Brinjikji, Waleed

Aim: The aim of this analysis was to assess the cost–effectiveness of the EmboTrap ® Revascularization Device compared with the Solitaire™ Revascularization Device and Trevo ® Retriever for the treatment of acute ischemic stroke (AIS) from the perspective of the Chinese healthcare system. Methods: According to MASTRO I, a recent living systematic literature review and meta-analysis, mechanical thrombectomy (MT) with EmboTrap in the treatment of AIS resulted in better functional outcomes compared with the use of Solitaire or Trevo. Based on the proportion of patients that achieved 90-day modified Rankin Scale (mRS) scores of 0–2, 3–5 and 6 reported in MASTRO I, a combined 90-day short-term decision tree and Markov model with a 10-year time horizon was used to compare the cost–effectiveness of the three devices. The primary outcome was the incremental cost–effectiveness ratio (ICER), representing the incremental cost (in 2022 Chinese Yuan [CNY]) per incremental quality-adjusted life-year (QALY). The ICERs were compared against willingness-to-pay (WTP) thresholds of 1, 1.5 and 3-times the 2022 national gross domestic product (GDP) per capita in China. Results: Treatment with EmboTrap resulted in total QALYs of 3.28 and total costs of 110,058 CNY per patient. Treatment with Trevo resulted in total QALYs of 3.05 and total costs of 116,941 CNY per patient. Treatment with Solitaire resulted in total QALYs of 2.81 and total costs of 99,090 CNY per patient. Trevo was dominated by EmboTrap as it was a more costly and less effective intervention. As such, Trevo was not cost-effective at any WTP threshold. Compared with Solitaire, EmboTrap was more effective and more costly, with an ICER of 23,615 CNY per QALY. This result suggests that EmboTrap is cost-effective when compared with Solitaire since the ICER was lower than all WTP thresholds assessed. Conclusion: EmboTrap dominated Trevo and is cost-effective for the treatment of patients with AIS compared with Solitaire when assessed from the perspective of the Chinese healthcare system and based on the device-level meta-analysis MASTRO I. Selecting a stent retriever (SR) that optimizes 90-day mRS score is an important consideration from both a clinical and healthcare payer perspective in China as it is associated with reduced long-term costs and increased quality of life.

Background The choice of angiography system could influence the outcomes of mechanical thrombectomy (MT) in the treatment of acute ischemic stroke (AIS), but its impact is not yet well understood. This study aims to compare the clinical and technical outcomes of MT performed with single plane versus biplane angiography systems. Method We conducted a systematic review and meta-analysis, following PRISMA guidelines, by searching PubMed, Embase, Web of Science, and Scopus to include studies on patients with AIS who underwent MT with either single plane or biplane angiography up to May 4, 2024. The primary outcome was a favorable outcome defined as a modified Rankin Scale (mRS) score of 0–2 at 90 days after the procedure. Data were analyzed using a random-effects model and heterogeneity was assessed using the I2 test and Q statistics. Results Five studies with a total of 1562 patients were analyzed. Of these, 68.4% were treated with biplane systems and 31.6% with single plane systems. Single plane angiography was associated with a significantly higher rate of favorable outcomes (OR 1.43; 95% CI 1.13 to 1.80; P<0.01). There were no significant differences in successful recanalization, periprocedural complications, procedure time, total fluoroscopy time, or contrast volume between the two systems. Conclusion While single plane angiography systems may offer slightly better outcomes in MT for AIS, both systems appear equally effective in most clinical and technical perspectives, suggesting that system selection may be more dependent on availability and procedural requirements rather than inherent superiority. Our findings may encourage clinicians to use single-plane angiography in settings where the biplane angiography suite availability is limited, but it should be noted that this observation may have been influenced by selection bias, particularly since the larger studies included in our meta-analysis did not observe this effect in adjusted analyses for potential confounder factors.

