Endovascular Treatment of Spetzler-Martin Grade III Arteriovenous Malformations: A Single-Center 12 years' Experience Stratified by the Spetzler-Martin Modified Scale.

BACKGROUND AND OBJECTIVES: Limited evidence exists for endovascular first-line treatment of Spetzler-Martin (SM) grade III brain arteriovenous malformations (AVMs). In this article, we sought to evaluate advanced endovascular techniques for treating SM III AVMs across different sizes, eloquence, and patterns of venous drainage. METHODS: Data from AVMs SM III treated between January 2010 and January 2022 were collected: size (S), eloquence (E), drainage (V), angioarchitecture features (arterial and venous aneurysms, venous drainage, and venous stenosis), treatment strategy (single arterial, double arterial, venous, both arterial and venous, and transvenous endovascular embolization with selective temporary flow arrest [TFATVE]), neoadjuvant treatment, and number of previous embolization sessions. AVMs were classified according to the modified SM grade as follows: small (S1V1E1/III-), medium/deep (S2V1E0/III), medium/eloquent (S2V0E1/III+), and large (S3V0E0). Treatment complications (hemorrhagic and ischemic), clinical discharge and 6-month outcomes (modified Rankin Scale 0-2, mRS), and angiographic occlusion rates were recorded. RESULTS: A total of 91 AVMs (62.6% ruptured, 72.5% S1V1E1, 7% S2V1E0, 19.7% S2V0E1, and 0% S3V0E0) in 91 patients (mean age 37 ± 15.8 years) were included. Treatment techniques included single arterial approach (28.6%), double arterial technique (30.8%), single venous strategy (9.9%), TFATVE (10.9%), and arterial and venous combined (19.8%). The angiographic occlusion rate was 91.2% (90.9% S1V1E1, 100% S2V1E0, and 88.9% S2V0E1) for all techniques, and 100% for the transvenous technique, isolated or combined with transarterial embolization. Minor complication (mRS 0-2), major complication (mRS >2), and mortality rate were 16.5%, 2.2%, and 3.4%, respectively. Overall, treatment morbimortality (mRS >2) was 3% (2/66) for S1V1E1, 0% for S2V1E0, and 16.7% (3/18) for S2V0E1. CONCLUSION: Although morbidity is non-negligible, endovascular treatment of SM grade III lesions with advanced techniques offers up to 100% rates of cure, which is of high interest, especially for ruptured deep-seated eloquent AVMs with high reruptured rates, and less amenable to microsurgery techniques.

Trial of Thrombectomy for Stroke with a Large Infarct of Unrestricted Size.

BACKGROUND: The use of thrombectomy in patients with acute stroke and a large infarct of unrestricted size has not been well studied. METHODS: We assigned, in a 1:1 ratio, patients with proximal cerebral vessel occlusion in the anterior circulation and a large infarct (as defined by an Alberta Stroke Program Early Computed Tomographic Score of ≤5; values range from 0 to 10) detected on magnetic resonance imaging or computed tomography within 6.5 hours after symptom onset to undergo endovascular thrombectomy and receive medical care (thrombectomy group) or to receive medical care alone (control group). The primary outcome was the score on the modified Rankin scale at 90 days (scores range from 0 to 6, with higher scores indicating greater disability). The primary safety outcome was death from any cause at 90 days, and an ancillary safety outcome was symptomatic intracerebral hemorrhage. RESULTS: A total of 333 patients were assigned to either the thrombectomy group (166 patients) or the control group (167 patients); 9 were excluded from the analysis because of consent withdrawal or legal reasons. The trial was stopped early because results of similar trials favored thrombectomy. Approximately 35% of the patients received thrombolysis therapy. The median modified Rankin scale score at 90 days was 4 in the thrombectomy group and 6 in the control group (generalized odds ratio, 1.63; 95% confidence interval [CI], 1.29 to 2.06; P<0.001). Death from any cause at 90 days occurred in 36.1% of the patients in the thrombectomy group and in 55.5% of those in the control group (adjusted relative risk, 0.65; 95% CI, 0.50 to 0.84), and the percentage of patients with symptomatic intracerebral hemorrhage was 9.6% and 5.7%, respectively (adjusted relative risk, 1.73; 95% CI, 0.78 to 4.68). Eleven procedure-related complications occurred in the thrombectomy group. CONCLUSIONS: In patients with acute stroke and a large infarct of unrestricted size, thrombectomy plus medical care resulted in better functional outcomes and lower mortality than medical care alone but led to a higher incidence of symptomatic intracerebral hemorrhage. (Funded by Montpellier University Hospital; LASTE ClinicalTrials.gov number, NCT03811769.).

