neurovascular-nuggets

Neurovascular-Nugget 26

"Navigating Complexities in Aneurysm Treatment: Join Us at the 9th MENA-SINO Conference!" #MENASINO Saruhan Cekirge ISIL SAATCI

Call for Clinical Case Submissions for the 9th MENA-SINO Conference! We are excited to announce the call for clinical case submissions for the upcoming 9th MENA-SINO Conference in Alexandria from September 25-27. This is a fantastic opportunity to showcase your expertise and contribute to the collective knowledge of our community. Categories for Case Submissions: Acute Ischemic Stroke (AIS) Primary Prevention Secondary Prevention Rehabilitation Endovascular Treatment (EVT) of AIS EVT in Aneurysm EVT in Arteriovenous Malformation (AVM) Other How to Submit: Submit your detailed case through our SurveyMonkey questionnaire. Make sure to include a comprehensive summary, key learning points, diagnostic and treatment details, and any relevant images or data. Submission Deadline: 31 August 2024 Link to Submit Your Case: https://lnkd.in/grVZgHKT Don't miss this chance to be part of a prestigious event and share your valuable insights with peers from around the world. Submit your case now and contribute to the advancement of our field! Thank you for your participation and support. We look forward to your submissions! SVIN - Society of Vascular and Interventional Neurology European Society of Neuroradiology World Stroke Organization ESMINT Society Society of NeuroInterventional Surgery #MENA-SINO2024 #CallForCases #ClinicalExcellence #StrokeConference #EndovascularTreatment

Neurovascular-Nugget 25 Reading of this manuscript may reflect 🎹 Key Findings: 🎹 ### Main Points ### #### Study Overview 👆**Objective:** Evaluate the safety and effectiveness of single-stent assisted coiling (L-stenting) in treating wide-neck bifurcation aneurysms (WNBAs). 👆 **Methods:** Retrospective study of 128 patients treated between 2015-2019 at three academic institutions. Angiographic imaging was evaluated by a core lab for accuracy. 👆 **Results:** 👆 **Patients:** 128 patients; 124 had follow-up angiographic data. 👆 **Outcomes:** - 88.7% had adequate occlusion (mRR 1 or 2). - 14.8% required retreatment. - Complications in 9.4% of patients, with 6.25% intraoperative SAEs. - **Predictors of Success:** Smaller aneurysm size and use of the transcellular technique. - **Predictors of Retreatment:** Larger aneurysm size, neck size, and dome to neck ratio. 👆 **Follow-Up:** Mean follow-up of 15.8 months. ### Main Points 🛜. **Effectiveness:** - High rate of adequate occlusion (88.7%). - 59.4% complete occlusion at last follow-up. 🛜. **Safety:** - 17 complications in 12 patients (9.4%). - No intraoperative or periprocedural aneurysmal ruptures. 🛜. **Technique:** - Single-stent L-stenting is effective and reduces the amount of metal used compared to dual-stent techniques. 🛜. **Comparison:** - Favorable outcomes compared to other techniques like Y-stenting and new devices like the WEB device. 🛜. **Predictors:** - Smaller aneurysm size and transcellular technique predict better outcomes. - Larger size and dome to neck ratio predict higher retreatment rates. ### Clinical Implications ### ✅**Treatment Choice:** - Single-stent L-stenting presents a viable alternative to dual-stent techniques, potentially reducing thromboembolic complications and procedural costs. ✅ **Patient Selection:** - Patients with smaller aneurysms and those suitable for the transcellular technique may benefit most from L-stenting. ✅ **Procedure Planning:** - Understanding predictors of success and retreatment can aid in better patient selection and pre-procedural planning. ✅ **Benchmarking:** - This study provides a validated comparator for future studies on new devices and techniques for WNBAs, setting a benchmark for efficacy and safety. ✅ **Cost Considerations:** - L-stenting could be more cost-effective due to the reduced use of stents and lower complication rates, though further studies are needed to confirm this. https://lnkd.in/dU984vPT

