Update on Neurointerventional Therapy for the Treatment of Acute Cerebral Ischemia.

Mechanical thrombectomy (MT) is a minimally invasive, fluoroscopically guided procedure to remove clots from the arteries in the head and neck. The procedure can be performed very quickly and effectively, with low complication rates, as techniques and technology have advanced in recent years. MT is among the most efficacious procedures performed today, with a very low number needed to treat (NNT) to impact outcomes.

Target Ultra and Nano coils in the endovascular treatment of small intracranial aneurysms (ULTRA Registry).

Objective: The ULTRA Registry is a national multicenter prospective study designed to assess aneurysm occlusion rates and safety profiles of the Target Ultra and Nano coils in the treatment of small intracranial aneurysms (IAs).

Methods: Patients with small (≤ 5 mm) ruptured and unruptured IAs were treated exclusively with Target Ultra and Nano coils. The primary endpoints were the initial rate of complete or near-complete aneurysm occlusion, aneurysm recurrence, and need for retreatment.

Comparative cost analysis of liquid embolization systems for brain arteriovenous malformation using a real-world US hospital database: TRUFILL versus Onyx.

Background: Liquid embolic systems (LES) such as n-butyl cyanoacrylate-based TRUFILL and ethylene vinyl-alcohol copolymer-based Onyx are widely used for the embolization of brain arteriovenous malformations (bAVMs). The purpose of this study was to compare hospital cost and length of stay (LOS) among unruptured bAVM patients undergoing embolization procedures with TRUFILL versus Onyx LES.

Methods: Adult patients with unruptured bAVMs undergoing endovascular embolization with TRUFILL or Onyx LES between January 1, 2010 and June 30, 2020 were identified from the Premier Healthcare Database.

Economic analysis of n-butyl cyanoacrylate compared with ethylene vinyl alcohol copolymer liquid embolic embolization of brain arteriovenous malformations (bAVMs) from a US hospital perspective.

Background: In US hospitals, the liquid embolic systems (LESs) n-butyl cyanoacrylate (n-BCA) and ethylene vinyl alcohol copolymer (EVOH) are used for brain arteriovenous malformation (bAVM) embolization to achieve presurgical devascularization. The aim of this study was to perform an economic analysis comparing four techniques for bAVM embolization based on LES, ancillary device, and angiography suite time costs.

Methods: An economic model was developed comparing the embolization costs for n-BCA, EVOH with the plug and push technique, EVOH with detachable-tip microcatheters, and EVOH with balloon microcatheters.

Artery of Davidoff and Schechter: A Large Angiographic Case Series of Dural AV Fistulas.

The artery of Davidoff and Schechter (ADS) is the only meningeal branch of the posterior cerebral artery (PCA), supplying the medial tentorial margin and posterior portions of the falx. Given its small size, it is rarely identified on angiographic studies, unless enlarged in pathologies such as dural arteriovenous fistulas (DAVFs) or vascularized masses. This artery was first described by Wollschlaeger and Wollschlaeger in 1965, and to date, only a few reports have described its significance.

Prestroke Disability and Outcome After Thrombectomy for Emergent Anterior Circulation Large Vessel Occlusion Stroke.

Background And Objectives: To determine the impact of endovascular therapy for large vessel occlusion stroke in patients with vs those without premorbid disability.

Methods: We performed a post hoc analysis of the TREVO Stent-Retriever Acute Stroke (TRACK) Registry, which collected data on 634 consecutive patients with stroke treated with the Trevo device as first-line endovascular thrombectomy (EVT) at 23 centers in the United States. We included patients with internal carotid or middle cerebral (M1/M2 segment) artery occlusions, and the study exposure was patient- or caregiver-reported premorbid modified Rank Scale (mRS) score ≥2 (premorbid disability [PD]) vs premorbid mRS score of 0 to 1 (no PD [NPD]).

A proposed framework for cerebral venous congestion.