Outcomes with General Anesthesia Compared to Conscious Sedation for Endovascular Treatment of Medium Vessel Occlusions: Results of an International Multicentric Study.

BACKGROUND: Optimal anesthetic strategy for the endovascular treatment of stroke is still under debate. Despite scarce data concerning anesthetic management for medium and distal vessel occlusions (MeVOs) some centers empirically support a general anesthesia (GA) strategy in these patients. METHODS: We conducted an international retrospective study of MeVO cases. A propensity score matching algorithm was used to mitigate potential differences across patients undergoing GA and conscious sedation (CS). Comparisons in clinical and safety outcomes were performed between the two study groups GA and CS. The favourable outcome was defined as a modified Rankin Scale (mRS) 0-2 at 90 days. Safety outcomes were 90-days mortality and symptomatic intracranial hemorrhage (sICH). Predictors of a favourable outcome and sICH were evaluated with backward logistic regression. RESULTS: After propensity score matching 668 patients were included in the CS and 264 patients in the GA group. In the matched cohort, either strategy CS or GA resulted in similar rates of good functional outcomes (50.1% vs. 48.4%), and successful recanalization (89.4% vs. 90.2%). The GA group had higher rates of 90-day mortality (22.6% vs. 16.5%, p < 0.041) and sICH (4.2% vs. 0.9%, p = 0.001) compared to the CS group. Backward logistic regression did not identify GA vs CS as a predictor of good functional outcome (OR for GA vs CS = 0.95 (0.67-1.35)), but GA remained a significant predictor of sICH (OR = 5.32, 95% CI 1.92-14.72). CONCLUSION: Anaesthetic strategy in MeVOs does not influence favorable outcomes or final successful recanalization rates, however, GA may be associated with an increased risk of sICH and mortality.

Brain Arteriovenous Malformation In Vitro Model for Transvenous Embolization Using 3D Printing and Real Patient Data.

BACKGROUND AND PURPOSE: Transvenous embolization has emerged as a novel technique for treating selected brain AVMs with high reported occlusion rates. However, it requires anatomic and technical skills to be successful and to ensure patient safety. Therefore, training and testing are essential for preparing clinicians to perform these procedures. Our aim was to develop and test a novel, patient-specific brain AVM in vitro model for transvenous embolization by using 3D printing technology. MATERIALS AND METHODS: We developed a brain AVM in vitro model based on real patient data by using stereolithography resin 3D printing. We created a closed pulsed circuit with flow passing from the arterial side to the venous side, and we tested the effect of mean arterial pressure on retrograde nidal filling with contrast injections. Transvenous embolization simulations were conducted for each of the 12 identical models divided into 2 groups (2×6). This involved the use of an ethylene-vinyl alcohol liquid embolic agent injected through microcatheters either without or with a coil in the vein (groups 1 and 2, respectively). RESULTS: Retrograde contrast advance to nidus was directly related to lower mean arterial pressure. Transvenous embolization tests with a liquid embolic agent adequately reproduced the usual embolization plug and push technique. We found no differences between the 2 group conditions, and additional venous coil neither increased nidus penetration nor reduced injection time in the model (57.6 versus 61.2% nidus occlusion rate, respectively). CONCLUSIONS: We were able to develop and test a functional in vitro brain AVM model for transvenous embolization by using 3D printing to emulate its conditions and characteristics. Better contrast penetration was achieved with less mean arterial pressure, and no embolization advantage was found by adding coil to the vein in this model.

Incidence and clinical outcomes of perforations during mechanical thrombectomy for medium vessel occlusion in acute ischemic stroke: A retrospective, multicenter, and multinational study.

