Interventional

The Impact of Conscious Sedation versus General Anesthesia for Stroke Thrombectomy on the Predictive Value of Collateral Status: A Post Hoc Analysis of the SIESTA Trial

Editor’s Choice

Using imaging data from the Sedation versus Intubation for Endovascular Stroke TreAtment (SIESTA) trial, the authors assessed collateral status with the score of Tan et al and graded it from absent to good collaterals (0–3). They examined the association of collateral status with 24-hour improvement of the NIHSS score, infarct volume, and mRS at 3 months according to the sedation regimen in a cohort of 104 patients. The sedation mode, conscious sedation or general anesthesia, did not influence the predictive value of collaterals in patients with large-vessel occlusion anterior circulation stroke undergoing thrombectomy in the SIESTA trial.

Acute Basilar Artery Occlusion: Differences in Characteristics and Outcomes after Endovascular Therapy between Patients with and without Underlying Severe Atherosclerotic Stenosis

Fellows’ Journal Club

Sixty-two patients with acute basilar artery occlusion underwent multimodal endovascular therapy with stent-retriever thrombectomy as a first-line endovascular therapy. Patients with underlying intracranial atherosclerotic stenosis underwent additional intracranial angioplasty and stent placement. Underlying intracranial atherosclerotic stenosis was identified at the occlusion site in 15 patients (24.1%). Occlusion in the proximal segment of the basilar artery was more common in patients with intracranial atherosclerotic stenosis (60% versus 6.4%), whereas occlusion in the distal segment was more common in those without it. Patients with and without underlying intracranial atherosclerotic stenosis who underwent endovascular therapy had similar outcomes.

Temporary Stent-Assisted Coil Embolization as a Treatment Option for Wide-Neck Aneurysms

Editor’s Choice

The authors intended to treat 33 aneurysms between January 2010 and December 2015 with temporary stent-assisted coiling, which formed the series for this study. Incidental and acutely ruptured aneurysms were included. Sufficient occlusion was achieved in 97.1% of the cases. In 94%, the stent could be fully recovered. Complications occurred in 5 patients (14.7%). They conclude that temporary stent-assisted coiling is an effective technique for the treatment of wide-neck aneurysms. Safety is comparable with that of stent-assisted coiling and coiling with balloon remodeling.

Large Basilar Apex Aneurysms Treated with Flow-Diverter Stents

Fellows’ Journal Club

The authors report their experience treating basilar apex aneurysms with flow-diverter stents and evaluate their efficacy and safety profile in this specific condition. Of the 175 aneurysms treated with flow-diverter stents at their institution, 5 patients received flow-diverter stents for basilar apex aneurysms. The mean follow-up after stent deployment was 21 months. They conclude that flow diversion is a feasible technique with an efficacy demonstrated at a midterm follow-up, especially in the case of basilar apex aneurysm recurrences after previous endovascular treatments.

Risk of Thrombus Fragmentation during Endovascular Stroke Treatment

Editor’s Choice

The authors evaluated the potential relationship between thrombus histology and clot stability in 85 patients with anterior circulation stroke treated with thrombectomy. The number and location of emboli after retrieving the primary thrombus, the number of maneuvers, and TICI scores were evaluated. H&E and neutrophil elastase staining of retrieved clots was performed. An inverse correlation between maneuvers required for thrombus retrieval and the number of distal and intermediate emboli was observed. Younger patients were at higher risk for periprocedural thrombus fragmentation. Bridging thrombolysis tended to be associated with fewer maneuvers but more emboli. They conclude that younger age, easy-to-retrieve thrombi, and bridging thrombolysis may be risk factors for periprocedural thrombus fragmentation. Higher neutrophil levels in the thrombus tissue were related to an increased risk of periprocedural thrombus fragmentation.

Feasibility of Flat Panel Detector CT in Perfusion Assessment of Brain Arteriovenous Malformations: Initial Clinical Experience

Editor’s Choice

Five patients with brain arteriovenous malformations were studied with flat panel detector CT, DSC-MR imaging, and vessel-encoded pseudocontinuous arterial spin-labeling. Flat panel detector CT, which was originally thought to measure blood volume, correlated more closely with ASL-CBF and DSC-CBF than with DSC-CBV. Flat panel detector CT perfusion depends on the time point chosen for data collection, which is triggered early in patients with AVMs. This finding, in combination with high data variability, makes flat panel detector CT inappropriate for perfusion assessment in brain AVMs.

Evaluation of Collaterals and Clot Burden Using Time-Resolved C-Arm Conebeam CT Angiography in the Angiography Suite: A Feasibility Study

Fellows’ Journal Club

Ten C-arm conebeam CT perfusion datasets from 10 subjects with acute ischemic stroke acquired before endovascular treatment were retrospectively processed to generate time-resolved conebeam CTA. From time-resolved conebeam CTA, 2 experienced readers evaluated the clot burden and collateral flow in consensus by using previously reported scoring systems and assessed the clinical value of this novel imaging technique. The 2 readers agreed that time-revolved C-arm conebeam CTA was the preferred method for evaluating the clot burden and collateral flow compared with other conventional imaging methods. They conclude that comprehensive evaluations of clot burden and collateral flow are feasible by using time-resolved C-arm conebeam CTA data acquired in the angiography suite.