OBJECTIVE The Woven EndoBridge (WEB) device was approved to treat wide-necked bifurcation aneurysms. The device is designed as an intrasaccular flow disruptor covering aneurysm widths up to 10 mm. Although prior studies combined all aneurysm sizes, it is known that aneurysms behave differently in response to endovascular treatment based on their size. Therefore, the authors’ objective was to identify ideal middle cerebral artery (MCA) aneurysm width and neck sizes most suitable for WEB treatment. METHODS The WorldWideWEB consortium is a large multicenter retrospective database that analyzes intracranial aneurysms treated with the WEB device. In this study, all unruptured MCA bifurcation aneurysms with available measurements were included. Cutoff values based on aneurysm width and neck in relation to aneurysm occlusion status were measured using the receiver operating characteristic (ROC) curve. Propensity score matching (PSM) was then used to compare treatment outcomes between aneurysms smaller and larger than the cutoff value for both width and neck size. RESULTS The ideal cutoff values for MCA bifurcation aneurysm width and neck were 6.1 mm and 4.6 mm, respectively. On PSM, 87 matched pairs were compared based on width size (≤ 6.1 mm and > 6.1 mm), and 77 matched pairs were compared based on neck size (≤ 4.6 mm and > 4.6 mm). There was a significant difference in adequate aneurysm occlusion between aneurysms smaller and larger than those cutoff values for both widths (93% vs 76%, p = 0.0017) and neck sizes (90% vs 70%, p = 0.0026). The retreatment rate was also significantly higher for larger aneurysms in both parameters. CONCLUSIONS This study shows that MCA bifurcation aneurysms ≤ 6.1 mm in width and ≤ 4.6 mm in neck size are significantly better candidates for WEB treatment, leading to improved occlusion status and reduced retreatment rate, which are important considerations when using WEB devices.

BACKGROUND AND OBJECTIVES: We aimed to develop and validate a prediction score for futile recanalization (FR) for large vessel occlusion (LVO) presenting low Alberta Stroke Program Early Computed Tomography Score (ASPECTS) for patients who underwent endovascular thrombectomy (EVT). METHODS: Patients with anterior circulation LVO with low ASPECTS (<6) who underwent successful EVT (modified treatment in cerebral ischemia score ≥2b) from Stroke Thrombectomy and Aneurysm Registry were retrospectively analyzed. FR was defined as 90-day modified Rankin Scale (mRS) scores ≥4 despite successful EVT. Multivariable logistic regression was used to identify independent predictors of FR, and they were used to create a clinical score. The performance of the score was assessed by receiver operating characteristic curve analyses. RESULTS: Of 219 patients, 170 and 49 patients were randomly assigned to the training and validation cohort, respectively. Independent predictors of FR identified in the training cohort were used to construct the SNAP score: site of occlusion (middle cerebral artery = 0, internal carotid artery = 1), National Institutes of Health Stroke Scale score at admission (≤10 = 0, 10 to 19 = 1, ≥20 = 2), age (<75 = 0, ≥75 = 2), and prestroke mRS score (0-3). Receiver operating characteristic curve analyses of the SNAP score in the training and validation cohorts showed areas under the curve of 0.79 (95% CI 0.72-0.86) and 0.79 (95% CI 0.65-0.92) for predicting FR, respectively. A SNAP score ≥5 had a positive predictive value of 92.1% [95% CI 78.8%-97.3%] for FR. CONCLUSION: The SNAP score may be useful in predicting FR after EVT in low-ASPECTS patients with LVO. It can provide patients, family members, and physicians with reliable outcome expectations among patients with acute ischemic stroke with large infarcts.

Historically, the management of carotid artery disease has primarily focused on the degree of stenosis as the main indicator for assessing stroke etiology, risk, and need for intervention. However, accumulating evidence suggests that structural and biological features within the arterial wall, such as intraplaque hemorrhage, may have superior diagnostic, prognostic, and therapeutic values. Under current guidelines, unless an atheroma results in ≥50% stenosis, it is not considered the cause of a cerebrovascular event. This results in extensive and often unproductive diagnostic workup, prescription of ineffective medical therapy, and preclusion of patients from receiving revascularization procedures that have been shown to prevent recurrent cerebrovascular events in cases of ≥50% stenosis. A subset of embolic strokes of undetermined source, which account for up to 25% of all ischemic cerebrovascular events, are thought to be due to thromboembolic phenomena from undiagnosed plaque disruptions in nonstenotic arteries (<50% stenosis). Recently, it has been proposed to reclassify this subgroup of patients as symptomatic nonstenotic carotid if the carotid plaque ipsilateral to the cerebrovascular event presents with high-risk features including intraplaque hemorrhage, lipid-rich necrotic core, thinning/rupture of the fibrous cap, and ulceration. In this review, we first provide a historical overview of the chain of events and circumstances that resulted in the present management of carotid artery disease. Second, we embed the contemporary biomarkers of plaque vulnerability in a modern mechanistic paradigm of carotid plaque disruption and thromboembolization. Third, we review the clinically available imaging tools to detect these biomarkers, and how their use has started to shed light on the prevalence and natural history of this underdiagnosed condition. Fourth, we review recent clinical studies employing a contemporary definition of symptomatic nonstenotic carotid and discuss targeted treatments for this condition. Finally, we make a case to generate the much-needed high-level evidence to align the clinical management of patients with symptomatic nonstenotic carotid with a contemporary understanding of plaque disruption and thromboembolization.