BACKGROUND: Mechanical thrombectomy (MT) has revolutionized the treatment of acute ischemic stroke (AIS) due to large vessel occlusion (LVO), but its efficacy and safety in medium vessel occlusion (MeVO) remain less explored. This multicenter, retrospective study aims to investigate the incidence and clinical outcomes of vessel perforations (confirmed by extravasation during an angiographic series) during MT for AIS caused by MeVO. METHODS: Data were collected from 37 academic centers across North America, Asia, and Europe between September 2017 and July 2021. A total of 1373 AIS patients with MeVO underwent MT. Baseline characteristics, procedural details, and clinical outcomes were analyzed. RESULTS: The incidence of vessel perforation was 4.8% (66/1373). Notably, our analysis indicates variations in perforation rates across different arterial segments: 8.9% in M3 segments, 4.3% in M2 segments, and 8.3% in A2 segments (p = 0.612). Patients with perforation had significantly worse outcomes, with lower rates of favorable angiographic outcomes (TICI 2c-3: 23% vs 58.9%, p < 0.001; TICI 2b-3: 56.5% vs 88.3%, p < 0.001). Functional outcomes were also worse in the perforation group (mRS 0-1 at 3 months: 22.7% vs 36.6%, p = 0.031; mRS 0-2 at 3 months: 28.8% vs 53.9%, p < 0.001). Mortality was higher in the perforation group (30.3% vs 16.8%, p = 0.008). CONCLUSION: This study reveals that while the occurrence of vessel perforation in MT for AIS due to MeVO is relatively rare, it is associated with poor functional outcomes and higher mortality. The findings highlight the need for increased caution and specialized training in performing MT for MeVO. Further prospective research is required for risk mitigation strategies.

Use of the pRESET LITE thrombectomy device in combined approach for medium vessel occlusions: A multicenter evaluation.

PURPOSE: Our purpose was to assess the efficacy and safety of the pRESET LITE stent retriever (Phenox, Bochum, Germany), designed for medium vessel occlusion (MeVO) in acute ischemic stroke (AIS) patients with a primary MeVO. METHODS: We performed a retrospective analysis of the MAD MT Consortium, an integration of prospectively maintained databases at 37 academic institutions in Europe, North America, and Asia, of AIS patients who underwent mechanical thrombectomy with the pRESET LITE stent retriever for a primary MeVO. We subcategorized occlusions into proximal MeVOs (segments A1, M2, and P1) vs. distal MeVOs/DMVO (segments A2, M3-M4, and P2). We reviewed patient and procedural characteristics, as well as angiographic and clinical outcomes. RESULTS: Between September 2016 and December 2021, 227 patients were included (50% female, median age 78 [65-84] years), of whom 161 (71%) suffered proximal MeVO and 66 (29%) distal MeVO. Using a combined approach in 96% of cases, successful reperfusion of the target vessel (mTICI 2b/2c/3) was attained in 85% of proximal MeVO and 97% of DMVO, with a median of 2 passes (IQR: 1-3) overall. Periprocedural complications rate was 7%. Control CT at day 1 post-MT revealed a hemorrhagic transformation in 63 (39%) patients with proximal MeVO and 24 (36%) patients with DMVO, with ECASS-PH type hemorrhagic transformations occurring in 3 (1%) patients. After 3 months, 58% of all MeVO and 63% of DMVO patients demonstrated a favorable outcome (mRS 0-2). CONCLUSION: Mechanical thrombectomy using the pRESET LITE in a combined approach with an aspiration catheter appears effective for primary medium vessel occlusions across several centers and physicians.

Embolization of the middle meningeal artery for the prevention of chronic subdural hematoma recurrence in high-risk patients: a randomized controlled trial-the EMPROTECT study protocol.

BACKGROUND: Middle meningeal artery (MMA) embolization has been proposed as a treatment of chronic subdural hematoma (CSDH). The benefit of the procedure has yet to be demonstrated in a randomized controlled trial. We aim to assess the efficacy of MMA embolization in reducing the risk of CSDH recurrence 6 months after burr-hole surgery compared with standard medical treatment in patients at high risk of postoperative recurrence. METHODS: The EMPROTECT trial is a multicenter open label randomized controlled trial (RCT) involving 12 French centers. Adult patients (≥18 years) operated for CSDH recurrence or for a first episode with a predefined recurrence risk factor are randomized 1:1 to receive either MMA embolization within 7 days of the burr-hole surgery (experimental group) or standard medical care (control group). The number of patients to be included is 342. RESULTS: The primary outcome is the rate of CSDH recurrence at 6 months. Secondary outcomes include the rate of repeated surgery for a homolateral CSDH recurrence during the 6-month follow-up period, the rate of disability and dependency at 1 and 6 months, defined by a modified Rankin Scale (mRS) score ≥4, mortality at 1 and 6 months, total cumulative duration of hospital stay during the 6-month follow-up period, directly or indirectly related to the CSDH and embolization procedure-related complication rates. CONCLUSIONS: The EMPROTECT trial is the first RCT evaluating the benefit of MMA embolization as a surgical adjunct for the prevention of CSDH recurrence. If positive, this trial will have a significant impact on patient care. TRIAL REGISTRATION NUMBER: NCT04372147.

