Endovascular Treatment of Anterior Circulation Cerebral Aneurysms by Using Guglielmi Detachable Coils: A 10-Year Single-Center Experience with Special Emphasis on the Use of Three-Dimensional GDC

Purpose:: To analyze the immediate, long-term angiographic and clinical results of endovascular treatment of anterior circulation aneurysms with special regard to the use of three-dimensional Guglielmi detachable coils (3D-GDC). Patients and Methods:: Between 1993 and 2003, 116 patients with 116 anterior circulation aneurysms were treated. 88 patients (75.9%) underwent embolization due to high surgical risk. To analyze the use of 3D-GDC, patients treated before (group 1) and after (group 2) implementation of 3D-GDC in 1999 were compared. Mean duration of angiographic follow-up was 13.9 months. Clinical follow-up was set at hospital discharge and using a questionnaire for long-term follow-up (mean 46.8 months). Results:: Overall, at initial intervention, complete occlusion was achieved in 65 aneurysms (56.0%), neck remnant in 42 (36.2%), and incomplete occlusion in nine (7.8%). Procedure-related permanent morbidity was 4.3% and mortality 2.6%. Recanalization rate at radiologic follow-up was 16.7%. Occlusion success at initial treatment correlated with aneurysm neck size (p = 0.001). Clinical outcome at hospital discharge was dependent on Hunt & Hess grade at presentation (p = 0.01). Subgroup analysis revealed that the use of 3D-GDC produced a higher initial obliteration rate compared to standard coils, but did not reach statistical significance (p = 0.059). Neither aneurysm neck size nor aneurysm dome size nor the use of 3D-GDC significantly influenced recanalization rate. Conclusion:: GDC technology is effective and safe, particularly in case of patients with high surgical risk. Aneurysm neck size was predictive of occlusion rate and Hunt & Hess grade of clinical outcome. Introduction of 3D-GDC probably improved occlusion rate, but did not significantly influence recanalization rat

The use of flat panel angioCT (DynaCT) for navigation through a deformed and fractured carotid stent

Navigation through a previously deployed and deformed stent is a difficult interventional task. Inadvertent navigation through the struts of a stent can potentially lead to incomplete secondary stent extension and vessel occlusion. Better visualisation of the pathway through the stent can reduce the risks of the procedural complications and reduce the reluctance of the interventionalist to navigate through a previously deployed stent. We describe a technique of visualisation of the pathway navigated by a guidewire through a previously deployed deformed and fractured carotid stent by the use of DynaCT. Three-dimensional reconstruction of the stent/microwire allows excellent visualisation of the correct pathway of the microwire within the sten

Natural history of carotid artery free-floating thrombus-A single center, consecutive cohort analysis.

Introduction Carotid free-floating thrombus (CFFT) is a rare cause of stroke and is thought to be associated with a high risk of recurrent cerebrovascular ischaemic events. The existing data on the natural history and optimal treatment modalities of CFFT is scanty and no clear recommendations exist. Objective A retrospective analysis, single-center cohort of consecutive patients diagnosed with CFFT was conducted, investigating the risk for recurrent cerebrovascular ischaemic events. Methods We performed a single-center retrospective analysis including all patients presenting at our tertiary center between January 2005 and December 2020 with symptoms consistent with ischaemic stroke and/or transient ischaemic attack. Digital subtraction angiography (DSA), computed tomography angiography (CTA) or magnetic resonance angiography (MRA) were used to diagnose CFFT. In all included patients, CFFT was confirmed with a second imaging modality. CFFT was defined on imaging as a defect in contrast filling extending into the carotid lumen. We gathered information on vascular risk factors, diagnosis and follow-up methods, modality of treatment and neurological outcome. A survival analysis was performed, assessing the risk for recurrent cerebrovascular events. Results In total, N = 62 patients presenting with symptomatic CFFT were included. Mean age was 68 years, 69% (43/62) of patients were male, 52% (32/62) current or previous smokers, 76% (47/62) suffered from arterial hypertension, 68% (42/62) from dyslipidaemia, and 31% (19/62) from diabetes mellitus. Overall, 71% (44/62) of patients received any kind of intervention [endovascular or surgical carotid thrombo-endartectomy (CEA)] at any time point during follow-up. Sixteen percent of patients (10/62) received intervention within 48 h after diagnosis of CFFT. The survival analysis and Kaplan-Meier model censoring patients at the time of intervention or last follow-up showed that the risk for any recurrent ischaemic stroke was 19.7% within the first 7 days and 27.4% within 3 months after diagnosis. No patients experienced a new ischaemic stroke beyond 11 days after diagnosis of CFTT (n = 17). Conclusion The risk of recurrent ischaemic events in patients with CFFT is high, especially in the first week after diagnosis. Prospective studies are needed to further investigate the optimal management of these patients

