Citations

Abstract BACKGROUND Recent randomized control trials (RCTs) established that mechanical thrombectomy is superior to medical therapy for patients with stroke due to a large vessel occlusion. OBJECTIVE To compare the safety and efficacy profile of the different mechanical thrombectomy strategies. METHODS A random-effects meta-analysis was performed and the I 2 statistic was used to assess heterogeneity according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. RESULTS Nineteen studies with a total of 2449 patients were included. No differences were identified between the stent retrieval and direct aspiration groups in terms of modified Thrombolysis in Cerebral Infarction (mTICI) 2b/3 and mTICI 3 recanalization rates, and favorable outcomes (modified Rankin Scale [mRS] ≤ 2). Adverse event rates, including 90-d mortality, symptomatic intracerebral hemorrhage (sICH), and subarachnoid hemorrhage (SAH), were similar between the stent retrieval and direct aspiration groups. The use of the stent retrieval was associated with a higher risk of vasospasm (odds ratio [OR]: 2.98; 95% confidence interval [CI]: 1.10-8.09; I 2 : 0%) compared to direct aspiration. When compared with the direct aspiration group, the subgroup of patients who underwent thrombectomy with the combined approach as a first-line strategy had a higher likelihood of successful mTICI 2b/3 (OR: 1.47; 95% CI: 1.02-2.12; I 2 : 0%) and mTICI 3 recanalization (OR: 3.65; 95% CI: 1.56-8.54), although with a higher risk of SAH (OR: 4.33; 95% CI: 1.15-16.32). CONCLUSION Stent retrieval thrombectomy and direct aspiration did not show significant differences. Current available evidence is not sufficient to draw conclusions on the best surgical approach. The combined use of a stent retriever and aspiration as a first-line strategy was associated with higher mTICI 2b/3 and mTICI 3 recanalization rates, although with a higher risk of 24-h SAH, when compared with direct aspiration.

Abstract Spinal cord meningiomas are rare, benign lesions typically found at the cervical or thoracic spinal region. They can cause symptoms through compression of the spinal cord and nerve roots. These tumors often have a challenging surgical course due to their location in relation to spinal cord and nerve rootlets. We present a 33-yr-old female who presented with cervical radicular and myelopathy symptoms. MRI of the cervical spinal demonstrated an anterolateral, 3 cm intradural, extrameduallary tumor causing significant cord compression at C6-7 level. The patient was taken to surgery for cervical laminoplasty and microsurgical tumor removal. The current 3-dimensional video demonstrates the steps involved during the microsurgical resection of the tumor. In order to facilitate spinal cord rotation without compromising blood supply the dentate ligaments at 3 levels (C5-C7) were identified and transected, the anterolateral-situated tumor was separated from the exiting right C6 and C7 nerve rootlet followed by circumferential dissection, and subsequent en bloc resection. No complications were encountered during the procedure; somatosensory and motor evoked potential registration remained intact. The patient recovered well from the procedure and was discharged on postoperative day three with improvement in her presenting symptoms.

An 80-year-old female presented with a long history of severe pulsatile tinnitus, vertigo, and decreased hearing. She was found to have a large right-sided tentorial arteriovenous fistula (AVF) with enlarged deep draining veins, including the vein of Rosenthal. The patient underwent Onyx embolization of the fistula via a combined transarterial and transvenous approach resulting in complete obliteration of the fistula. Her symptoms improved immediately after the procedure and at 6-months’ follow-up she was clinically asymptomatic with no evidence of residual fistula on neuroimaging. Transvenous embolization of AVF is at times necessary when transarterial access is not possible. The video can be found here: https://youtu.be/uOMHY7eaOoQ .

Craniocervical junction dural arteriovenous fistulas (dAVFs) are rare vascular lesions with a potentially dangerous natural history due to the onset of neurological deficit secondary to intracranial hemorrhage or myelopathy due to venous congestion. Despite advances in endovascular techniques, many dAVFs located in this area continue to require surgical treatment as embolization is often not feasible or safe. In this video, the authors illustrate a patient with a symptomatic craniocervical junction dAVF who had undergone attempted Onyx embolization at another institution. Because of persistent filling of the fistula and worsening myelopathy after the previous attempt, the patient was referred to the authors’ clinic for definitive surgical treatment. The video illustrates the typical location of the early draining vein in most craniocervical junction dAVFs immediately below the emergence of the vertebral artery from the dura. The patient underwent successful definitive clip ligation of the fistula, which was exposed through a lateral suboccipital craniotomy. The video can be found here: https://youtu.be/Bvg6VKLgwO0 .

Objectives Remote ischemic preconditioning has been proposed as a possible potential treatment for ischemic stroke. However, neuroprotective benefits of the pre-procedural administration of remote ischemic preconditioning have not been investigated in patients undergoing an elective endovascular intracranial aneurysm repair procedure. This study investigated the safety and feasibility of remote ischemic preconditioning in patients with an unruptured intracranial aneurysm who undergo elective endovascular treatment. Methods In this single-center prospective study, patients with an unruptured intracranial aneurysm undergoing elective endovascular treatment with flow diverters or coiling were recruited. Patients received three intermittent cycles of 5 minutes arm ischemia followed by reperfusion using manual blood cuff inflation/deflation less than 5 hours prior to endovascular treatment. Patients were monitored and followed up for remote ischemic preconditioning-related adverse events and ischemic brain lesions by diffusion -weighted magnetic resonance imaging within 48 hours following endovascular treatment. Results A total of seven patients aged 60 ± 5 years with an unruptured intracranial aneurysm successfully completed a total of 21 sessions of remote ischemic preconditioning and the required procedures. Except for two patients who developed skin petechiae over their arms, no other serious procedure-related adverse events were observed as a result of the remote ischemic preconditioning procedure. On follow-up diffusion -weighted magnetic resonance imaging, a total of 19 ischemic brain lesions with a median (interquartile range) volume of 245 (61–466) mm 3 were found in four out of seven patients. Conclusions The application of remote ischemic preconditioning prior to endovascular intracranial aneurysm repair was well tolerated, safe and clinically feasible. Larger sham-controlled clinical trials are required to determine the safety and efficacy of this therapeutic strategy in mitigating ischemic damage following endovascular treatment of intracranial aneurysms.