WEB shape modifications: angiography-histopathology correlations in rabbits.

BACKGROUND: WEB Shape Modification (WSM) over time is frequent after aneurysm treatment. In this study, we explored the relationship between histopathological changes and angiographic evolution over time in experimental aneurysms in rabbits treated with the Woven EndoBridge (WEB) procedure. METHODS: Quantitative WSM was assessed using flat-panel computed tomography (FPCT) during follow-up by calculating height and width ratio (HR, WR), defined as the ratio between either measurement at an index time point and the measurement immediately after WEB implantation. The index time point varied from 1 day to 6 months. HR and WR were evaluated with angiographic and histopathological assessments of aneurysm healing. RESULTS: Final HR of devices varied from 0.30 to 1.02 and final WR varied from 0.62 to 1.59. Altogether, at least 5% of HR and WR variations were observed in 37/40 (92.5%) and 28/40 (70%) WEB devices, respectively, at the time of final assessment. There was no significant correlation between complete or incomplete occlusion groups and HR or WR (p=0.15 and p=0.43). Histopathological analysis revealed a significant association between WR and aneurysm healing and fibrosis 1 month following aneurysm treatment (both p<0.05). CONCLUSION: Using longitudinal FPCT assessment, we observed that WSM affects both the height and width of the WEB device. No significant association was found between WSM and aneurysm occlusion status. Although presumably a multifactorial phenomenon, the histopathological analysis highlighted a significant association between width variations, aneurysm healing and fibrosis in the first month following aneurysm treatment.

First pass effect as an independent predictor of functional outcomes in medium vessel occlusions: An analysis of an international multicenter study.

INTRODUCTION: First pass effect (FPE), achievement of complete recanalization (mTICI 2c/3) with a single pass, is a significant predictor of favorable outcomes for endovascular treatment (EVT) in large vessel occlusion stroke (LVO). However, data concerning the impact on functional outcomes and predictors of FPE in medium vessel occlusions (MeVO) are scarce. PATIENTS AND METHODS: We conducted an international retrospective study on MeVO cases. Multivariable logistic modeling was used to establish independent predictors of FPE. Clinical and safety outcomes were compared between the two study groups (FPE vs non-FPE) using logistic regression models. Good outcome was defined as modified Rankin Scale 0-2 at 3 months. RESULTS: Eight hundred thirty-six patients with a final mTICI ⩾ 2b were included in this analysis. FPE was observed in 302 patients (36.1%). In multivariable analysis, hypertension (aOR 1.55, 95% CI 1.10-2.20) and lower baseline NIHSS score (aOR 0.95, 95% CI 0.93-0.97) were independently associated with an FPE. Good outcomes were more common in the FPE versus non-FPE group (72.8% vs 52.8%), and FPE was independently associated with favorable outcome (aOR 2.20, 95% CI 1.59-3.05). 90-day mortality and intracranial hemorrhage (ICH) were significantly lower in the FPE group, 0.43 (95% CI, 0.25-0.72) and 0.55 (95% CI, 0.39-0.77), respectively. CONCLUSION: Over 2/3 of patients with MeVOs and FPE in our cohort had a favorable outcome at 90 days. FPE is independently associated with favorable outcomes, it may reduce the risk of any intracranial hemorrhage, and 3-month mortality.

Safety and effectiveness of the LVIS and LVIS Jr devices for the treatment of intracranial aneurysms: Final results of the LEPI multicenter cohort study.