Neurovascular-Nugget 24 Reading of this manuscript may reflect 🎹 Key Findings: 🎹 Main Points ☝️ Background: - Acute ischemic stroke (AIS) due to isolated posterior cerebral artery occlusion (iPCAO) lacks robust management guidelines from randomized trials. ☝️ Methods: - This was a multicenter, retrospective, case-control study from the PLATO cohort, including 1,059 patients with iPCAO. - Patients were assessed based on initial stroke severity (NIHSS ≤6 vs. >6) and occlusion site (P1 vs. P2 segment). - The primary outcome was the shift in the modified Rankin Scale (mRS) at 3 months. Secondary outcomes included excellent outcome (mRS 0-1), functional independence (mRS 0-2), symptomatic intracranial hemorrhage (sICH), and mortality. ☝️ Results: - Baseline NIHSS: - EVT was associated with better outcomes in patients with baseline NIHSS >6 compared to those with NIHSS ≤6. - In patients with NIHSS >6, EVT resulted in higher rates of excellent outcome (30.6% vs. 17.7%) and functional independence (46.1% vs. 31.9%) compared to MM. - Patients with NIHSS ≤6 did not benefit significantly from EVT in terms of functional independence or excellent outcomes. - EVT was associated with more sICH and increased mortality, particularly in patients with NIHSS ≤6. - Occlusion Site: - The site of occlusion (P1 vs. P2 segment) did not significantly modify the outcomes of EVT versus MM. - Patients with P1 occlusions had higher baseline NIHSS scores and were more frequently treated with EVT than those with P2 occlusions. ✅ Clinical Implications✅ 🎈 Patient Selection for EVT: Moderate to Severe Strokes (NIHSS >6)**: - EVT should be considered more strongly for patients with higher NIHSS scores, as the benefits in terms of functional outcomes and excellent outcomes are more pronounced. - However, clinicians must weigh these benefits against the risks of sICH and increased mortality. Mild Strokes (NIHSS ≤6)**: - Caution should be exercised when considering EVT for patients with mild deficits, given the lack of significant benefit and the higher risk of complications. 🎈 **Treatment Strategy**: - The decision to pursue EVT should incorporate baseline NIHSS scores to optimize patient outcomes. - For patients with mild strokes, MM might be preferable to avoid the higher procedural risks associated with EVT. 🎈 **Risk Management**: - Given the higher risk of sICH and mortality associated with EVT, especially in patients with lower NIHSS scores, thorough risk assessment and patient counseling are essential. - Strategies to mitigate these risks should be developed and implemented in clinical practice. https://lnkd.in/d95VhcuU

Neurovascular-Nugget 23 Reading of this manuscript may reflect 🎹 Key Findings: 🎹 👆Introduction: - IH frequently complicates CVT, affecting around 40% of patients acutely and 10% long-term. - IH is associated with severe outcomes, including visual loss and increased morbidity and mortality. - The study aimed to evaluate the diagnostic performance, reversibility, and factors influencing normalization of neuroimaging indicators in CVT patients. 👆 Methods: - The study included 26 acute CVT patients and 26 healthy controls. - Patients were classified as having IH based on CSF pressure > 25 cmH₂O, papilledema, or optic disc protrusion on ocular MRI. - Various neuroimaging signs such as optic nerve sheath diameter (ONSD), optic nerve tortuosity, bulbar flattening, and ventricle size were assessed at baseline and follow-up. 👆Results: - Prevalence: 46% of CVT patients had IH. - Diagnostic Performance**: ONSD enlargement > 5.8 mm, optic nerve tortuosity, and pituitary grade ≥ III were the most sensitive indicators, while ocular bulb flattening and pituitary grade ≥ III had the highest specificity. - Reversibility: ONSD and pituitary grade were significantly associated with recanalization. However, some indicators like ONSD enlargement and partially empty sella persisted even after treatment. - Follow-up: ONSD size and pituitary grade significantly improved but did not reach normal control levels. Other neuroimaging signs showed variable degrees of reversibility. ✅Clinical Implications✅ 🎈Diagnosis and Monitoring: - Neuroimaging indicators like ONSD and pituitary grade are valuable for diagnosing and monitoring IH in CVT patients. - High specificity indicators (ocular bulb flattening, pituitary grade) can indicate a low probability of IH when absent. 🎈Management of IH: - Persistent neuroimaging signs post-treatment necessitate continuous monitoring and potentially extended anticoagulation therapy. - The results support the use of non-invasive methods such as ONSD measurement for ongoing assessment of CVT-related IH. 🎈Clinical Decision-Making: - Neuroimaging indicators should be considered alongside clinical presentation and other IH risk factors to guide diagnostic and therapeutic decisions. - In cases of persistent IH indicators without symptoms, non-invasive follow-up methods should precede invasive procedures like lumbar puncture. 🎈Treatment Duration: - Individualized counseling on anticoagulation duration is necessary, especially in patients with incomplete recanalization. - The findings suggest that the optimal duration of anticoagulation remains uncertain and should be tailored based on recanalization status and IH indicators. https://lnkd.in/dHCCTvBH