BACKGROUND AND OBJECTIVES: First-line therapy for most intracranial dural arteriovenous fistulas (dAVFs) is endovascular embolization, but some require microsurgical ligation due to limited endovascular accessibility, anticipated lower cure rates, or unacceptable risk profiles. We investigated the most common surgically treated dAVF locations and the approaches and outcomes of each. METHODS: The Consortium for Dural Arteriovenous Fistula Outcomes Research database was retrospectively reviewed. Patients who underwent dAVF microsurgical ligation were included. Patient demographics, angiographic information, surgical details, and postoperative outcomes were collected. The 5 most common surgically treated dAVF locations were analyzed about used surgical approaches and postoperative outcomes. Univariate analyses were performed with statistical significance set at a threshold of P < .05. RESULTS: In total, 248 patients in the Consortium for Dural Arteriovenous Fistula Outcomes Research database met inclusion criteria. The 5 most common surgically treated dAVF locations were tentorial, anterior cranial fossa (ACF), transverse-sigmoid sinus (TSS), convexity/superior sagittal sinus (SSS), and torcular. Most tentorial dAVFs were approached using a suboccipital, lateral supracerebellar infratentorial approach (39.3%); extended retrosigmoid approach (ERS) (25%); or posterior subtemporal approach (19.6%). All ACF dAVFs used a subfrontal approach; 5.3% also included an anterior interhemispheric approach. Most TSS dAVFs were ligated via ERS (31.3%) or subtemporal (31.3%) approaches. All convexity/SSS dAVFs used an interhemispheric approach. All torcular dAVFs used the suboccipital, lateral supracerebellar infratentorial approach, with 10.5% undergoing simultaneous ERS craniotomy. Angiographic occlusion rates after microsurgery were 85.5%, 100%, 75.8%, 79.2%, and 73.7% for tentorial, ACF, TSS, convexity/SSS, and torcular dAVFs, respectively ( P = .02); the permanent neurological complication rates were 1.8%, 2.6%, 9.1%, 0%, and 0% ( P = .31). There were no statistically significant differences in development of complications ( P = .08) or Modified Rankin Scale at the last follow-up ( P = .11) by fistula location. CONCLUSION: Although endovascular embolization is the first-line treatment for most intracranial dAVFs, surgical ligation is an important alternative. ACF and tentorial fistulas particularly demonstrate high rates of postoperative obliteration.

Background Cerebral sinus venous thrombosis (CSVT) has traditionally been treated medically with systemic anticoagulation. Recent advances in endovascular therapy (EVT) may represent an alternative treatment to medical therapy for CSVT. We conducted a systematic review and meta-analysis to evaluate the use of EVT for CSVT. Methods We conducted a systematic literature review using PubMed, Embase, Scopus, and Web of Science. We included studies that reported outcomes following EVT for CSVT. The primary outcome of interest was rate of modified Rankin Scale (mRS) 0–2. Secondary outcomes of interest were rates of complete, partial, and failed recanalization, mortality, and new or expansion of hematoma. We calculated pooled rates (%) and their corresponding 95% confidence intervals (CIs). Results Thirty-eight studies with 682 patients were included. Rate of mRS 0–2 was 82.6% (95% CI, 75.3%–88.0%). Rate of complete recanalization was 60.9% (95% CI, 49.1%–71.5%), rate of partial recanalization was 34.2% (95% CI, 24.1%–45.9%), and rate of failed recanalization was 5.4% (95% CI, 3.1%–9.2%). Rate of mortality was 6.7% (95% CI, 4.1%–10.8%), and rate of new hematoma or expansion of hematoma was 5.1% (2.9%–8.8%). Conclusions In this systematic review and meta-analysis, EVT for CSVT was associated with favorable rates of mRS 0–2 and recanalization. Furthermore, EVT was associated with a promising safety profile. Future prospective, comparative studies are warranted to assess EVT for CSVT.