BACKGROUND: The Low profile visualized intraluminal support (LVIS)/LVIS Jr is a self-expanding braiding stent for the treatment of intracranial aneurysm. This study is to determine the safety and effectiveness of the LVIS/LVIS Jr for the treatment of intracranial aneurysms in a real-world setting. METHODS: This prospective, observational, multicenter study enrolled patients with unruptured, ruptured and recanalized intracranial aneurysms treated with the LVIS stents, between February 2018 to December 2019. Primary endpoint was the cumulative morbidity and mortality rate (CMMR) assessed at 12 months follow-up (FU). RESULTS: A total of 130 patients were included (62.3 % women, mean age 55.9 ± 11.4) on an intention-to-treat basis. Four patients (3.1 %) had 2 target aneurysms; 134 total aneurysms were treated. The aneurysms were mainly located on the middle cerebral artery (41/134; 30.6 %) and the anterior communicating artery (31/134; 23.1 %). The CMMR at 1 year linked to the procedure and/or device was 4.6 % (6/130). The overall mortality was 1.5 % (2/130), none of these deaths adjudged as being linked to the procedure and/or device. All aneurysms (134/134, 100 %) were successfully treated with LVIS stent and/or other devices. At a mean FU of 16.8 months post-procedure, complete/nearly complete occlusion was achieved in 112 aneurysms (92.6 %), and only 3 patients (2.5 %) required aneurysm retreatment. CONCLUSION: This study provides evidence that the LVIS/LVIS Jr devices are safe and effective in the treatment of complex intracranial aneurysms, with very high rates of adequate occlusion at FU. These angiographic results are stable over time with an acceptable complication rate. TRIAL REGISTRATION: ClinicalTrial.gov under NCT03553771.

Safety and Efficacy of Flow Diverters for Treatment of Unruptured Anterior Communicating Artery Aneurysms: Retrospective Multicenter Study.

BACKGROUND: The anterior communicating artery (AComm) region is the most common site of intracranial aneurysms, with increased rupture risk compared with other locations. Overall, flow diverters present as a safe and efficacious treatment for intracranial aneurysms, but there is paucity of data for their use in the treatment of unruptured AComm aneurysms. We present the largest multicentric analysis evaluating the outcomes of flow diverters in AComm aneurysm treatment. METHODS: Databases from 10 centers were retrospectively reviewed for unruptured AComm aneurysms treated with flow diverters. Demographics, clinical presentation, radiographic characteristics, procedural complications, and outcomes were assessed. RESULTS: A total of 144 patients harboring 147 AComm aneurysms were treated between January 2012 and December 2021. Seventy-four were women (51.4%) and median age was 60 (IQR 50-67) years. All were unruptured AComm aneurysms. Half of the cohort had similar anterior cerebral artery sizes (51.4%). The most common morphology was saccular (94.6%), with a branch involvement in 32.7% of cases. Median vessel diameter was 2.4 mm, and the Pipeline Flex was the most prevalent device (32.7%). Median follow-up time was 17 months, with complete occlusion in 86.4% at the last follow-up. Functional independence (modified Rankin Scale score 0-2) was reported in 95.1%. Intraprocedural complications occurred in 5.6%, and postoperative complications were noted in 9.7% of cases. Combined major complication and mortality rate was 2.1%. CONCLUSIONS: Our study suggests that flow diverters are a useful treatment for AComm aneurysms. Mid-term results indicated favorable aneurysm occlusion with a good safety profile. Additional prospective studies with longer follow-up periods and independent adjudication are warranted to better assess these results.

Evaluating the safety and efficacy of transvenous embolization for brain arteriovenous malformation: A systematic review and meta-analysis.