Neurovascular-Nugget 22 Reading of this manuscript may reflect 🎹 Key Findings: 🎹 Study Population: The study included 1326 patients with poor-grade aSAH (WFNS grade III-V), divided into SC (847 patients) and EC (479 patients) groups. Propensity score matching (PSM) was used to create matched cohorts of 316 patients each for SC and EC. 🔔 Clinical Outcomes: Unfavorable Clinical Outcomes: Before PSM, unfavorable clinical outcomes (mRS scores 3-6) were 72.0% for SC and 66.2% for EC (P = .026). After PSM, these were 70.6% for SC and 63.3% for EC (P = .025). In-Hospital Mortality: Before PSM, in-hospital mortality was significantly higher for EC (16.1%) compared to SC (10.5%, P = .003). After PSM, the difference was not significant (EC: 12.7%, SC: 10.4%, P = .384). 🎤 Predictors of Unfavorable Outcomes: 🥁 Common Predictors: WFNS grade V, age older than 70 years, and Fisher CT grade 4 were predictors of unfavorable outcomes in both SC and EC groups. 🥁 SC-Specific Predictors: WFNS grade IV and Fisher CT grade 3 were associated with unfavorable outcomes only in the SC group. 🥁 EC-Specific Predictors: Ages in the 50s and 60s were associated with unfavorable outcomes only in the EC group. 🎤 Conclusion: EC was associated with significantly more favorable clinical outcomes than SC in patients with poor-grade aSAH, without significant differences in in-hospital mortality after PSM. The benefit of EC over SC might be particularly notable in patients with WFNS grade IV and Fisher CT grade 3. 📣 📣 Implications on Clinical Practice ✅ Treatment Strategy Shift: The findings suggest that EC may be preferred over SC for patients with poor-grade aSAH due to better clinical outcomes at discharge. This could lead to a shift in treatment protocols favoring EC, especially in high-risk cases. ✅ Patient Selection: Clinicians might consider WFNS grade IV and Fisher CT grade 3 as indicators for opting for EC over SC. Understanding the specific predictors of unfavorable outcomes can help tailor treatment plans to individual patient profiles, potentially improving overall outcomes. ✅ Age Considerations: With older age being a significant predictor of unfavorable outcomes, more careful consideration and possibly more aggressive management might be necessary for elderly patients undergoing either EC or SC. ✅ Resource Allocation: High-volume cerebrovascular centers equipped to perform both SC and EC may need to allocate more resources and training towards enhancing EC capabilities, given its demonstrated advantages. ✅ Guideline Revisions: The study’s results might influence revisions of existing guidelines from bodies such as the American Heart Association/American Stroke Association and European Stroke Organization to reflect the potential superiority of EC in poor-grade aSAH cases.

Neurovascular-Nugget 21 Reading of this manuscript may reflect Main Points: - For the second thrombectomy pass, switching from stent retriever to the combined technique was associated with higher chances of complete reperfusion compared to repeating stent retriever, while switching to aspiration alone was not. - For the second pass, switching from aspiration to the combined technique was associated with higher chances of complete reperfusion compared to repeating aspiration, while switching to stent retriever alone was not. - For the third pass after two failed stent retriever passes, switching to the combined technique was associated with higher chances of complete reperfusion compared to switching to aspiration or repeating stent retriever. - After two failed aspiration passes, switching to the combined technique for the third pass was associated with higher chances of complete reperfusion compared to repeating aspiration, while switching to stent retriever was not. - After two failed passes with the combined technique, switching to aspiration for the third pass was associated with lower chances of complete reperfusion compared to repeating the combined technique, while switching to stent retriever alone was not. - The combined technique achieved earlier complete reperfusion compared to aspiration alone when analyzing the first three passes. - No differences in functional outcomes were seen based on technique switching. Critiques of Methodology: - Retrospective analysis with its inherent limitations. - No central adjudication of angiographic outcomes. - Heterogeneity in devices and techniques used between centers and operators. - Limited sample sizes for some technique comparisons. - Did not evaluate impact of technique switching on clinical outcomes. Clinical Implications: - Early switching to the combined technique after failed standalone stent retriever or aspiration passes may improve reperfusion rates. - Repeating the same standalone technique after failed passes may not improve reperfusion as much as early switching. - More data needed to confirm impact on clinical outcomes.

