Bilgin, Cem

Abstract Introduction Flow diverter (FD) stents are widely used to treat giant aneurysms by reducing blood flow into the aneurysm sac. However, choosing the optimal FD for a patient can be challenging when a nearby artery, such as the ophthalmic artery (OA), is jailed by the FD placement. This study compares the impact of two FD stents with different effective metal surface area (EMSA) values on OA occlusion. Materials and Methods A numerical model of a 59-year-old female patient with a giant aneurysm in the left internal carotid artery and a jailed OA was created based on clinical data. Two FD stents, FRED4017 and FRED4518, with different EMSA values at the aneurysm neck and OA inlet, were virtually deployed in the model. Blood flow and occlusion amount in the OA were simulated and compared between the two FD stents. Results FRED4017 had higher EMSA values than FRED4518 at the aneurysm neck (35% vs. 24.6%) and lower EMSA values at the OA inlet (15% vs. 21.2%). FRED4017 caused more occlusion in the OA than FRED4518 (40% vs. 28%), indicating a higher risk of ocular ischemic syndrome. Conclusion The EMSA value of FD stents affects the blood flow and occlusion amount in the jailed OA. Therefore, selecting an FD stent with a low EMSA value at the OA inlet may be beneficial for patients with a nearby jailed artery at the aneurysm neck.

Background Intracranial dissecting aneurysms present a challenging subset linked to considerable morbidity and mortality, necessitating effective therapeutic strategies to prevent complications. Traditional treatments face technical limitations, while emerging endovascular modalities like stent-assisted coiling, multiple stenting, and flow-diverting devices (FDDs) offer promise in reducing periprocedural risks and enhancing patient outcomes. The aim of this study is to compare the safety and efficacy outcomes of endovascular treatment for intracranial dissecting aneurysms using FDDs versus stents (with or without coiling). Methods A systematic review and meta-analysis were conducted following established guidelines. The search included PubMed, Scopus, Web of Science, and Embase databases up to July 30, 2023. Eligible studies reporting outcomes of interest in both FDD and stent-treated groups were included, and the data was extracted and analyzed using STATA software. Results Six studies were analyzed, involving 131 patients in the FDD group and 199 patients in the stent group. The pooled rates for favorable functional outcomes (86.8% vs. 86%), mortality (3.9% vs. 6%), adequate occlusion (79.7% vs. 86.3%), aneurysm recurrence (1.3% vs. 13.3%), in-stent stenosis/thrombosis (7% vs. 6.9%), ischemic events/infarctions (6.7% vs. 7.8%), retreatment (7% vs. 8.6%), and technical success (100% vs. 98.7%) were comparable in individuals treated with FDDs and stents (p > 0.05 in all cases). Additionally, complete occlusion rates were not significantly different between FDD (62.7%) and stent-treated patients (75.2%) (p = 0.06). However, after excluding one study in a leave-one-out analysis of the random effects meta-analysis, a significant difference in the pooled rates of this outcome was observed between the FDD (59.2%) and stent (75.2%) groups (p = 0.034). Conclusion FDDs present a promising approach for the treatment of intracranial dissecting aneurysms, yielding outcomes that are roughly comparable to stent-based methods. However, the absence of randomized trials and data limitations highlight the need for further research to enhance treatment strategies.

Background Mechanical thrombectomy (MT) is a safe and effective treatment option for acute ischemic stroke due to large vessel occlusion. To investigate differences in outcomes between patients receiving left-sided and right-sided MT, we performed a systematic review and meta-analysis. Methods A systematic literature review was performed using Embase, PubMed, Scopus, and Web of Science databases. Additional literature was searched for manually. Studies reporting safety and efficacy metrics for MT were included. Data regarding the modified Rankin scale (mRS), thrombolysis in cerebral infarction (TICI), symptomatic intracranial hemorrhage (sICH), and 90-day mortality were included. A random-effects model was used to calculate pooled odds ratios (ORs), mean differences (MDs), and 95% confidence intervals (CIs). Results The literature search yielded 13 reports consisting of 19 studies ranging from 98 to 5590 patients. Patients presenting with left-sided stroke had a National Institutes of health stroke scale score 2.89 greater than patients presenting with right-sided stroke (MD = 2.89; 95% CI = 2.09–3.68; P -value < 0.001). There were no differences between left-sided and right-sided MT patients for mRS 0–2 (OR = 0.94; 95% CI = 0.85–1.04; P -value = 0.224), TICI 2b–3 (OR = 1.05; 95% CI = 0.88–1.25; P -value = 0.598), sICH (OR = 0.83; 95% CI = 0.61–1.14; P -value = 0.255), or 90-day mortality (OR = 1.06; 95% CI = 0.84–1.33; P -value = 0.610). Conclusions There does not appear to be a difference in outcomes for patients undergoing left-sided or right-sided thrombectomy.