BACKGROUND: Transvenous embolization is a potential therapy for brain arteriovenous malformation, involving the use of microcatheters to guide an ethylene vinyl alcohol coil for vessel occlusion. However, the safety and efficacy of transvenous embolization are not fully established. OBJECTIVE: To evaluate the safety and efficacy of transvenous embolization for brain arteriovenous malformation. METHODS: A systematic review of the literature of studies investigating the safety and efficacy of transvenous embolization for brain arteriovenous malformation was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Databases, including PubMed, Cochrane Library, Web of Science, and Embase were queried. RESULTS: In the final analysis of 16 studies involving 368 brain arteriovenous malformation cases who received transvenous embolization, the complete occlusion was achieved in 91% (95% CI: 88%, 94%; I2 = 43%, p = 0.04) of cases. The overall rate of good outcomes after discharge was high at 89% (95% CI: 82%, 95%; I2 = 60%, p < 0.01). Ischemic complications were reported in 1% of cases (95% CI: 0%, 2%; I2 = 0%, p = 0.96), while hemorrhagic complications occurred in 6% of cases (95% CI: 3%, 8%; I2 = 8%, p = 0.37), and technical complications rate of 8% (95% CI: 4%, 11%; I2 = 8%, p = 0.36). Finally, only one death was related to the procedure. CONCLUSION: Transvenous embolization for brain arteriovenous malformation shows promising safety and effectiveness, with low mortality, a considerable rate of positive outcomes, and a relatively low incidence of complications. The majority of patients achieved complete occlusion, indicating transvenous embolization as a potential option, especially for challenging deep-seated lesions.

Comparison of arterial wall integration of different flow diverters in rabbits: The CICAFLOW study.

BACKGROUND AND PURPOSE: New coated flow diverters (FDs) claim antithrombotic properties and increased arterial wall integration. The aim of this study is to compare in vivo endothelial coverage of coated and uncoated FD in the context of different antiplatelet regimens. METHODS: Different FDs (Silk Vista - SV, Pipeline with Shield technology - PED shield and Surpass Evolve - SE) were implanted in the aorta of rabbits, all 3 in each animal with 3 different antiplatelet regimens: no antiplatelet therapy, aspirin alone, or aspirin and ticagrelor. Four weeks after FD implantation, angiography, flat-panel CT, and optical coherence tomography (OCT) were performed before harvesting the aorta. Extensive histopathology analyses were performed including environmental scanning electron microscopy (ESEM), multiphoton microscopy (MPM) and histological staining with qualitative and/or quantitative assessment of device coverage. RESULTS: All 23 FDs that were implanted remained patent without hyperplasia. Qualitative stent coverage assessment revealed that there were no statistically significant differences between the FD groups (p = 0.19, p = 0.45, p = 0.40, and p = 0.84 for OCT, ESEM, MPM and histology, respectively). Quantitative neointimal measurement of histological sections also showed similar results in all 3 FD groups (p = 0.70). However, there were significant differences between the 3 groups of antiplatelet regimens (p = 0.07) with a higher rate in the no antiplatelet group (p = 0.05 versus aspirin alone and p = 0.03 versus aspirin and ticagrelor). CONCLUSION: Our study provides evidence that FD integration into the arterial wall is similar with coated (PED shield) and uncoated devices (SV, SE), regardless of the antiplatelet regimen. FD integration with specific surface coverage should be promoted. TRIAL REGISTRATION: APAFIS #2022011215518538.

Fucoidan-coated coils improve healing in a rabbit elastase aneurysm model.

BACKGROUND: Recanalization of coiled aneurysms remains unresolved. To limit aneurysm recanalization after embolization with coils, we propose an innovative approach to optimize aneurysm healing using fucoidan-coated coils. OBJECTIVE: To evaluate the short-term efficacy and long-term safety of the new coil system with conventional angiography, histology, and multiphoton microscopy for follow-up of fibrosis and neointima formation. METHODS: We conducted a feasibility study on rabbit elastase-induced aneurysms. Embolization was carried out with bare platinum coils, fucoidan-coated coils, or dextran-coated coils. Aneurysms were controlled after 1 month by digital subtraction angiography (DSA). Aneurysm samples were collected and processed for histological analysis. Aneurysm healing and fibrosis were measured by quantifying collagen according to the histological healing score by combining standard light microscopy and multiphoton imaging. We divided 27 rabbits into three groups: bare platinum group, fucoidan group, and dextran group as controls. RESULTS: Angiographic grading showed a trend toward less recanalization in the fucoidan group, although there were no significant differences among the three groups (P=0.21). Histological healing was significantly different according to the presence of more collagen in the neck area of aneurysms in the fucoidan group versus the bare platinum group (P=0.011), but not in the dextran group. Histological index was significantly better at the aneurysm neck in the fucoidan group than in the bare platinum group (P=0.004). Collagen organization index was also significantly better in the fucoidan group than in the bare platinum group (P=0.007). CONCLUSION: This proof-of-concept study demonstrated the feasibility and efficacy of treatment with fucoidan-coated coils to improve aneurysm healing. The results in this rabbit in vivo model showed that fucoidan-coated coils have the potential to improve healing following endovascular treatment.

