.94; p = 0.003), higher ASPECTS (OR 1.50; 95% CI 1.02-2.19; p = 0.038), and mTICI 3 reperfusion (OR 3.56; 95% CI 1.18-10.76; p = 0.024) were independent predictors of good outcome at 90 days. CONCLUSIONS: Acute endovascular treatment of tandem anterior circulation occlusions yields good outcomes and has similar outcome predictors to isolated intracranial occlusions. Given their comparable clinical behavior, these patients should be included in future trials.

Endovascular Management vs Intravenous Thrombolysis for Acute Stroke Secondary to Carotid Artery Dissection: Local Experience and Systematic Review.

BACKGROUND: Little is known regarding the endovascular management of acute ischemic stroke (AIS) related to carotid artery dissection (CAD). OBJECTIVE: To report our interventional experience in AIS from CAD and to compare it with conservative treatment of CAD with intravenous thrombolysis (IVT) via systematic review. METHODS: Retrospective analysis of consecutive high-grade steno-occlusive CAD with National Institutes of Health Stroke Scale (NIHSS) >5 and ≤12 hours of last seen normal from 2 tertiary centers. A systematic review for studies on IVT in the setting of CAD via PubMed was performed for comparison. RESULTS: Of 1112 patients treated with endovascular interventions within the study period, 21 met the inclusion criteria. Mean age was 52.0 ± 10.9 years, 76% were male, NIHSS was 17.4 ± 5.8, 52% received IVT before intervention, and 90% had tandem occlusions. Mean time from last-known-normal to puncture was 4.8 ± 2.1 hours and procedure length 1.8 ± 1.0 hours. Stents were used in 52% of cases, and reperfusion (modified Treatment in Cerebral Ischemia 2b-3) achieved in 95%. No parenchymal hemorrhages were observed and 71% achieved good outcome (90-day modified Rankin Scale 0-2). The literature review identified 8 studies concerning thrombolysis in the CAD setting fitting inclusion criteria (n = 133). Our endovascular experience compared with the pooled IVT reports indicated that, despite presenting with higher NIHSS (17 vs 14; P = .04) and experiencing a longer time to definitive therapy (287 vs 162 minutes; P < .01), patients treated intra-arterially had similar rates of symptomatic cerebral/European Cooperative Acute Stroke Study-parenchymal hematoma 2 hemorrhage (0% vs 6%; P = .43) and good outcomes (71% vs 52%; P = .05). CONCLUSION: Our study provides evidence that the endovascular management of AIS in the setting of CAD is a feasible, safe, and promising strategy.

Large Volumes of Critically Hypoperfused Penumbral Tissue Do Not Preclude Good Outcomes After Complete Endovascular Reperfusion: Redefining Malignant Profile.

BACKGROUND AND PURPOSE: Acute ischemic stroke patients with large volumes of severe hypoperfusion (Tmax>10 s>100 mL) on magnetic resonance imaging have a higher likelihood of intracranial hemorrhage and poor outcomes after reperfusion. We aim to evaluate the impact of the extent of Tmax>10 s CTP lesions in patients undergoing successful treatment. METHODS: Retrospective database review of endovascular acute ischemic stroke treatment between September 2010 and March 2015 for patients with anterior circulation occlusions with baseline RAPID CTP and full reperfusion (mTICI 3). The primary outcome was the impact of the Tmax>10 s lesion spectrum on infarct growth. Secondary safety and efficacy outcomes included parenchymal hematomas and good clinical outcomes (90-day modified Rankin Scale score, 0-2). RESULTS: Of 684 treated patients, 113 patients fit the inclusion criteria. Tmax>10 s>100 mL patients (n=37) had significantly higher baseline National Institutes of Health Stroke Scale (20.7±3.8 versus 17.0±5.9; P<0.01), more internal carotid artery terminus occlusions (29% versus 9%; P=0.02), and larger baseline (38.6±29.6 versus 11.7±15.8 mL; P<0.01) and final (60.7±60.0 versus 29.4±33.9 mL; P<0.01) infarct volumes when compared with patients without Tmax>10 s>100 mL (n=76); however, the 2 groups were otherwise well balanced. There were no significant differences in infarct growth (22.1±51.6 versus 17.8±32.4 mL; P=0.78), severe intracranial hemorrhage (PH2: 2% versus 4%; P=0.73), good outcomes (90-day mRS score, 0-2: 56% versus 59%; P=0.83), or 90-day mortality (16% versus 7%; P=0.28). On multivariate analysis, only baseline National Institutes of Health Stroke Scale (odds ratio, 1.19; 95% confidence interval, 1.06-1.34; P<0.01) and baseline infarct core volume (odds ratio, 1.05; 95% confidence interval, 1.02-1.08; P<0.01) were independently associated with Tmax>10 s>100 mL. There was no association between Tmax>10 s>100 mL with any PH, good outcome, or infarct growth. CONCLUSIONS: In the setting of limited baseline ischemic cores, large Tmax>10 s lesions on computed tomographic perfusion do not seem to be associated with a higher risk of parenchymal hematomas and do not preclude good outcomes in patients undergoing endovascular reperfusion with contemporary technology.

