Multicenter investigation of technical and clinical outcomes after thrombectomy for Proximal Medium Vessel Occlusion (pMeVO) by frontline technique.

BACKGROUND: Endovascular thrombectomy(EVT) is the standard of care for large vessel occlusion(LVO) stroke. Data on technical and clinical outcome in proximal medium vessel occlusions(pMeVOs) comparing frontline techniques remain limited. METHODS: We report an international multicenter retrospective study of patients undergoing EVT for stroke at 32 centers between 2015-2021. Patients were divided into LVOs(ICA/M1/Vertebrobasilar) or pMeVOs(M2/A1/P1) and categorized by thrombectomy technique. Primary outcome was 90-day good functional outcome(mRS ≤ 2). Multivariate logistic regressions were used to evaluate the impact of technical variables on clinical outcomes. Propensity score matching was used to compare outcome in patients with pMeVO treated with aspiration versus stent-retriever. RESULTS: In the cohort of 5977 LVO and 1287 pMeVO patients, pMeVO did not independently predict good-outcome(p = 0.55). In pMeVO patients, successful recanalization irrespective of frontline technique(aOR = 3.2,p < 0.05), procedure time ≤ 1-h(aOR = 2.2,p < 0.05), and thrombectomy attempts ≤ 4(aOR = 2.8,p < 0.05) were independent predictors of good-outcomes.In a propensity-matched cohort of aspiration versus stent-retriever pMeVO patients, there was no difference in good-outcomes. The rates of hemorrhage were higher(9%vs.4%,p < 0.01) and procedure time longer(51-min vs. 33-min,p < 0.01) with stent-retriever, while the number of attempts was higher with aspiration(2.5vs.2,p < 0.01). Rates of hemorrhage and good-outcome showed an exponential relationship to procedural metrics, and were more dependent on time in the aspiration group compared to attempts in the stent-retriever group. CONCLUSIONS: Clinical outcomes following EVT for pMeVO are comparable to those in LVOs. The golden hour or 3-pass rules in LVO thrombectomy still apply to pMeVO thrombectomy. Different techniques may exhibit different futility metrics; SR thrombectomy was more influenced by attempts whereas aspiration was more dependent on procedure time.

Novel balloon-and-aspiration method for cerebral venous sinus thrombosis: dental-floss technique.

Cerebral venous sinus thrombosis is sometimes fatal. The standard treatment for sinus thrombosis is anticoagulation, but endovascular intervention must be considered when medical treatment fails. Mechanical thrombectomy is usually required when a large clot burden exits. Unfortunately, in sinus thrombosis attributable to a clot burden larger than that in an intracranial artery, the conventional technique used for intraarterial acute stroke intervention with a stent retriever and/or aspiration is not very effective. The authors describe here their endovascular approach to mechanical thrombectomy for sinus thrombosis using aspiration combined with angioplasty balloon support.

Endoport-assisted surgery for the management of spontaneous intracerebral hemorrhage.

The aim of this retrospective study is to report our initial experience with endoport-assisted microsurgical evacuation (EAME) of intracerebral hemorrhages (ICH). Neurosurgical intervention has not been shown to significantly improve patient outcomes after spontaneous ICH. Minimally invasive technologies, such as endoport systems, may offer a better risk to benefit profile for ICH evacuation than conventional approaches. We performed a retrospective review of all patients who underwent EAME of ICH from January 2013 to February 2015 using the BrainPath endoport system (NICO, Indianapolis, IN, USA). The baseline and follow-up patient and ICH characteristics were analyzed. Of the 11 patients included for analysis, seven were women (64%), and the median age was 65 years (range: 23-84). The ICH was supratentorial in nine patients (82%), and the median ICH score was 2 (range: 1-4). The median preoperative and postoperative ICH volumes were 51 cm(3) (range: 8-168) and 10 cm(3) (range: 0.4-59), respectively, with a median reduction in ICH volume of 87% (range: 38-99). The median preoperative and postoperative amounts of midline shift were 6.7 mm (range: 4.9-14.3) and 3.7 mm (range: 2.2-8.9), respectively, with a median reduction in midline shift of 38% (range: 18-61). At the 90 day follow-up, four patients (36%) were functionally independent (modified Rankin Scale 0-2). Four patients had ICH-related mortalities (36%). EAME appears to be a safe and effective treatment option for ICH. Further studies are necessary to assess the comparative effectiveness of EAME in relation to medical therapy or other interventional techniques, for the management of ICH patients.