Balloon Pressure Technique with the Scepter Mini Balloon as Part of the Endovascular Strategy for Brain Arteriovenous Malformations Embolization : Preliminary Multicenter Experience.

BACKGROUND: The balloon pressure technique (BPT) is an alternative to the pressure cooker technique. A dual lumen balloon (DLB) is used to inject the liquid embolic agent through the working lumen while the balloon is inflated. The purpose of our study was to report our early experience using the Scepter Mini dual lumen balloons for BPT in brain arteriovenous malformation (bAVM) embolization. MATERIAL AND METHODS: Consecutive patients treated from July 2020 to July 2021 in 3 tertiary centers using the BPT with low-profile dual lumen balloons (Scepter Mini, Microvention, Tustin, CA, USA) by endovascular means for bAVMs were retrospectively reviewed. Patient demographics and bAVM angio-architectural features were collected. The feasibility of Scepter Mini balloon navigation close to the nidus was evaluated. Technical as well as clinical (ischemic and/or hemorrhagic) complications were also systematically assessed. The occlusion rate was evaluated on follow-up DSA. RESULTS: A total of 19 patients (10 females; mean age = 38.2 years) consecutively treated for a bAVM (8 ruptured/11 unruptured) using the BPT with a Scepter Mini through 23 embolization sessions were included in our series. Navigation of the Scepter Mini was feasible in all cases. Of the patients 3 (16%) had procedure-related ischemic stroke and 2 patients (10.5%) had late hemorrhages. None of these complications led to severe permanent sequela. Complete occlusion of bAVM embolized with intention to cure was recorded in 11/13 cases (84.6%). CONCLUSION: The BPT using low-profile dual lumen balloons is feasible and seems safe for embolization of bAVMs. It may help to reach high occlusion rates, especially when performed in the intent to cure by embolization only.

Nidus Compacity Determined by Semi-Automated Segmentation is a Strong Quantitative Predictor of Brain Arterio-Venous Malformation Cure.

BACKGROUND AND OBJECTIVE: A compact nidus is a well-known feature of good outcome after treatment in brain arteriovenous malformations (bAVM). This item, included in the "Supplementary AVM grading system" by Lawton, is subjectively evaluated on DSA. The present study aimed to assess whether quantitative nidus compacity along with other angio-architectural bAVM features were predictive of angiographic cure or the occurrence of procedure-related complications. MATERIALS AND METHODS: Retrospective analysis of 83 patients prospectively collected data base between 2003 to 2018 having underwent digital subtraction 3D rotation angiography (3D-RA) for pre-therapeutic assessment of bAVM. Angio-architectural features were analyzed. Nidus compacity was measured with a dedicated segmentation tool. Univariate and multivariate analyses were performed to test the association between these factors and complete obliteration or complication. RESULTS: Compacity was the only significant factor associated with complete obliteration in our predictive model using logistic multivariate regression; the area under the curve for compacity predicting complete obliteration was excellent (0.82; 95% CI 0.71-0.90; p < 0.0001). The threshold value maximizing the Youden index was a compacity > 23% (sensitivity 97%; specificity 52%; 95% CI 85.1-99.9; p = 0.055). No angio-architectural factor was associated with the occurrence of a complication. CONCLUSION: Nidus high compacity quantitatively measured on 3D-RA, using a dedicated segmentation tool is predictive of bAVM cure. Further investigation and prospective studies are warranted to confirm these preliminary results.

Endovascular treatment simulations using a novel in vitro brain arteriovenous malformation model based on three-dimensional printing millifluidic technology.

