Thrombectomy for M2 occlusions and the role of the dominant branch.

INTRODUCTION: The benefits of thrombectomy for occlusion of M2 segments remain controversial. The aim of this study is to assess thrombectomy's efficacy and safety in patients with M2 segment occlusion and associations between occlusion sites and anatomic variations of M1 division. MATERIALS AND METHODS: A prospective series of 30 patients with acute ischemic stroke (AIS) resulting from M2 segment occlusion of the middle cerebral artery (MCA) who underwent thrombectomy was analyzed. The primary endpoint was assessed by the Extended Treatment in Cerebral Infarction scale (eTICI). The secondary endpoints were the incidence of symptomatic hemorrhagic transformation (sICH), mortality and good functional outcome at three months. RESULTS: The mean patient age was 69.2 years. The mean National Institutes Health Stroke Scale score (NIHSS) upon hospital admission was 16. The recanalization rates were eTICI 2b/3 in 90% and 2c/3 in 60% of the patients. Total recanalization of the M2 branch was achieved in 53% of patients. sICH incidence was 6.6%, the mortality rate was 30%, and a good functional outcome (mRS ≤2) was observed in 50% of the patients. Twenty-seven patients (90%) had a dominant M2 branch and all were occluded. Regarding the site of M2 occlusions, 74% of patients had proximal M2 occlusions. CONCLUSIONS: Thrombectomy appears to be a safe and effective method for the treatment of acute M2 segment occlusions of the MCA. Most of the cases had a dominant M2 branch, and all of them were occluded. Larger studies are needed to verify the benefits of thrombectomy for different settings of M2 occlusions.

Intracranial aneurysms: treatment with bare platinum coils--aneurysm packing, complex coils, and angiographic recurrence.

PURPOSE: To retrospectively assess, with three-dimensional rotational angiography, the relationship between packing, complex coils, and angiographic recurrence of aneurysms treated with coils. MATERIALS AND METHODS: Informed consent was waived by the institutional review board that approved the study. Results at follow-up angiography of 255 aneurysms in 223 patients (161 female and 62 male patients; mean age, 48 years) were dichotomized into presence or absence of recurrence. The degree of packing of aneurysms treated with complex coils alone, with complex and helical coils, and with helical coils only was compared for significant differences. With generalized estimating equations analysis, relative risk (RR) for recurrence was calculated for mode of manifestation, duration of follow-up, aneurysm volume, packing, initial angiographic result, percentage of complex coils, aneurysm location, and multiplicity of aneurysms. RESULTS: Follow-up angiography revealed recurrence in 28.6% of aneurysms at a mean follow-up of 12 months; 5.5% were amenable to re-treatment. Aneurysms treated with complex and those treated with helical coils only had a mean packing of 27% and 26%, respectively. There was no significant difference between packing of aneurysms treated with complex and those treated with helical coils (P = .538). Recurring and stable aneurysms both had a mean packing of 27%. Generalized estimating equations analysis showed significant differences between duration of follow-up and recurrence (P = .001, RR = 3.39), between aneurysm volume and recurrence (P < .001, RR = 6.15), and between hemorrhagic manifestation and recurrence (P = .002, RR = 3.17). There was no significant difference between packing and recurrence, between initial angiographic result and recurrence, between percentage of complex coils and recurrence, between aneurysm location and recurrence, or between multiplicity of aneurysms and recurrence. CONCLUSION: More angiographic recurrences are detected over time. Complex coils do not augment aneurysm packing. Packing is not related to protection against recurrence.

Stent-grafts in the management of hemorrhagic complications related to hemostatic closure devices: report of two cases.

We report 2 cases of hemorrhagic complications related to use of the Angio-Seal hemostatic closure device that were successfully managed with stent-grafts. Two patients with subarachnoid hemorrhage were referred to our departments for endovascular treatment of ruptured intracranial aneurysms. The treatment was performed through a femoral access; the sheaths were removed immediately after the procedures, and the punctures sites closed by Angio-Seals. Both patients presented clinical signs of hypovolemic shock after treatment. The diagnosis of active bleeding through the puncture site was made by emergency digital subtraction angiography. The lesions were managed with stent-grafts. The use of stent-grafts proved to be efficient in the management of these life-threatening hemorrhagic complications following the use of the Angio-Seal hemostatic closure device.