Safety of the Solitaire 4 × 40 mm Stent Retriever in the Treatment of Ischemic Stroke.

PURPOSE Stent retrievers apply mechanical force to the intracranial vasculature. Our aim was to evaluate the safety and efficacy of the long Solitaire 4 × 40 mm stent retriever for large vessel occlusion in stroke patients. METHODS We conducted a retrospective analysis of all patients treated for acute ischemic large vessel occlusion stroke with the Solitaire 2 FR 4 × 40 device between May and October 2016 at our institution. Patient-specific data at baseline and at discharge were documented. Reperfusion was graded with the thrombolysis in cerebral infarction (TICI) classification. Postinterventional angiograms and follow-up cross-sectional imaging were used to evaluate complications. RESULTS TICI 2b/3 recanalization was achieved in 20 of 23 patients (87.0%), in 17 patients with the first retriever pass. NIHSS improved from a mean score at presentation of 16 (range 4-36) to 11 (range 0-41) at discharge. Mean mRS score at discharge was 3 (range 0-6) and 3 (range 0-6) at 90 days post-treatment. No infarcts in other territories were observed. One patient showed a (reversible) vasospasm in the postinterventional angiogram and another a small contrast extravasation in follow-up imaging. CONCLUSION The Solitaire 2 FR 4 × 40 stent retriever is a safe and efficient device for large vessel occlusion acute ischemic stroke with a high recanalization rate and a low peri- and postinterventional complication rate together with a good clinical outcome. Despite potentially higher friction and shearing forces, no increased incidence of visible damage to the vessel wall was observed

Evaluation of Sine Spin flat detector CT imaging compared with multidetector CT.

BACKGROUND Flat detector computed tomography (FDCT) is widely used for periprocedural imaging in the angiography suite. Sine Spin FDCT (SFDCT) is the latest generation of cone beam CT using a double oblique trajectory for image acquisition to reduce artefacts and improve soft tissue brain imaging. This study compared the effective dose, image quality and diagnostic performance of the latest generation of SFDCT with multidetector CT (MDCT). METHODS An anthropomorphic phantom equipped with MOSFET detectors was used to measure the effective dose of the new 7sDCT Sine Spin protocol on a latest generation biplane angiographic C-arm system. Diagnostic performance was evaluated on periprocedurally acquired SFDCT for depiction of anatomical details, detection of hemorrhage, and ischemia and was compared with preprocedurally acquired MDCT. Inter- and intra-rater correlation as well as sensitivity and specificity were calculated. RESULTS Both modalities showed equal diagnostic performance in the supratentorial ventricular system. SFDCT provided inferior image quality in grey-white matter differentiation and infratentorial structures. Intraventricular, subarachnoid and parenchymal hemorrhages were diagnosed with a sensitivity of 83.3%, 84.2% and 75% and a specificity of 97.3%, 80.0% and 100%, respectively; early ischemic lesions with a sensitivity of 73.3% and specificity 94.7%. The effective dose measured for the 7sDCT Sine Spin protocol was 2 mSv. CONCLUSIONS Our findings confirm the high diagnostic sensitivity and specificity of SFDCT in detecting intracranial hemorrhage and early ischemic lesions. The delineation of grey-white matter differentiation and infratentorial structures remains a limiting factor. In comparison to previous studies, the new 7sDCT Sine Spin protocol showed a lower effective dose

Diagnosis of Small Unruptured Intracranial Aneurysms : Comparison of 7 T versus 3 T MRI.