Background: While venous congestion in the peripheral vasculature has been described and accepted, intracranial venous congestion remains poorly understood. The characteristics, pathophysiology, and management of cerebral venous stasis, venous hypertension and venous congestion remain controversial, and a unifying conceptual schema is absent. The cerebral venous and lymphatic systems are part of a complex and dynamic interaction between the intracranial compartments, with interplay between the parenchyma, veins, arteries, cerebrospinal fluid, and recently characterized lymphatic-like systems in the brain.

Major complications of dural venous sinus stenting for idiopathic intracranial hypertension: case series and management considerations.

Background: Venous sinus stenting (VSS) is a safe, effective, and increasingly popular treatment option for selected patients with idiopathic intracranial hypertension (IIH). Serious complications associated with VSS are rarely reported.

Methods: Serious complications after VSS were identified retrospectively from multicenter databases.

Pivotal trial of the Neuroform Atlas stent for treatment of posterior circulation aneurysms: one-year outcomes.

Background: Stent-assisted coiling of wide-necked intracranial aneurysms (IAs) using the Neuroform Atlas Stent System (Atlas) has shown promising results.

Objective: To present the primary efficacy and safety results of the ATLAS Investigational Device Exemption (IDE) trial in a cohort of patients with posterior circulation IAs.

Methods: The ATLAS trial is a prospective, multicenter, single-arm, open-label study of unruptured, wide-necked, IAs treated with the Atlas stent and adjunctive coiling.

Distal radial artery (snuffbox) access for carotid artery stenting - Technical pearls and procedural set-up.

Purpose: To report use of distal radial artery (dRA) access for carotid artery stenting (CAS) and to discuss procedural setup and technical considerations for a successful intervention.

Methods: A retrospective review of our prospective neurointerventional database of CAS was conducted between May 2019 and March 2020. All CAS cases via dRA in the anatomical snuffbox were identified.

Radial artery neuro guide catheter entrapment during mechanical thrombectomy for acute ischemic stroke: Rescue brachial plexus block.

To our knowledge, radial artery catheter entrapment during mechanical thrombectomy for acute ischemic stroke using an 8 F neuro guiding catheter (.088 in ID) and successful use of a brachial plexus block has not been described in the literature. In this technical note, we describe a patient that underwent rapid and successful radial access mechanical thrombectomy for an acute right middle cerebral artery occlusion, however, during withdrawal of the Balt Ballast 0.

Radial Access for Neurovascular Procedures.

Radial access is increasingly being considered in neurovascular procedures after becoming the standard access route in percutaneous cardiovascular interventions. Current barriers include a lack of dedicated equipment for radial to neurovascular target vessels, lack of training for physicians and fellows, and physician bias toward femoral access secondary to greater experience and familiarity. Radial access has been proven to be safer and the preferred access route by most patients.

First Pass Effect in Patients Treated With the Trevo Stent-Retriever: A TRACK Registry Study Analysis.

The first pass effect (FPE; achieving complete recanalization with a single thrombectomy device pass) has been shown to be associated with higher rates of good clinical outcomes in patients with acute ischemic stroke. Here, we investigate clinical and radiographic factors associated with FPE in a large U.S.

Effect of balloon guide catheter on clinical outcomes and reperfusion in Trevo thrombectomy.

Introduction: The Solitaire stent retriever registry showed improved reperfusion, faster procedure times, and better outcome in acute stroke patients with large vessel occlusion treated with a balloon guide catheter (BGC) and Solitaire stent retriever compared with a conventional guide catheter. The goal of this study was to evaluate whether use of a BGC with the Trevo stent retriever improves outcomes compared with a conventional guide catheter.

Methods: The TRACK registry recruited 23 sites to submit demographic, clinical, and site adjudicated angiographic and outcome data on consecutive patients treated with the Trevo stent retriever.

Dural venous sinus stenting for idiopathic intracranial hypertension: An updated review.

