Endovascular therapy in the distal neurovascular territory: results of a large prospective registry.

BACKGROUND: There is a paucity of data regarding mechanical thrombectomy (MT) in distal arterial occlusions (DAO). We aim to evaluate the safety and efficacy of MT in patients with DAO and compare their outcomes with proximal arterial occlusion (PAO) strokes. METHODS: The Trevo Registry was a prospective open-label MT registry including 2008 patients from 76 sites across 12 countries. Patients were categorized into: PAO: intracranial ICA, and MCA-M1; and DAO: MCA-M2, MCA-M3, ACA, and PCA. Baseline and outcome variables were compared across the PAO vs DAO patients with pre-morbid mRS 0-2. RESULTS: Among 407 DAOs including 350 (86.0%) M2, 25 (6.1%) M3, 10 (2.5%) ACA, and 22 (5.4%) PCA occlusions, there were 376 DAO with pre-morbid mRS 0-2 which were compared with 1268 PAO patients. The median baseline NIHSS score was lower in DAO (13 [8-18] vs 16 [12-20], P<0.001). There were no differences in terms of age, sex, IV-tPA use, co-morbidities, or time to treatment across DAO vs PAO. The rates of post-procedure reperfusion, symptomatic intracranial hemorrhage (sICH), and 90-mortality were comparable between both groups. DAO showed significantly higher rates of 90-day mRS 0-2 (68.3% vs 56.5%, P<0.001). After adjustment for potential confounders, the level of arterial occlusion was not associated with the chances of excellent outcome (DAO for 90-day mRS 0-1: OR; 1.18, 95% CI [0.90 to 1.54], P=0.225), successful reperfusion or SICH. However, DAO patients were more likely to be functionally independent (mRS 0-2: OR; 1.45, 95% CI [1,09 to 1.92], P=0.01) or dead (OR; 1.54, 95% CI [1.06 to 2.27], P=0.02) at 90 days. CONCLUSION: Endovascular therapy in DAO appears to result in a comparable safety and technical success profile as in PAO. The potential benefits of DAO thrombectomy should be investigated in future randomized trials.

Beyond the first pass: revascularization remains critical in stroke thrombectomy.

BACKGROUND: The first pass effect has been recently reported as a predictor of good clinical outcome after stroke thrombectomy. We evaluate the first pass effect on outcome and the influence of revascularization in these and other patients. METHODS: We performed a retrospective analysis of a prospectively maintained database on anterior cerebral circulation stroke thrombectomy cases from April 2012 to April 2018. Data compiled included patient demographics, presenting National Institutes of Health Stroke Scale score, vessel occlusion site, thrombectomy procedural details, and 90 day modified Rankin Scale scores. RESULTS: 205 patients were included. The numbers of patients who underwent one, two, three, four, five, and six passes were 69, 70, 55, 9, 1, and 1, respectively. Successful revascularization was achieved in 87%, 83%, and 64% of patients in the one, two, and 3 or more passes groups, respectively (p=0.002). Good functional outcome was inversely correlated with number of passes when comparing the one, two, and three or more passes groups (54%, 43%, 29%; P=0.014). In patients with full revascularization, there was no significant difference in good functional outcomes between the one, two, and three or more passes groups (64%, 65%, 50%; P=0.432). Number of passes was not an independent negative predictor of good clinical outcome (OR 1.66, 95% CI 0.82 to 3.39; P=0.165). CONCLUSIONS: First pass thrombectomy patients have better functional outcomes compared with beyond-first pass patients. This effect is related at least in part to a higher rate of revascularization in one pass patients. Revascularization beyond the first pass should continue to be the goal of stroke thrombectomy.

Pipeline embolization device diameter is an important factor determining the efficacy of flow diversion treatment of small intracranial saccular aneurysms.

OBJECTIVE: Flow diversion using the Pipeline embolization device (PED) has become a widely used treatment method for intracranial aneurysms. However, a subset of aneurysms will fail to occlude following treatment and the factors that influence the efficacy of flow diversion remain uncertain. As smaller diameter PEDs inherently have greater metal density than larger devices, we elected to investigate whether PED diameter influences treatment efficacy when using a single device. We also evaluated other factors that may influence treatment outcomes with PED. METHODS: We retrospectively evaluated all patients treated for an intracranial saccular aneurysm at our institution with a single PED at least 12 months prior to the time of data collection. Patients treated with multiple devices, adjunctive coiling, traumatic and fusiform target aneurysms, as well as patients with inadequate imaging follow-up (<12 months) were excluded. RESULTS: 158 aneurysms in 124 patients (128 treatments) met the inclusion criteria for our study. 123 aneurysms (80%) were occluded over an average follow-up of 26.6 months. Multivariable logistic regression showed that branch vessel incorporation into the target aneurysm sac (p<0.001, OR=0.15) was significantly associated with aneurysm persistence, while smaller PED diameter was significantly associated with aneurysm occlusion (p=0.008; OR=0.30). CONCLUSIONS: PED diameter significantly impacts outcomes when using a single device for the treatment of small anterior circulation intracranial saccular aneurysms, most likely due to the inherent greater metal density of smaller devices. This factor should be taken into account when planning endovascular aneurysm treatment with PED.

Focal, transient mechanical narrowing of a pipeline embolization device following treatment of an internal carotid artery aneurysm.

Flow diversion is a promising technique for cerebral aneurysm treatment but presents new and sometimes unique challenges. Transient reversible narrowing due to device reconfiguration of the pipeline embolization device (PED) has not been previously described. Here we describe a patient with dolichoectasia of the distal right internal carotid artery with an associated saccular sidewall aneurysm who developed asymptomatic circumferential narrowing of the proximal aspect of the PED in the first month following deployment. The patient was followed conservatively and demonstrated partial resolution of device narrowing on 6 month follow-up imaging.

Focal, transient mechanical narrowing of a pipeline embolization device following treatment of an internal carotid artery aneurysm.

Flow diversion is a promising technique for cerebral aneurysm treatment but presents new and sometimes unique challenges. Transient reversible narrowing due to device reconfiguration of the pipeline embolization device (PED) has not been previously described. Here we describe a patient with dolichoectasia of the distal right internal carotid artery with an associated saccular sidewall aneurysm who developed asymptomatic circumferential narrowing of the proximal aspect of the PED in the first month following deployment. The patient was followed conservatively and demonstrated partial resolution of device narrowing on 6 month follow-up imaging.