PURPOSE Differentiating normal anatomical variants such as an infundibulum or a vascular loop from true intracranial aneurysms is crucial for patient management. We hypothesize that high-resolution 7 T magnetic resonance imaging (MRI) improves the detection and characterization of normal anatomical variants that may otherwise be misdiagnosed as small unruptured aneurysms. METHODS This is a retrospective, single-center study. All patients were scanned on a clinically approved 7 T MRI scanner and on a 3 T scanner. Image analysis was performed independently by three neuroradiologists blinded to clinical information. The presence of an unruptured intracranial aneurysm (UIA) and level of diagnostic certainty were assessed and the interrater agreement was calculated. If an aneurysm was present, the anatomic location and shape were recorded and compared. RESULTS In total, 53 patients with equivocal cerebrovascular findings on 1.5 T or 3 T MRI referred for a 7T MRI examination were included. Aneurysms were suspected in 42 patients examined at 3 T and in 23 patients at 7 T (rate difference 36%, 95% confidence interval, CI, 19-53%, p-value < 0.001). Major disagreement between the field strengths was observed in the A1 segment of anterior cerebral artery/anterior communicating artery (A1/ACOM) complex. The interrater agreement among the readers on the presence of an aneurysm on 7 T MRI was higher than that for 3 T MRI (0.925, 95% CI 0.866-0.983 vs. 0.786, 95% CI 0.700-0.873). CONCLUSION Our analysis demonstrates a significantly higher interrater agreement and improved diagnostic certainty when small intracranial aneurysms are visualized on 7 T MRI compared to 3 T. In a selected patient cohort, clinical implementation of 7 T MRI may help to establish the definitive diagnosis and thus have a beneficial impact on patient management

Evaluation of time-resolved whole brain flat panel detector perfusion imaging using RAPID ANGIO in patients with acute stroke: comparison with CT perfusion imaging.

BACKGROUND In contrast to conventional CT perfusion (CTP) imaging, flat panel detector CT perfusion (FD-CTP) imaging can be acquired directly in the angiosuite. OBJECTIVE To evaluate time-resolved whole brain FD-CTP imaging and assess clinically important qualitative and quantitative perfusion parameters in correlation with previously acquired conventional CTP using the new RAPID for ANGIO software. METHODS We included patients with internal carotid artery occlusions and M1 or M2 occlusions from six centers. All patients underwent mechanical thrombectomy (MT) with preinterventional conventional CTP and FD-CTP imaging. Quantitative performance was determined by comparing volumes of infarct core, penumbral tissue, and mismatch. Eligibility for MT according to the perfusion imaging criteria of DEFUSE 3 was determined for each case from both conventional CTP and FD-CTP imaging. RESULTS A total of 20 patients were included in the final analysis. Conventional relative cerebral blood flow (rCBF) 6 s versus FD-CTP Tmax >6 s and CTP mismatch versus FD-CTP mismatch showed more variability (R2=0.57, and R2=0.33, respectively). Based on FD-CTP, 16/20 (80%) patients met the inclusion criteria for MT according to the DEFUSE 3 perfusion criteria, in contrast to 18/20 (90%) patients based on conventional CTP. The vessel occlusion could be correctly extrapolated from the hypoperfusion in 18/20 cases (90%). CONCLUSIONS In our multicenter study, time-resolved whole brain FD-CTP was technically feasible, and qualitative and quantitative perfusion results correlated with those obtained with conventional CTP

Outcome, efficacy and safety of endovascular thrombectomy in ischaemic stroke according to time to reperfusion: data from a multicentre registry