BACKGROUND: Brain arteriovenous malformations (bAVM) are complex vascular diseases. Several models have been used to simulate endovascular treatments; thus in vitro models have not been widely employed because it has been difficult to recreate realistic phantoms of this disease. OBJECTIVE: To describe the development and evaluate the preliminary experience of a novel bAVM in vitro model for endovascular embolization using millifluidic three-dimensional (3D) printing technology. METHODS: We designed a bAVM phantom starting from simple to more complex designs, composed of a nidus, feeding arteries and draining vein. We recreate the design by using millifluidic technology with stereolithography 3D printing. Structural and functional tests were performed using angiographic images and computer flow dynamics. Treatment simulations with ethylene vinyl alcohol were tested using two different microcatheter position techniques. A Likert-scale questionnaire was applied to perform a qualitative evaluation of the model. RESULTS: We developed a realistic model of a bAVM with hollow channels. The structural evaluation showed a high precision of the 3D printing process. Embolization tests with the liquid agent gave similar sensations and material behaviour as in vivo cases. There were no significant differences between microcatheter position techniques, thus we observed a trend for better nidus filling with a deeper in-nidus position technique. CONCLUSIONS: We were able to create and test a novel bAVM in vitro model with stereolithography 3D printing in resin. It showed a high capacity for simulating endovascular embolization characteristics, with an excellent user experience. It could be potentially used for training and testing of bAVM embolizations.

Neurophysiological monitoring during endovascular treatment of brain arteriovenous malformations: A meta-analysis.

BACKGROUND: Treatment of brain arteriovenous malformations (b-AVM) carries a risk of iatrogenic injury to eloquent brain regions. Intraoperative neuro-monitoring (IONM) has increasingly been used to monitor spontaneous or evoked neural activity during neurosurgery, but its use is not as well characterized in the endovascular treatment (EVT) of b-AVMs. We aimed to provide a systematic review and meta-analysis of studies reporting any neurological deficit after b-AVM embolization with IONM, with or without provocative test (PT), and no-IONM. METHODS: This systematic review followed the PRISMA guidelines. Medline, EMBASE, and Scopus were searched from conception until March 1, 2022 for studies evaluating EVT with IONM and PT. Primary outcome was the rate of postoperative neurological deficits in EVT with IONM versus no-IONM, while secondary outcome was the subanalysis of IONM with or without PT. Meta-analysis was performed using the Mantel-Haenszel method and random effects modeling. RESULTS: Six studies reached synthesis. Out of a total of 192 EVT, 14 events occurred. Results demonstrated a nonsignificant trend favoring IONM compared to no-IONM to prevent neurological deficits (OR 0.09, 95% CI 0-4.68). Among the EVT with IONM, PT was done in 411 branches with 10 events (0.2%) despite a negative PT. There was a nonsignificant trend favoring IONM plus PT compared to IONM without PT (OR 0.16, 95% CI 0.02-1.07). CONCLUSIONS: Our study suggests that b-AVM EVT with IONM plus PT might reduce rates of postprocedural neurological deficits compared with EVT without IONM. Further studies are needed to confirm these results.

Treatment of A3.2 and A2 traumatic thoracolumbar spine compression fractures using vertebral body stenting: a 63-patient series.

BACKGROUND: Percutaneous treatments for spinal injury are underused by neuroradiologists and spine surgeons, mainly owing to a lack of data on indications. OBJECTIVE: To assess the safety and efficacy of vertebral body stenting (VBS) for post-traumatic A3.2 and A2 fractures (Magerl classification) and determine the factors that influence the improvements. METHODS: We retrospectively reviewed patients who underwent VBS to treat a single traumatic thoracolumbar fracture from 2010 to 2019. Kyphosis, loss of vertebral body height (VBH), and clinical and functional outcomes (including the Visual Analog Scale pain score and Oswestry Disability Index) were assessed. We examined the overall effects of VBH in all patients by constructing a linear statistical model and evaluated whether the efficacy was dependent on the characteristics of the patients or fractures. RESULTS: We included 63 patients comprising 44 A3.2 and 19 A2 fractures. No patient had worsening neurological symptoms or wound infection. The average rates of change were 67.1% (95% CI 59.1% to 75%) for kyphosis and 88.5% (95% CI 85.6% to 91.3%) for VBH (both p<0.0001). After 1 year, the VBS treatment was more effective for kyphosis in younger patients and at the L1 level, and for VBH in younger patients and cases of Magerl A3.2 fracture. CONCLUSIONS: This large reported series on VBS validates this surgical treatment. All patients had improved kyphosis and restored VBH. We recommend using VBS rather than open surgery for A3.2 and A2 fractures at the thoracolumbar junction and in young patients.