Hydrogel versus Bare Platinum Coils in Patients with Large or Recurrent Aneurysms Prone to Recurrence after Endovascular Treatment: A Randomized Controlled Trial

Editor’s Choice

This Level 1 expedited report was a pragmatic, multicenter, parallel, randomized (1:1) trial evaluating patients who were at high risk of aneurysm recurrence after endovascular treatment, including patients with large aneurysms (Patients Prone to Recurrence After Endovascular Treatment PRET-1) or with aneurysms that had previously recurred after coiling (PRET-2). The trial was stopped once 250 patients in PRET-1 and 197 in PRET-2 had been recruited because of slow accrual. A poor primary outcome occurred in 44.4% of those in PRET-1 allocated to platinum compared with 52.5% of patients allocated to hydrogel and in 49.0% in PRET-2 allocated to platinum compared with 42.1% allocated to hydrogel. Adverse events and morbidity were similar. The authors conclude that coiling of large and recurrent aneurysms is safe but often poorly effective according to angiographic results. Hydrogel coiling was not shown to be better than platinum.

Endovascular Stroke Treatment of Nonagenarians

Fellows’ Journal Club

The purpose of this study was the evaluation of procedural and outcome data of patients 90 years of age or older undergoing endovascular stroke treatment. The authors retrospectively analyzed prospectively collected data of 29 patients (mean age 91.9 years) in whom endovascular stroke treatment was performed between January 2011 and January 2016 (from a cohort of 615 patients). Successful recanalization (TICI % 2b) was achieved in 22 patients (75.9%). In 9 patients, an NIHSS improvement ≥ 10 points was noted between admission and discharge. After 3 months, 17.2% of the patients had an mRS of 0-2. Despite high mortality rates (∼45%) and moderate overall outcome, 17.2% of the patients achieved mRS 0-2 or prestroke mRS, and no serious procedure-related complications occurred.

Abstract

BACKGROUND AND PURPOSE

Although endovascular treatment has become a standard therapy in patients with acute stroke, the benefit for very old patients remains uncertain. The purpose of this study was the evaluation of procedural and outcome data of patients ≥90 years undergoing endovascular stroke treatment.

MATERIALS AND METHODS

We retrospectively analyzed prospectively collected data of patients ≥90 years in whom endovascular stroke treatment was performed between January 2011 and January 2016. Recanalization was assessed according to the TICI score. The clinical condition was evaluated on admission (NIHSS, prestroke mRS), at discharge (NIHSS), and after 3 months (mRS).

RESULTS

Twenty-nine patients met the inclusion criteria for this analysis. The median prestroke mRS was 2. Successful recanalization (TICI ≥ 2b) was achieved in 22 patients (75.9%). In 9 patients, an NIHSS improvement ≥ 10 points was noted between admission and discharge. After 3 months, 17.2% of the patients had an mRS of 0–2 or exhibited prestroke mRS, and 24.1% achieved mRS 0–3. Mortality rate was 44.8%. There was only 1 minor procedure-related complication (small SAH without clinical

Endovascular Therapy of M2 Occlusion in IMS III: Role of M2 Segment Definition and Location on Clinical and Revascularization Outcomes

Fellows’ Journal Club

The authors reviewed the impact of revascularization on clinical outcomes in 83 patients with M2 occlusions in the Interventional Management of Stroke III trial according to specific M1–M2 segment anatomic features. AnmRS 0–2 outcome was associated with reperfusion for M2 trunk (n = 9) or M2 division (n = 42) occlusions, but not for M2 branch occlusions (n = 28). Of the 83 participants with M2 occlusion who underwent endovascular therapy, 41.0% achieved mRS 0–2 at 90 days, including 46.6% with modified TICI 2–3 reperfusion compared with 26.1% with modified TICI 0–1 reperfusion. They conclude that mRS 0–2 at 90 days was dependent on reperfusion for M2 trunk but not for M2 branch occlusions in IMS III.

Abstract

Figure 1 from paper
A, Right M1 trunk gives rise to the ATA with the posterior temporal branch filling on microcatheter injection. B, Lateral view baseline common carotid arteriogram confirms mid- and posterior temporal lobe cortical supply from the patent posterior temporal artery.

BACKGROUND AND PURPOSE

Uncertainty persists regarding the safety and efficacy of endovascular therapy of M2 occlusions following IV tPA. We reviewed the impact of revascularization on clinical outcomes in 83 patients with M2 occlusions in the Interventional Management of Stroke III trial according to specific M1-M2 segment anatomic features.

MATERIALS AND METHODS

Perfusion of any M2 branch distinguished M2-versus-M1 occlusion. Prespecified modified TICI and arterial occlusive lesion revascularization and clinical mRS 0–2 end points at 90 days for endovascular therapy–treated M2 occlusions were analyzed. Post hoc analyses of the relationship of outcomes to multiple baseline angiographic M2 and M1 subgroup characteristics were performed.

RESULTS

Of 83 participants with M2 occlusion who underwent endovascular therapy, 41.0% achieved mRS 0–2 at 90 days, including 46.6% with modified TICI 2–3 reperfusion compared with 26.1% with modified TICI 0–1 reperfusion (risk