Endovascular; Mechanical thrombectomy; StrokeEndovascular; Trombectomia mecànica; Accident cerebrovascularEndovascular; Trombectomía mecánica; Accidente cerebrovascularBACKGROUND AND PURPOSE: In acute ischaemic stroke (AIS) of the anterior circulation (AC) treated with mechanical thrombectomy (MT), data point to a decline of treatment effect with increasing time from symptom onset to treatment. However, the magnitude of the decline will depend on the clinical setting and imaging selection used. The aims of this study were (1) to evaluate the clinical effect of time to reperfusion (TTR); and (2) to assess the safety and technical efficacy of MT according to strata of TTR. METHODS: Using the retrospective multicentre BEYOND-SWIFT registry data (ClinicalTrials.gov identifier: NCT03496064), we compared safety and efficacy of MT in 1461 patients between TTR strata of 0-180 min (n = 192), 180-360 min (n = 876) and >360 min (n = 393). Clinical effect of TTR was evaluated using multivariable logistic regression analyses adjusting for pre-specified confounders [adjusted odds ratios (aOR) and 95% confidence intervals (95% CI)]. Primary outcome was good functional outcome (modified Rankin Scale: mRS 0-2) at day 90. RESULTS: Every hour delay in TTR was a significant factor related to mRS 0-2 (aOR 0.933, 95% CI 0.887-0.981) with an estimated 1.5% decreased probability of good functional outcome per hour delay of reperfusion, and mRS 0-1 (aOR 0.929, 95% CI 0.877-0.985). Patients with late TTR had lower rates of successful and excellent reperfusion, higher complication rates and number of passes. CONCLUSIONS: TTR is an independent factor related to long-term functional outcome. With increasing TTR, interventional procedures become technically less effective. Efforts should be made to shorten TTR through optimized prehospital and in-hospital pathways

Long-term outcome of symptomatic severe ostial vertebral artery stenosis (OVAS)

Introduction: The optimal management of patients with symptomatic severe ostial vertebral artery stenosis (OVAS) is currently unclear. We analyzed the long-term outcome of consecutive patients with OVAS who received either medical treatment (MT) or vertebral artery stenting (VAS). Methods: Thirty-nine (>70%) patients with severe OVAS were followed for a mean period of 2.8years. The decision for VAS (n = 10) or MT (n = 29) was left to the clinician. The Kaplan-Meier method was used to assess the risk of recurrent stroke, transient ischemic attack (TIA), or death over the study period. Results: Patients in the VAS group were significantly younger and more likely to have bilateral VA disease (P = 0.04 and P = 0.02). VAS was successfully performed in all ten patients. The periprocedural risk within 30days was 10% (one TIA). The overall restenosis rate was 10%. One restenosis occurred after 9months in a patient treated with bare-metal stent. At 4years of follow-up, VAS showed a nonsignificant trend toward a lower risk for the combined endpoint of TIA and stroke in posterior circulation compared to medical treatment (10% vs. 45%, P = 0.095; relative risk (RR) = 0.24, 95% confidence interval (CI) 0.031-1.85). Patients with bilateral VA disease had a significantly lower recurrence risk after VAS compared with medical treatment (0% vs. 91% at 4years, P = 0.004; RR 0.10, 95% CI 0.022-0.49) Conclusion: VAS was performed without permanent complications in this small series of patients with symptomatic severe OVAS. The long-term benefit seems to be confined to patients with bilateral but not to those with unilateral VA diseas

Temporal Trends and Risk Factors for Delayed Hospital Admission in Suspected Stroke Patients.

(1) Background: The benefit of acute ischemic stroke (AIS) treatment declines with any time delay until treatment. Hence, factors influencing the time from symptom onset to admission (TTA) are of utmost importance. This study aimed to assess temporal trends and risk factors for delays in TTA. (2) Methods: We included 1244 consecutive patients from 2015 to 2018 with suspected stroke presenting within 24 h after symptom onset registered in our prospective, pre-specified hospital database. Temporal trends were assessed by comparing with a cohort of a previous study in 2006. Factors associated with TTA were assessed by univariable and multivariable regression analysis. (3) Results: In 1244 patients (median [IQR] age 73 [60-82] years; 44% women), the median TTA was 96 min (IQR 66-164). The prehospital time delay reduced by 27% in the last 12 years and the rate of patients referred by Emergency medical services (EMS) increased from 17% to 51% and the TTA for admissions by General Practitioner (GP) declined from 244 to 207 min. Factors associated with a delay in TTA were stroke severity (beta-1.9; 95% CI-3.6 to -0.2 min per point NIHSS score), referral by General Practitioner (GP, beta +140 min, 95% CI 100-179), self-admission (+92 min, 95% CI 57-128) as compared to admission by emergency medical services (EMS) and symptom onset during nighttime (+57 min, 95% CI 30-85). Conclusions: Although TTA improved markedly since 2006, our data indicates that continuous efforts are mandatory to raise public awareness on the importance of fast hospital referral in patients with suspected stroke by directly informing EMS, avoiding contact of a GP, and maintaining high effort for fast transportation also in patients with milder symptoms