Background Many devices are used to perform mechanical thrombectomy in the setting of large vessel occlusion acute ischemic stroke. We sought to evaluate the efficacy and safety of pRESET stent-retriever systems. Methods We conducted a comprehensive systematic review and meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Relevant studies up to March 2024 were retrieved from PubMed, Scopus, Web of Science, and Embase databases. Results A total of 8 papers met the inclusion/exclusion criteria comprising a total of 1140 participants (average age 72.4 ± 11.9, female percentage (50%). Preintervention intravenous thrombolysis was utilized in 46.5% (range 32.9–65.4) of patients, with a median National Institute of Health Stroke Scale at presentation of 15 (range 0–38). The middle cerebral artery was the most commonly affected artery, with a prevalence of 76.4% (range 62.8–100). The pRESET stent-retriever systems demonstrated a first-passing effect rate of 53.4% [95% confidence interval [CI] 44.8; 61.7] and a final thrombolysis in cerebral infarction 2b-3 grade rate of 90.41% [95% CI 82.13; 95.08]. Ninety-day modified Rankin Scale (0–2) rate was 42.2% [95% CI 27.6; 58.4], and 90-day mortality rate was 15.1% [95% CI 9.8; 22.6]. Postintervention hemorrhage occurred at a rate of 28.6% [CI 17.2; 43.6]. Conclusion Our systematic review and meta-analysis describes the efficacy of the pRESET stent retriever system in managing acute ischemic stroke patients. The pRESET device was found to have a similar safety and efficacy profile to other mechanical thrombectomy devices currently in use.

Purpose Optimizing the preparation of a 10 ml syringe for manual injection of contrast media can help operators obtain easier and faster injections. This study aims to compare the flow rates of different contrast media injection methods. Methods Different contrast media solutions were compared: 100% contrast (10 ml contrast), mixed contrast solution (8:2 contrast/saline), and layered contrast below saline (“Parfait”) in different volumes. Contrast media were injected at room temperature (20°C) and after heating (37°C). Four operators injected 10 ml syringes filled with different mediums through 5-French angiographic catheters. The average flow rate was used to compare different contrast injection mediums. The Kruskal-Wallis test with post-hoc pairwise comparisons using Bonferroni correction or Mann-Whitney U-tests were employed depending on the type of comparison. Results Compared to the 100% contrast solution, every Parfait media and mixed contrast solution demonstrated significantly higher flow rates (p < 0.001). The 5 ml saline Parfait had the highest flow rate among the Parfait solutions. The 5 ml saline Parfait and the mixed solution had comparable flow rates (p = 0.237). Higher flow rates were observed upon heating both 100% contrast (p < 0.001) and mixed contrast solutions (p < 0.001) in comparison to their flow rates at room temperature. Conclusion This study demonstrates the capability of the Parfait and mixed contrast injections to achieve higher flow rates than the 100% contrast solutions. Heating the contrast media to 37°C also proves to be a viable strategy for further enhancing the flow rates for 100% and mixed contrast solutions.

Background A higher number of recanalization attempts reduces the efficacy of endovascular thrombectomy (EVT) for acute ischemic stroke secondary to large vessel occlusion (LVO). We assessed the impact of switching EVT techniques after a failed first pass on procedural and clinical outcomes. Methods This multicenter international study, conducted between January 2013 and December 2022, included patients undergoing EVT for anterior circulation LVO (internal carotid artery or M1 segments) with failed first pass recanalization. Propensity score matching identified a 1:1 matched cohort of patients in whom EVT technique was changed after a failed first pass and those with the same technique repeated. The primary outcome was successful recanalization at second attempt defined as Thrombolysis in Cerebral Ischemia (TICI) score of 2B or higher. Secondary outcomes were 90-day modified Rankin Score (mRS) and postprocedural hemorrhage. Results Among 2167 patients, converting to an alternative technique after a failed first pass was associated with higher odds of successful recanalization (adjusted OR (aOR)=1.5, p=0.041), and higher odds of mRS 0–2 at 90 days (aOR=1.6, p=0.005) without additional risk of symptomatic hemorrhage (p=0.379). Using a propensity score matched cohort of 490 patients, technique conversion at second attempt increased odds of successful recanalization at second attempt (aOR=1.32, p=0.006) and 90-day mRS 0–2 (aOR=1.38, p=0.008). Conclusions Early conversion to an alternative EVT technique after a failed first pass recanalization in patients with AIS is associated with better technical success and clinical outcomes.