Neurovascular-Nugget 20 the main points from the article: - Recent trials have shown endovascular therapy (EVT) can be effective for patients with large ischemic cores, but optimal imaging modality to define large core is unclear. - This study compares CT perfusion (CTP) vs non-contrast CT Alberta Stroke Program Early CT Score (ASPECTS) for predicting outcomes after EVT. Methods - Retrospective analysis of 1115 EVT patients from international stroke registry who had CTP and non-contrast CT. - Large core defined as CTP core volume ≥70mL or ASPECTS ≤5. - Primary outcome was poor functional outcome (modified Rankin Scale 5-6) at 3 months. Results - CTP core ≥70mL better predicted poor outcome after EVT than ASPECTS ≤5. - CTP core ≥70mL consistently predicted poor outcome <6 hours and >6 hours from stroke onset. - ASPECTS ≤5 under-predicted poor outcome <6 hours but predicted outcome >6 hours. - CTP ≥70mL better predicted poor outcome than ASPECTS ≤5 in time window ≤6 hours. Discussion - CTP-defined large core better predicts poor outcome after EVT than ASPECTS-defined large core. - CTP core ≥70mL more consistently predicts poor outcome regardless of time window. - ASPECTS may under-estimate large core in early window due to reversible ischemia. - Study suggests functional outcomes may improve if CTP used for patient selection in early window. Limitations: - Retrospective cohort study with selection bias - Small sample sizes in some subgroups - Qualitative ASPECTS scoring without software Overall, the study provides evidence that CTP-defined large core is more accurate than ASPECTS for predicting poor outcome after EVT, especially within 6 hours of stroke onset. The findings suggest CTP may be better for patient selection in the early time window. World Stroke Organization Middle East North Africa stroke and interventional neurotherapies organization ( MENA-SINO ) European Society of Neuroradiology

Neurovascular-Nugget 19 Main points of the article  ➤Methods: Fresh thrombi were collected from acute ischemic stroke patients undergoing thrombectomy. Each thrombus was divided into two parts, one for thrombolysis and the other for histological analysis. Thrombolysis was performed in normal human plasma at 37°C using either r-tPA alone, r-tPA + DNase-1, or r-tPA + N,N'-diacetyl-L-cystine (diNAC). Thrombus weight was measured over time to calculate percent lysis. Histological analysis quantified the content of red blood cells (RBCs), platelets, fibrin, von Willebrand Factor (VWF), and DNA in each thrombus. The degree of r-tPA-mediated lysis was correlated with the histological composition of each thrombus. Thrombi were classified as RBC-rich or RBC-poor based on the median RBC content. ➤Results: r-tPA effectively lysed thrombi overall compared to control (no r-tPA), but there was significant variability in lysis between individual thrombi. The effectiveness of r-tPA strongly correlated with thrombus composition: a. RBC content positively correlated with r-tPA-mediated lysis. b. VWF and DNA content negatively correlated with r-tPA-mediated lysis. RBC-rich thrombi were highly susceptible to r-tPA, while RBC-poor thrombi, which had higher platelet, VWF, and DNA content, were resistant to r-tPA. Combining r-tPA with either DNase-1 or diNAC significantly improved lysis of RBC-poor, r-tPA-resistant thrombi, but did not further enhance lysis of RBC-rich thrombi compared to r-tPA alone. The combination of r-tPA, DNase-1, and diNAC did not show additional benefit over r-tPA + DNase-1 or r-tPA + diNAC in a small subset of thrombi. 🧠🧠The clinical implications of this study are: Thrombus composition could be an important factor underlying the variable efficacy of r-tPA in stroke patients. Knowing the composition of the occluding thrombus may help predict response to r-tPA and guide treatment decisions. Imaging modalities like CT and MRI, which can identify RBC-rich thrombi, may be useful to predict r-tPA susceptibility. RBC-poor thrombi, not detectable by these methods, are likely to be r-tPA resistant. For patients with r-tPA resistant thrombi (RBC-poor/platelet-rich), combining r-tPA with drugs targeting thrombus components like DNA (DNase-1) or VWF (diNAC) could be a promising approach to improve thrombolysis and recanalization rates. A composition-tailored thrombolytic strategy, using r-tPA alone for RBC-rich thrombi and r-tPA + DNase-1/diNAC for RBC-poor thrombi, may expand the range of thrombi amenable to successful pharmacological lysis, especially benefiting patients currently failing r-tPA therapy. If proven safe in terms of bleeding risk, a combination therapy targeting both fibrin and non-fibrin components could potentially be given to all patients, eliminating the need to determine thrombus composition beforehand. https://lnkd.in/dzusGFZw