Background: Dural venous sinus stenting (DVSS) is an accepted treatment option in selected patients with medically refractory idiopathic intracranial hypertension and obstructive venous outflow physiology prior to cerebrospinal flow diversion (CSFD) surgery. There are no randomized controlled studies focusing on outcomes and complication rates for dural venous sinus stenting.

Purpose: We present the largest comprehensive meta-analysis on DVSS for idiopathic intracranial hypertension (IIH) focusing on success rates, complications, and re-stenting rates to date.

Indirect carotid cavernous fistula mimicking ocular myasthenia.

71-year-old woman with progressive left-sided, monocular diplopia and ptosis. Her symptoms mimicked ocular myasthenia, but she had an indirect carotid cavernous fistula (CCF). She was diagnosed with monocular myasthenia gravis (negative acetylcholinesterase antibody) after a positive ice test and started on Mestinon and underwent a thymectomy complicated by a brachial plexus injury.

TREVO stent-retriever mechanical thrombectomy for acute ischemic stroke secondary to large vessel occlusion registry.

Background: Recent randomized clinical trials (RCTs) demonstrated the efficacy of mechanical thrombectomy using stent-retrievers in patients with acute ischemic stroke (AIS) with large vessel occlusions; however, it remains unclear if these results translate to a real-world setting. The TREVO Stent-Retriever Acute Stroke (TRACK) multicenter Registry aimed to evaluate the use of the Trevo device in everyday clinical practice.

Methods: Twenty-three centers enrolled consecutive AIS patients treated from March 2013 through August 2015 with the Trevo device.

Patient Preference for Transradial Access over Transfemoral Access for Cerebrovascular Procedures.

Purpose: Shared decision-making, when physicians and patients collaborate and agree on health care decisions, is a key tenant of patient-centered care. Choice of access site for neurovascular procedures is rarely a shared decision point between physicians and patients. We present our initial evaluation of patient preference for radial over femoral access for cerebrovascular procedures.

Dural venous sinus stenting for medically and surgically refractory idiopathic intracranial hypertension.

Background Idiopathic intracranial hypertension (IIH) is a syndrome defined by elevated intracranial hypertension without radiographic evidence of a mass lesion in the brain. Dural venous sinus stenosis has been increasingly recognized as a treatable cause, and dural venous sinus stenting (DVSS) is increasingly performed. Methods A 5 year single-center retrospective analysis of consecutive patients undergoing DVSS for medically refractory IIH.

Mechanical thrombectomy for pediatric acute ischemic stroke: review of the literature.

Objective: Given recent strongly positive randomized controlled adult mechanical thrombectomy trials, we sought to perform a comprehensive review of available literature on IA pediatric stroke intervention, with a focus on modern mechanical devices.

Methods: PubMed search for pediatric patients undergoing IA treatment of acute ischemic stroke (AIS) using modern devices between 2008 and 2015. 29 patients were included in this analysis.

Basilar artery perforator aneurysms (BAPAs): review of the literature and classification.

Basilar artery perforator aneurysms (BAPAs) are an uncommon subtype of perforating artery aneurysms, with only 18 published cases since their initial description in 1996 by Ghogawala To date, there are only seven published cases of ruptured BAPAs treated using endovascular techniques. Given the rarity of these aneurysms, the natural history and ideal approach to treatment has not been established. We describe a new endovascular approach to treating these aneurysms using staged telescoping stents, summarize all published cases of BAPAs, and present a unique classification system to enable future papers to standardize descriptions.

Subclavian steal: Endovascular treatment of total occlusions of the subclavian artery using a retrograde transradial subintimal approach.

Introduction: In symptomatic subclavian steal syndrome, endovascular treatment is the first line of therapy prior to extra-anatomic surgical bypass procedures. Subintimal recanalization has been well described in the literature for the coronary arteries, and more recently, in the lower extremities. By modifying this approach, we present a unique retrograde technique using a heavy tip microwire to perform controlled subintimal dissection.