Abstract Herein, we demonstrate a case of a large, wide-necked, basilar apex aneurysm (BAA) that was treated with neck reconstruction-assisted coil embolization using the PulseRider device (PulsarVascular, Los Gatos, California), a novel neck-reconstruction device. A 68-yr-old man was found to have large BAA during work-up for sinusitis. Computed tomography angiogram revealed an 11 × 10-mm BAA. Patient has history of coronary artery disease, atrial fibrillation (currently taking Warfarin), recent left hip replacement and right femoral bypass. Treatment of the aneurysm was advised due to its location and size. Microsurgical clip reconstruction was high risk for general anesthesia due to his medical comorbidities and anticoagulation. Wide-necked bifurcation aneurysms are challenging to treat with traditional balloon- or stent-assisted techniques. To mitigate these challenges, novel neck-reconstruction devices have been developed. The Pulsar is one of these neck-reconstruction devices that removes the need to selectively catheterize branch arteries; it is available in a “Y” and “T” configuration. Under conscious sedation and through a radial artery approach, the patient underwent endovascular reconstruction of BAA with Pulsar device and coils. A 6-Fr guide catheter, a 0.021" microcatheter for the Pulsar device and a 0.017" microcatheter for coil delivering were used. A 3 × 8.6 mm Pulsar device was selected based on aneurysm neck and basilar artery measurements. Complete embolization (Raymond-Roy 1 obliteration) of the aneurysm was successfully achieved with no complications. The patient remained neurologically intact and was discharged on postoperative day 1. Parts of this video were published in Intracranial Aneurysms (1st Edition), Ringer (Ed), online companion to chapter 33B, Copyright Elsevier (2018).

Purpose: To examine the safety profile of transcervical access (TCA) in comparison with the transfemoral approach (TFA) in carotid artery stenting. Materials and Methods: A systematic review and meta-analysis was performed according to current guidelines. Eleven eligible studies including 11,592 patients (10,736 in the TFA group and 856 in the TCA group) were identified through a search of the PubMed, Scopus, and Cochrane databases up to October 2018. A random effects model meta-analysis was conducted, and the I 2 statistic was used to assess heterogeneity. Publication bias was assessed using funnel plots and quantified using the Egger method. Results: The TFA group had a statistically significantly higher risk of periprocedural (30-day) stroke compared with the TCA group (OR 1.98, 95% CI 1.08 to 3.63, p=0.027; I 2 =0%). Also, patients in the TFA group had a significantly higher risk of developing new ischemic lesions (OR 2.97, 95% CI 1.48 to 5.96, p=0.002; I 2 =0%) on diffusion-weighted magnetic resonance imaging (DW-MRI). No differences in terms of transient ischemic attack (OR 1.50, 95% CI 0.73 to 3.10, p=0.268; I 2 =5.9%), myocardial infarction (OR 0.64, 95% CI 0.30 to 1.35; p=0.242; I 2 =0%), local hematoma (OR 0.53, 95% CI 0.12 to 2.25, p=0.389; I 2 =0%), or mortality (OR 1.35, 95% CI 0.62 to 2.92, p=0.449; I 2 =0%) were identified between the groups. Conclusion: TCA is associated with a significantly lower risk for periprocedural stroke and DW-MRI ischemic lesions compared with TFA. Other periprocedural outcomes were similar between the groups.

Cerebral protection device utilization during carotid artery stenting (CAS) has been demonstrated to decrease the risk of perioperative stroke. The ProximAl Protection with the MO.MA Device During CaRotid Stenting (ARMOUR) Trial had the lowest event rates of any independently adjudicated study. In this video of two cases of severe carotid artery stenosis, the authors present the nuances of the CAS procedure utilizing a dual-balloon guide catheter device (MO.MA). This device has the benefit of being in place before the lesion is crossed with any device, being able to arrest flow while the atherosclerotic lesion is crossed, and aiding in protection from distal emboli and stroke. The video can be found here: https://youtu.be/0o8DlC1n6_M .

Transvenous embolization (TE) has been increasingly applied for arteriovenous malformation (AVM) treatment. Transient cardiac standstill (TCS) has been described in cerebrovascular surgery but is uncommon for endovascular embolization. The authors present a patient with a ruptured thalamic AVM in whom both techniques were applied simultaneously. Surgery was considered, but the patient refused. Transarterial embolization was performed with an incomplete result. The deep-seated draining vein provided sole access to the AVM. A microcatheter was advanced into the draining vein. Under TCS, achieved with rapid ventricular pacing, complete AVM embolization was obtained. One-year magnetic resonance imaging and cerebral angiography demonstrated no residual AVM. The video can be found here: https://youtu.be/CAzb9md_xBU .