Introduction: While balloon guide catheters (BGCs) enhance safety and efficacy of mechanical thrombectomy in large vessel occlusions, their impact on distal medium vessel occlusion (DMVO) remains underexplored. This study aimed to compare the outcomes of BGC vs non-BGC in DMVO thrombectomy. Methods: This retrospective study focused on DMVO cases defined as occlusions in M2-M4 middle cerebral artery, anterior cerebral artery, and posterior cerebral artery. Baseline characteristics and technical and clinical outcomes were compared between the two groups, with subgroup analysis in first-line thrombectomy techniques, including ADAPT, stent retriever, and Solumbra. First pass effect (FPE) was defined as a modified Thrombolysis in Cerebral Infarction (mTICI) score ≥ 2C after the first pass. Results: A total of 1,508 patients were included, of whom 231 (15.3%) were in the BGC group and 1,277 (84.7%) were in the Non-BGC group. The BGC group was associated with a lower mTICI score ≥ 2C (overall: 43.2% vs. 52.7%, p = 0.01; ADAPT: 42.2% vs. 57.1%, p = 0.01; Solumbra: 32.4% vs. 51.4%, p = 0.005), longer puncture to intracranial access time (overall: 15 vs. 8 min, p < 0.001; ADAPT: 17 vs. 8 min, p < 0.001; Solumbra: 12 vs. 8 min, p = 0.02), and longer puncture to recanalization time (overall: 97 vs. 35 min, p < 0.001; ADAPT: 100 vs. 28 min, p < 0.001; Solumbra: 78 vs. 46 min, p < 0.001; Stent retriever: 95 vs. 45 min, p < 0.001 ). The BGC group also had a lower FPE rate (17.4% vs. 30.7%, p = 0.03) in the Solumbra subgroup. In terms of clinical outcomes, the BGC group had a lower rate of distal embolization (overall: 8.8% vs. 14.9%, p = 0.02), but there were no significant differences in other clinical outcomes between the two groups in first-line thrombectomy techniques. Conclusions: Our findings showed that the use of BGC in DMVO had a lower mTICI score, reduced FPE rates, decreased distal embolization, and longer procedure times. Figure 1: Figure 2:

Background The modified Rankin Scale (mRS) score of ≤2 (functional independence) has been the most common primary endpoint of modern mechanical thrombectomy (MT) trials. However, unlike mRS 0-1, mRS score of 2 indicates disability. An important proportion of the mRS 2 patients are home dependent and report a significant decrease in their quality of life. Purpose To investigate excellent outcome (mRS 0-1) rates after MT. Methods We systematically searched Ovid MEDLINE, Ovid EMBASE, Cochrane Central Register of Controlled Trials, Scopus, and Web of Science databases. Randomized controlled trials (RCTs) investigating the role of modern MT in acute ischemic stroke were screened. Posterior circulation and large-core infarct trials were excluded from the study. The data regarding excellent outcomes (mRS: 0-1), functional independence (mRS: 0-2), and reperfusion were collected. Results Twenty-two RCTs comprising 5692 patients were included in the meta-analysis. The overall mRS 0-1 rate was 31.24% (95% CI = 26.95–36.2). The rate of successful reperfusion was 81.8% (95% CI = 77.93–85.86). MT achieved significantly higher rates of mRS 0-1 compared to standard care alone (OR = 2.04; 95% CI = 1.64–2.55; P-value < 0.001), with no heterogeneity detected among studies (I 2 = 0%; P-value = 0.52). The direct MT and MT plus intravenous thrombolytic treatment groups’ excellent outcome rates were comparable (OR = 0.98; 95% CI = 0.82–1.18; P-value = 0.863). Also, aspiration and stent retriever thrombectomy techniques provided similar excellent outcome rates (OR = 0.76; 95% CI = 0.55–1.05; P-value = 0.141). Conclusions Our results prove the additional benefit of MT over standard care, using a stricter definition for favorable functional outcome. Nearly one-third of patients presenting with large artery occlusion and treated with MT had no disability at 90 days. While this is remarkable, our results also indicate that reperfusion alone is often not enough to prevent disability and underline the need for better neuroprotection strategies.

