neurovascular-nuggets

🟢Neurovascular-Nugget 26 🟢 Bridging the Gap: Training and Infrastructure Solutions for Mechanical Thrombectomy in Low- and Middle-Income Countries https://lnkd.in/dSWmZZaS ###Main_Points - Critical Stroke Burden in LMICs: Stroke, particularly ischemic stroke due to large vessel occlusions (LVOs), is a major global health issue. LMICs bear an overwhelming burden—accounting for most stroke-related morbidity and mortality—compounded by delayed presentations, low symptom awareness, and inadequate infrastructure. - Limited Access to Mechanical Thrombectomy (MT): Despite the proven long-term benefits of MT, access in LMICs is hampered by severe infrastructural constraints, high upfront costs, and insufficient specialized training. These challenges translate into high costs for patients and delayed development of robust stroke care systems. - Multifaceted Training Strategies: The article proposes a range of training approaches to address these challenges: - E-Fellowship Programs: Remote training through online lectures and recorded cases. While cost-effective and accessible, they do not fully replace hands-on experience. - Short-Term International Training: Intensive courses that provide practical skills and immediate exposure to MT procedures, ideally supplemented with on-site supervision. - Simulation-Based Training: The use of flow models and virtual reality to complement practical experience, especially important for handling complex anatomical cases. - Institutional and Regional Collaborations: Partnerships between local centers and high-volume international facilities, creating regional training hubs that enable sustained skill development. - Economic and Structural Considerations: The high initial costs of equipment and consumables in LMICs necessitate creative funding models that involve government subsidies, industry partnerships, and the eventual integration of MT training into traditional medical education and fellowship programs. - Call for Tailored, Sustainable Solutions: The paper underlines that a “one size fits all” model is not feasible given the diversity across LMICs. Instead, innovative, context-specific training and infrastructural strategies are essential for timely skill development and improved stroke care outcomes. Sheila Cristina Ouriques Martins Thanh Nguyen Fawaz Al-Mufti Hisham Salahuddin @syed F zaidi Ossama Mansour World Stroke Organization SVIN - Society of Vascular and Interventional Neurology Middle East North Africa stroke and interventional neurotherapies organization ( MENA-SINO )

✳️ Neurovascular - Nugget 26-B ✳️ Reading in Thrombectomy in MEVO via recently published RCTs DISTAL (NCT05029414; Marios Psychogios, Prof. Dr. et al.) 1- https://lnkd.in/eEAFzCMm ESCAPE-MeVO (NCT05151172; Mayank Goyal et al.) 2- https://lnkd.in/e_zRcfPd "Given the methodological heterogeneity and distinct patient populations enrolled in the DISTAL and ESCAPE-MeVO trials, caution is warranted when attempting to synthesize or directly compare their findings. The disparate designs and inclusion criteria limit the cumulative interpretability of the results, necessitating independent evaluation of each study's conclusions. Furthermore, the following nuances necessitate careful consideration when interpreting each study's findings, as they may significantly influence the reader's understanding of the efficacy and safety of endovascular treatment for medium and distal vessel occlusions." 🔴 Vessel Definition & Patient Population: DISTAL (Broader): Diluted EVT benefit due to inclusion of potentially less severe distal occlusions and exclusion of known EVT-responsive dominant M2s. Impact: Underestimation of EVT potential. ESCAPE-MeVO (Narrower): Targeted a more specific group, but chosen locations may have been less amenable to EVT or higher risk. Impact: Potential for negative result. Overall Impact: Differences may explain DISTAL's neutral result vs. ESCAPE-MeVO's harm signal. 🔴 Time Window: DISTAL (Longer - 24h): Allowed more patients but increased irreversible damage and spontaneous recanalization. Impact: Diluted treatment effect. ESCAPE-MeVO (Shorter - 12h): Enriched for potentially responsive patients but may have missed others who could benefit. Impact: Potentially missed benefit, workflow negated any potential benefit. Imaging (ESCAPE-MeVO): 🔴 Salvageable Tissue Required: Focused EVT on those with potential benefit, but specific criteria could have biased selection. Impact: Potential exclusion of treatable patients. 🔴 Device Mandate (ESCAPE-MeVO): Solitaire X Only: Reduced procedural variability but limited operator choice and real-world applicability. Impact: Potential for suboptimal device selection, skewed real-world applicability. 🔴 Mortality (ESCAPE-MeVO): Increased Mortality Signal: Serious concern suggesting potential harm in this specific context. Impact: Strong argument against routine EVT in this population. 🔴 Workflow Times: 🟢 Prolonged Times (Both, esp. ESCAPE-MeVO): Delays could negate EVT benefits due to irreversible damage. Impact: Undermined potential efficacy. 🟢Spontaneous Recanalization (ESCAPE-MeVO): Recanalization Before EVT: Unnecessary EVT in some, diluting treatment effect and cumulating risk. Impact: Obscured potential benefit.

✳️ Neurovascular - Nugget 26-A ✳️ Reading in Thrombectomy in MEVO via recently published RCTs DISTAL (NCT05029414; Marios Psychogios, Prof. Dr. et al.) 1- https://lnkd.in/eEAFzCMm ESCAPE-MeVO (NCT05151172; Mayank Goyal et al.) 2- https://lnkd.in/e_zRcfPd Both DISTAL and ESCAPE-MeVO evaluated endovascular thrombectomy (EVT) versus standard medical therapy for medium / distal vessel occlusions (e.g., M2, M3, ACA, PCA branches). Neither trial found a significant clinical benefit of EVT over medical therapy at 90 days, ❗ despite achieving ~70–75% recanalization rates with thrombectomy. ❗ ❗A high proportion of patients received IV thrombolysis❗, yet many recanalizations occurred spontaneously—calling into question the necessity of device-based interventions in certain cases. ❗Late-window provisions (up to 24 hours) and broad lesion definitions❗(including non-dominant / co-dominant M2, M3, A/P segments) introduced study heterogeneity, making it difficult to pinpoint specific subgroups that might benefit more clearly. Overall, these trials do not support a “one-size-fits-all” approach to performing EVT in medium or distal occlusions, emphasizing instead the need for careful patient selection and a ❗better understanding of the interplay between IV thrombolysis and mechanical thrombectomy in this unique different disease❗ . ✅ find the main points summarized in the following table ✅

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.