Citations

Background and purpose The Alberta Stroke Program Early CT Score (ASPECTS) is a commonly used scoring system to select patients with stroke for endovascular treatment (EVT). However, the inter- and intra-reader variability is high. Objective To determine whether the inter- and intra-reader variability is different for various regions of the ASPECTS scoring system by evaluating the interobserver variability of ASPECTS between different readers in a per-region analysis. Materials and methods All patients with acute ischemic stroke who proceeded to EVT in our institutions over a 4-year period were retrospectively identified from a prospectively maintained database. Images were reviewed by two experienced neuroradiologists, who recalculated the ASPECTS independently. We examined each region of the ASPECTS system to evaluate agreement between the raters in each area. Results 375 patients were included. The median total ASPECTS was 9 (IQR 8–9). The most common region showing ischemic change was the insula, with the M6 region being least commonly affected. Overall interobserver agreement for ASPECTS using Cohen’s κ was 0.56 (95% CI 0.51 to 0.61). The region with the highest agreement was the insula (κ=0.56; 0.48 to 0.64). The region with the lowest agreement was M3 (κ=0.34; 0.12 to 0.56). Agreement was relatively good when ASPECTS were dichotomized into 0–5 versus 6–10 (κ=0.66; 0.49 to 0.84). Conclusions Substantial interobserver variability is found when calculating ASPECTS. This variability is region dependent, and practitioners should take this into account when using ASPECTS for treatment decisions in patients with acute stroke.

Background and purpose Cervical internal carotid artery (ICA) tortuosity is thought to impede distal catheterization during attempted mechanical thrombectomy in patients with acute ischemic stroke. This study sought to assess the morphologic characteristics of ICAs and the effects of tortuosity on thrombectomy attempts. Methods A retrospective review was completed of neck CTAs of patients with acute ischemic stroke due to a large vessel occlusion that underwent attempted endovascular recanalization. Significant tortuosity of ICAs was defined as the presence of kink(s) (acute (<90°) angulation), loop(s) (C- or S-shaped curvature with 2+ areas of acute (<90°) angulation), or coil(s) (full 360° turn arterial bend). Findings were statistically compared to procedure time, successful recanalization rate, patient demographics, and co-morbidities. Results Of 120 included patients, 47 (39.2%) had some form of tortuosity of one or both ICAs. Twenty-eight patients (23.3%) had a kink of one or both ICAs; this was followed in frequency by loops (n = 20; 16.7%) and coils (n = 8; 6.7%). Kinks were associated with lower rates of successful recanalization (p = 0.02). The presence of any tortuosity (kinks, loops, or coils) was not associated with number of passes during thrombectomy (p = 0.88), successful recanalization (p = 0.11), or total procedure time (p = 0.22). No association was noted between the presence of tortuosity and age (p = 0.96) or prior or current tobacco use (p = 0.75 and p = 0.69, respectively). Conclusion Among patients referred for urgent revascularization for large vessel occlusion, approximately 40% exhibit some tortuosity. Kinks may portend lower likelihood of recanalization success, although tortuosity as a whole seems to have little effect on endovascular thrombectomy.

Abstract Flow diverters have drastically changed the landscape of intracranial aneurysm treatment and are now considered first-line therapy for select lesions. Their mechanism of action relies on intrinsic alteration in hemodynamic parameters, both at the parent artery and within the aneurysm sac. Moreover, the device struts act as a nidus for endothelial cell growth across the aneurysm neck ultimately leading to aneurysm exclusion from the circulation. In silico computational analyses and investigations in preclinical animal models have provided valuable insights into the underlying biological basis for flow diverter therapy. Here, we review the present understanding pertaining to flow diverter biology and mechanisms of action, focusing on stent design, induction of intra-aneurysmal thrombosis, endothelialization, and alterations in hemodynamics.

Background Preliminary clinical studies on the safety and efficacy of the pipeline embolization device (PED) for the treatment of small/medium aneurysms have demonstrated high occlusion rates with low complications. Objective To evaluate the safety and effectiveness of the PED for treatment of wide necked small and medium intracranial aneurysms. Methods PREMIER is a prospective, multicenter, single arm trial. Patients were treated with the PED for unruptured wide necked aneurysms, measuring ≤12 mm along the internal carotid artery or vertebral artery, between July 2014 and November 2015. At 1 year post-procedure, the primary effectiveness endpoint was complete occlusion (Raymond grade 1) without major parent vessel stenosis (≤50%) or retreatment, and the primary safety endpoint was major stroke in the territory supplied by the treated artery or neurologic death. Results A total of 141 patients were treated with PEDs (mean age 54.6±11.3 years, 87.9% (124/141) women). Mean aneurysm size was 5.0±1.92 mm, and 84.4% (119/141) measured <7 mm. PED placement was successful in 99.3% (140/141) of patients. Mean number of PEDs implanted per patient was 1.1±0.26; a single PED was used in 92.9% (131/141) of patients. At 1 year, 97.9% (138/141) of patients underwent follow-up angiography with 76.8% (106/138) of patients having met the study’s primary effectiveness endpoint. The combined major morbidity and mortality rate was 2.1% (3/140). Conclusions Treatment of wide necked small/medium aneurysms with the PED results in high rates of complete occlusion without significant parent vessel stenosis and low rates of permanent neurologic complications. Trial registration NCT02186561 .