Endovascular treatment of PICA aneurysms with a Low-profile Visualized Intraluminal Support (LVIS Jr) device.

OBJECTIVE: To describe the treatment of posterior inferior cerebellar artery (PICA) aneurysms with the Low-profile Visualized Intraluminal Support Device (LVIS Jr) stent. MATERIALS AND METHODS: The databases of three institutions were retrospectively reviewed. Patients who underwent endovascular treatment of PICA aneurysms using a reconstructive technique where the LVIS Jr stent was totally or partially deployed into the PICA were included in the analysis. Clinical presentation, aneurysm and PICA sizes, procedural complications, and clinical and angiographic follow-up information was recorded and analyzed. RESULTS: Seven patients who underwent endovascular treatment of PICA aneurysms with an LVIS Jr stent were identified. Four aneurysms were treated in the acute phase of subarachnoid hemorrhage (SAH). There were no symptomatic complications. One patient had spasm distal to the stent as a result of mechanical straightening of the vessel. One patient was treated in the acute phase of SAH and required a gycoprotein IIb/IIIa inhibitor after the stent was implanted. This patient needed to be re-treated to complete embolization. All patients had good clinical outcomes (Glasgow Outcome Scale 5). No in-stent stenosis or occlusion was seen on short-term angiographic follow-up and the aneurysms were occluded. CONCLUSIONS: This small series suggests that the use of a reconstructive technique with the LVIS Jr stent for the treatment of PICA aneurysms is feasible, safe and effective in the short term.

The Trevo XP 3×20†mm retriever ('Baby Trevo') for the treatment of distal intracranial occlusions.

OBJECTIVE: To report our single-center initial experience using the Trevo XP ProVue Retriever 3×20 mm ('Baby Trevo') for distal intracranial occlusions. METHODS: We performed a retrospective review of our interventional database for consecutive patients who underwent treatment for acute ischemic stroke with the Baby Trevo device between February and December 2014. RESULTS: Of 134 patients treated during the study period, 8 underwent treatment with the Baby Trevo for distal occlusions. Their mean age was 51±20 years, 5 (62.5%) were male, mean baseline National Institutes of Health Stroke Scale was 19±5. The mean interval between the time the patient was last-known normal to groin puncture was 527±285 min, and the overall procedural length was 110±26 min. Intra-arterial tissue plasminogen activator was used in 5 (62.5%) cases. The device was used for a total of 10 branches: five middle cerebral artery (four superior M3 and one inferior M3), three anterior cerebral arteries (two pericallosal and one callosomarginal), and two posterior cerebral arteries (one P2 and one P3) occlusions. All patients achieved complete recanalization of the artery targeted by the Baby Trevo (arterial occlusive lesion 3). Good capillary reperfusion (TICI 2b-3) was noted in 6 (75%) cases. One pass was performed in 7 vessels and 2 passes in three branches. Vasospasm was noted in 5 (62.5%) of the vessels and fully responded to intra-arterial vasodilator infusion. Follow-up MRI revealed no infarct within the territory vascularized by the artery targeted by the Baby Trevo in 4 cases, partial infarct in 5, and complete infarct in 1. Two patients had parenchymal hematomas (one PH1 and one PH2). No vessel perforations, dissections, or subarachnoid hemorrhage were noted. CONCLUSIONS: Our initial data suggest that treatment of distal cerebrovascular occlusions with the Trevo XP 3×20 mm Retriever is feasible. Although this device emerges as a promising technology for small and tortuous distal intracranial vessels, larger studies are still necessary to establish its safety and clinical benefit.