Background Although direct contact aspiration has emerged as one of the leading techniques for mechanical thrombectomy (MT), there is still ongoing debate about the aspiration/suction pump devices that can optimize recanalization rates. To address this gap, we conducted a meta-analysis comparing the aspiration efficacy of 60 ml syringe and pump devices in benchtop MT models. Methods Systematic literature review was conducted using Medline, Embase, Web of Science, and Scopus in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Outcomes of interest included flow rate and vacuum pressure delivered by a 60 ml syringe and several aspiration pumps. We used a random effects model to calculate the mean difference (MD) with 95% confidence intervals (CIs) and a statistically significant difference was considered as a two-sided p -value of less than 0.05. Results We included six benchtop studies comparing 60 ml syringes and vacuum pumps. Our meta-analysis showed that there were no significant differences in vacuum pressure (MD:0.71inHg, 95% CI: [−0.81;2.23], p = 0.359) and flow rate (MD:0.27 mL/s, 95% CI: [−3,07; 3.61], p = 0.873) between 60 ml syringes and vacuum pumps groups. Conclusions Our study demonstrated comparable performance in terms of vacuum pressure and flow rates between a 60 ml syringe and a heterogeneous combination of commercially available aspiration pumps.

Background The comparison of mechanical thrombectomy (MT) outcomes between patients with the hyperdense middle cerebral artery sign (HMCAS) and non-HMCAS is important to evaluate the impact of this radiological finding on treatment efficacy. This meta-analysis aimed to assess the association between HMCAS and clinical outcomes in patients undergoing thrombectomy, comparing the outcomes over non-HMCAS. Methods A systematic literature search was conducted in PubMed, Ovid Embase, Google Scholar, and Cochrane Library to identify studies on MT outcomes for M1 occlusions of HMCAS over non-HMCAS. Inclusion criteria encompassed modified Rankin Scale (mRS) score, mortality, symptomatic intracranial hemorrhage (sICH), and successful recanalization. Using R software version 4.1.2, we calculated pooled odds ratios (ORs) and their corresponding 95% confidence intervals (CI). Results The meta-analysis was performed for 5 studies with 724 patients. There was no association found between presence of HMCAS and achieving mRS 0–2 (OR = 0.65, 95% CI: 0.29–1.47; p = .544). Mortality analysis also showed no significant association with presence of HMCAS (OR = 0.78, 95% CI: 0.37–1.65; p = .520). No significant difference in sICH risk (OR = 1.54, 95% CI: 0.24–9.66; p = .646) was found between groups. Recanalization analysis showed a non-significant positive association (OR = 1.23, 95% CI: 0.67–2.28; p = .501). Heterogeneity was observed in all analyses. Conclusion Our findings showed that there is no statistically significant difference in mRS scores, mortality, sICH, and recanalization success rates between the HMCAS and non-HMCAS groups.