A minimally invasive anterior skull base approach for evacuation of a basal ganglia hemorrhage.

We describe the technical nuances of a minimally invasive anterior skull base approach for microsurgical evacuation of a large basal ganglia hematoma through an endoport. Patients who suffer from large spontaneous intracerebral hemorrhages (ICH) of the basal ganglia have a very poor prognosis. However, the benefit of surgery for the management of ICH is controversial. The development of endoport technology has allowed for minimally invasive access to subcortical lesions, and may offer unique advantages over conventional surgical techniques due to less disruption of the overlying cortex and white matter fiber tracts. A 77-year-old man presented with a hypertensive ICH of the right putamen, measuring 9 cm in maximal diameter and 168 cm(3) in volume. We planned an endoport trajectory through the long axis of the hematoma using frameless stereotactic neuronavigation. In order to access the optimal cortical entry point at the lateral aspect of the basal frontal lobe, a miniature modified orbitozygomatic skull base craniotomy was performed through an incision along the superior border of the right eyebrow. Using the BrainPath endoport system (NICO, Indianapolis, IN, USA), the putaminal hematoma was successfully evacuated, resulting in an 87% postoperative reduction in ICH volume. Thus, we show that, in appropriately selected cases, endoport-assisted microsurgery is safe and effective for the evacuation of large ICH. Furthermore, minimally invasive anterior skull base approaches can be employed to expand the therapeutic potential of endoport-assisted approaches to include subcortical lesions, such as hematomas of the basal ganglia.

Embolization-induced angiogenesis in cerebral arteriovenous malformations.

Endovascular occlusion of cerebral arteriovenous malformations (AVM) is often utilized as adjunctive therapy in combination with radiosurgery or microsurgery. Evidence supports that partial occlusion of AVM via endovascular embolization leads to increased angiogenesis. This phenomenon may be a contributing factor to the decreased efficacy of AVM radiosurgery following embolization. We review the literature for potential mechanisms of embolization-induced angiogenesis. A comprehensive literature search was performed using PubMed to identify studies that sought to elucidate the pathophysiology behind embolization-induced angiogenesis. The terms "arteriovenous malformation", "embolization", and "angiogenesis" were used to search for relevant publications individually and together. Three distinct mechanisms for embolization-induced angiogenesis were described in the literature: (1) hypoxia-mediated angiogenesis, (2) inflammatory-mediated angiogenesis, and (3) hemodynamic-mediated angiogenesis. Embolization-induced angiogenesis of cerebral AVM likely results from a combination of the three aforementioned mechanisms. However, future research is necessary to determine the relative contribution of each individual mechanism to overall post-embolization AVM neovascularization.

Treatment of ophthalmic segment carotid aneurysms using the pipeline embolization device: clinical and angiographic follow-up.

OBJECTIVES: Aneurysms of the ophthalmic segment of the internal carotid artery (ICA) often present unique challenges to endovascular treatment due to their proximity to or involvement of the ophthalmic artery, and the subsequent risk of post-operative visual complications. The pipeline embolization device (PED) represents a paradigm shift and promising new therapy in the treatment of intracranial aneurysms. We reviewed the ophthalmic segment ICA aneurysms treated with the PED at Barrow Neurological Institute (BNI) to report outcome data, including patency of the ophthalmic artery and visual complications. METHODS: The prospectively maintained BNI endovascular database was reviewed for all patients with ophthalmic segment ICA aneurysms treated with the PED since May 2011. Patient charts and digital subtraction angiograms were reviewed to report angiographic outcomes and visual complications. Only patients with at least 6 months of follow-up were included in the analysis. RESULTS: Of 30 patients treated with ophthalmic segment aneurysms during the study period, sufficient follow-up was available for 29 patients with 38 aneurysms, all of which were treated electively. The PED was successfully deployed for all lesions, with 92·1% complete or near-complete obliteration rate at angiographic follow-up. All but one patient were found to have a patent ophthalmic artery at short-term follow-up and 100% of patients retained intact vision. Five patients had minor periprocedural hemorrhagic complications but no permanent morbidities. There were no intracranial hemorrhages, thromboembolic phenomena, vessel dissections, or mortalities. CONCLUSION: Treatment of ophthalmic segment ICA aneurysms with the PED is safe and effective at short-term follow-up.