Sulcal effacement with preserved gray-white junction: a sign of reversible ischemia.

BACKGROUND AND PURPOSE: Sulcal effacement with preserved underlying gray-white matter junction (isolated sulcal effacement [ISE]) in acute ischemic stroke may not represent irreversible parenchymal injury. We aimed to evaluate the frequency and significance of ISE in patients with large vessel occlusion acute ischemic stroke. METHODS: Consecutive acute ischemic stroke patients with middle cerebral artery M1 or internal carotid artery terminus occlusions who underwent computed tomography angiogram/perfusion followed by intra-arterial therapy were screened for ISE. RESULTS: Out of the 568 patients who underwent intra-arterial therapy between March 2011 and September 2014, 108 fulfilled inclusion criteria. ISE was present in 8 (7.4%) patients (age 55.7±10.5 years, 6 female, baseline National Institutes of Health Stroke Scale 16.1±3.8, 5 middle cerebral artery-M1, and 3 internal carotid artery terminus occlusions). Computed tomography angiogram revealed engorged/dilated leptomeningeal vessels obliterating the sulci within the areas of effacement, whereas computed tomography perfusion indicated normal-to-increased cerebral blood volume and prolonged Tmax in all patients. Modified treatment in cerebral ischemia (mTICI) 2b-3 reperfusion was achieved in all patients. Follow-up imaging confirmed no infarct in the ISE area in all patients, and 5 (62%) had modified Rankin Scale 0 to 2 at 3 months. CONCLUSIONS: Sulcal effacement with preserved gray-white delineation is occasionally visualized in patients with proximal occlusion strokes, relates to robust leptomeningeal collaterals, and indicates preserved underlying parenchyma. ISE should not be used to exclude patients from thrombectomy.

Comparing validity of Edinburgh scale and SRQ20 in screening for post-partum depression.

The Edinburgh Postnatal Depression Scale (EPDS) is the instrument most used worldwide for screening of Post-Partum Depression (PPD). The SRQ20 questionnaire has been largely used for screening of minor psychiatric disorders. This study aimed to compare the accuracy of the two instruments in screening for PPD. At the third-month follow-up home visit to infants of the 2004 Pelotas Birth Cohort, Southern Brazil, a sub-sample of 378 mothers was selected. Among other questions, EPDS and SRQ20 were applied by trained fieldworkers. Up to 15 days later, a mental health professional re-interviewed the mother (the gold standard interview). Sensitivity and specificity of each cutoff point were calculated for EPDS and SRQ20 and the results were plotted at a ROC curve. The areas under both curves were compared. Highest sensitivity and specificity cutoff were observed for EPDS >/= 10 (sensitivity 82.7%, 95%CI 74.0 - 89.4; specificity 65.3%, 95%CI 59.4 - 71.0) and for SRQ20 >/= 6 (sensitivity 70.5%, 95%CI 60.8 - 79.0%; specificity 75.5%, 95%CI 70.0 - 80.5%). Shape of ROC curves and areas under both curves were virtually identical (respectively, 0.8401 +/- 0.02 for EPDS and 0.8402 +/- 0.02 for SRQ20; p = 0.9). In conclusion SRQ20 showed to be as valid as EPDS as a screening tool for PPD at third month after delivery.