Background Cervicofacial arteriovenous malformations (AVMs) are a significant source of morbidity. Endovascular embolization has emerged as a promising treatment technique for these lesions. However, current literature on cervicofacial AVM embolization mostly consists of single-agent oriented case series, and to date, no comprehensive study has compared the outcomes of available embolic agents. Purpose To investigate the performance of different embolic agents in the management of cervicofacial AVMs. Methods We systematically searched Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials Scopus, and Web of Science. Studies providing data for the endovascular treatment of cervicofacial AVMs were included. The data regarding complication and cure rates were collected for each embolic agent. Pooled event rates were presented as descriptive statistics. Results Eleven studies comprising 204 patients were included in the review. The overall complete and partial cure rates were 62.2% (127/204) and 36.2% (74/204), respectively. Embolization failed to achieve significant improvement in only 1.6% (3/204) of the patients. The complete cure rates were 87.5% (75–100%) for n-Butyl cyanoacrylate (NBCA, glue), 80.5% (61–100%) for Onyx (Medtronic, MN, USA), and 51.5% (18–85%) for ethanol. The overall complication rate was 30% (61/204). The complication rates were 33% (12.5–53%) for ethanol, 14% (0–28%) for Onyx, and 0% for NBCA. Conclusions Our systematic review supports that endovascular embolization is an effective treatment option for cervicofacial AVMs. In our review, the use of Onyx and NBCA was associated with consistently high complete cure rates and a promising safety profile. However, more research is needed to investigate the use of different embolic agents in the treatment of cervicofacial AVMs.

Background Distal transradial artery access (dTRA) has received increasing consideration for performing diagnostic cerebral angiography and neurointerventional procedures. In this meta-analysis, we aim to evaluate the safety and efficacy of dTRA compared to conventional transradial access (cTRA) for cerebral angiography and neurointerventions. Method A systematic review and meta-analysis were conducted on studies investigating outcomes of dTRA and cTRA in neurointerventions. The primary outcome was technical success rates. Secondary outcomes included access site complication rates, crossover rates to alternative vessels, fluoroscopy time, and contrast volume. The random effects model was used to calculate the mean difference (MD) and odds ratios (OR) with 95% confidence intervals (Cl). Results Eight retrospective observational studies with a total of 1477 patients who underwent 1175 diagnostic cerebral angiography and 516 neurointerventional procedures using 546 dTRA and 1164 cTRA approaches were included in our meta-analysis. The technical success rate was similar between dTRA and cTRA groups (95.8% vs 91.4%; OR:1.65; 95% Cl: 0.52 to 5.22; P = 0.40). Similarly, no difference was seen in dTRA and cTRA regarding access site complications (2% vs 1.4%; OR: 1.31; 95% CI: 0.47 to 3.61; P = 0.61) and access site crossover (2.1% vs 5.3%; OR: 0.55; 95% Cl: 0.28 to 1.05; P = 0.07). After resolving heterogeneity among included studies, dTRA was associated with a shorter fluoroscopy time (MD: −0.91 min; 95% CI: −1.74 to −0.09; P = 0.03) and lower contrast volume (MD: −8.32 mL; 95% CI = −14.7 to −1.94; P = 0.011). Conclusion Our findings suggest that the dTRA approach is a safe and effective alternative to the cTRA approach in patients undergoing cerebral angiography and neurointerventions.

Background The Woven EndoBridge (WEB) device is used to treat wide-neck bifurcation aneurysms (WNBAs). We conducted a systematic review and meta-analysis to determine the retreatment rate strategies following aneurysmal recurrence of WEB device treated WNBAs. Methods This study is reported following the PRISMA 2020 guidelines. We conducted a systematic review of the literature using PubMed, Scopus, Embase, and Web of Science. Data were pooled using a random-effects model. We calculated pooled prevalence and corresponding 95% confidence intervals (CI). Results We included 11 studies. The overall retreatment rate was 171/1875 aneurysms (10.3%; 95% CI = 8.3–12.9). Stent-assisted coiling was used to treat 59 aneurysms (36.7%; 95% CI = 26.4–48.5), and flow diverters were used to treat 44 aneurysms (18.7%; 95% CI = 9.9–32.5). Following retreatment, the complete occlusion rate was 57/91 aneurysms (62.8%; 95% CI = 48.2–75.3) and the adequate occlusion rate was 24/91 aneurysms (26.4%; 18.4%–36.4%). The most common aneurysmal recurrence site was the anterior communicating artery (44/136 aneurysms, 32.4%; 95% CI = 25.0–40.7). Conclusions Roughly 10% of WNBAs initially treated with the WEB device will undergo retreatment. Retreatment is an effective strategy for WEB-treated aneurysms, with high rates of adequate and complete occlusion. Future studies should work to identify risk factors for aneurysmal recurrence.