Distal M1 Research Articles

Stent retrievers with segmented design improve the efficacy of thrombectomy in tortuous vessels

IntroductionTortuous vascular anatomy is one of the greatest challenges in mechanical thrombectomy. This study examines the impact of vascular tortuosity on the performance of stent retrievers and evaluates the efficacy...

Endovascular Therapy versus Thrombolysis in Patients with Mild Strokes and Large Vessel Occlusions within the Anterior Circulation

Background: In patients with large vessel occlusions, endovascular treatment (ET) has been shown to be superior to intravenous thrombolysis (IVT) in recent trials. However, it is currently unclear if patients with mild strokes also benefit from ET. Methods: We compared the discharge rates of good outcome (modified Rankin scale [mRS] ≤2), very good outcome (mRS 0–1), symptomatic intracranial hemorrhages (SICH), and infarct sizes in patients with mild strokes (admission National Institutes of Health Stroke Scale ≤10) and distal intracranial carotid artery, M1, and M2 occlusions during two time periods. Results: From 1/2008 to 10/2012 160 patients (mean age: 72 ± 12 years) were treated with IVT, and from 11/2012 to 11/2016 145 patients (mean age: 71 ± 13 years,) received ET with or without IVT. The clinical results were comparable between both treatment groups (59% after ET vs. 56% after IVT, p = 0.5 for an mRS 0–2) and (38% after ET vs. 32% after IVT, p = 0.3 for an mRS 0–1). In the subgroup of patients with an mRS ≤6, the early outcome did not differ significantly between ET and IVT either. The rates of SICH as well as the infarct sizes were not significantly different after ET compared with IVT. Conclusion: Compared with IVT, the routine use of ET did not significantly improve the early clinical or radiological outcome in patients with mild strokes and anterior circulation large vessel occlusions. Further randomized trials are urgently needed to determine the role of ET in this cohort.

Endovascular therapy versus thrombolysis in patients with large vessel occlusions within the anterior circulation aged ≥80 years

Background and purposeIn patients with large vessel occlusions, endovascular treatment (ET) has been shown to be superior to intravenous thrombolysis (IVT) in recent trials. However, the effectiveness of ET in...

Abstract TMP15: Penumbral Rescue by Normobaric O2 in Ischemic Stroke With Target Mismatch ProFile (PROOF)

Introduction/Hypothesis: Despite effective reperfusion therapies, outcome following ischemic stroke (IS) often remains poor. Shortly after IS onset, the already necrotic area is surrounded by the severely hypoperfused but still viable penumbra. Sustaining the latter may widen treatment time windows and improve outcomes. As tissue damage in IS is primarily mediated by hypoxia, increasing penumbral oxygen (O2) supply seems a logical approach. Normobaric hyperoxygenation (NBHO) increased penumbral O2 and attenuated brain injury when initiated early in animal models of transient vessel occlusion. The few clinical trials conducted so far did not adapt these insights: NBHO initiation was late (treatment windows of more than 9 hours) and patients eligible for intravenous thrombolysis and endovascular treatment were excluded. Methods: Multi-center, randomized phase-II proof-of-concept trial studying NBHO adjunct to standard IS treatment; adaptive patient sample size of 180 to 460 depending on interim analysis. Eligibility: Patients with an acute large vessel occlusion in the anterior circulation (terminal ICA plus M1, proximal M1, or distal M1) and an Alberta Stroke Program Early CT Score of 7 or higher. Study treatment must be initiated prior to recanalization therapy and within 3 hours after IS onset. NBHO is achieved by administration of high-flow O2 (40 L/min) via non-rebreather face mask with reservoir or FiO2 of 1.0 during mechanical ventilation. NBHO will be stopped after endovascular treatment or applied for a maximum of four hours in case of not-attempted endovascular treatment. Controls will receive standard O2 supplementation whenever required. Primary Endpoint: Infarct growth from baseline to 24 hours; key secondary endpoint: Δ24h-NIHSS. Conclusion: PROOF is the first clinical trial to incorporate two cornerstones of effective experimental NBHO: early initiation and fast reperfusion. If proven beneficial, phase-III trials may be undertaken. Considering its low cost, NBHO may impact stroke care worldwide.

Abstract TP5: Mr Predicts a Reliable and Useful Tool in Identifying Benefit of Mechanical Thrombectomy in Patients With Large Vessel Occlusion

Background: The AHA/ASA guideline recommends endovascular therapy for patients with acute ischemic stroke within 6 hours from symptom onset. Identification of the patients most likely to benefit (and those most likely to be harmed) from reperfusion plays a pivotal role in decision-making. We applied the MR PREDICTS tool (clinical decision making tool derived from MR CLEAN clinical trial) on a real-world sample of patients with acute ischemic stroke to assess its utility in predicting clinical benefit from endovascular therapy. Methods: We identified all patients with acute ischemic stroke with occlusion of the distal internal carotid artery, proximal M1, or M2 segment of the middle cerebral artery who underwent endovascular reperfusion procedure (thrombectomy and/or intra-arterial thrombolysis) from July 2016 to June 2017. Patients were divided into two groups; those with a good outcome (90 Day mRS 0-2) and those with a poor outcome (90 Day mRS 3-6). The MR PREDICTS tool was used to determine absolute treatment benefit for each patient. This predicted outcome was compared to actual patient outcome. Results: A total of 22 patients were identified. Eight patients had a good outcome and 14 patients had a poor outcome. The calculated absolute treatment benefit from endovascular therapy using the MR PREDICTS tool was consistently higher among patients in the good outcome group, with an average absolute treatment benefit of 12% greater among these patients compared to those in the poor outcome cohort (19% versus 7%). Of note, patients with a poor outcome had a higher rate of prior stroke, higher baseline NIHSS, longer symptom onset to groin puncture time, less favorable collaterals and lower rate of successful recanalization defined as TICI 2b or 3 (100% versus 64%). Conclusion: There is a strong correlation between predicted treatment benefit by MR PREDICTS tool and actual patient outcomes which supports broader use of this tool during the decision-making process for endovascular therapy in patients with acute ischemic stroke.

Abstract 108: Mechanical Thrombectomy in Patients With Milder Strokes and Large Vessel Occlusions - A Multicenter and Matched Analysis

Background: In patients with acute ischemic strokes (AIS) and milder symptoms (NIHSS</=5) harboring a large vessel occlusion (LVO) best clinical management is unclear. To describe the safety and efficacy of immediate mechanical thrombectomy (MT) in patients with LVO and milder symptoms versus best medical management, including rescue MT. Methods: Retrospective cohort study on consecutive patients for a descriptive analysis regarding clinical and safety outcomes. From local prospectively run databases of six international comprehensive stroke centers data was pooled. 300 Patients with LVO (distal internal carotid artery, MCA-M1 and/or M2 segments, or basilar artery with or without tandem occlusions) and milder symptoms were identified and divided into two groups for analysis: immediate MT (i-MT) or best medical management which included rescue MT after neurological deterioration (n/r-MT). Uni- and multivariate analysis were performed to compare baseline and outcome variables across the two groups. Additional comparisons were performed after patient-level matching for age, baseline NIHSS and occlusion site. The primary outcome was defined as good outcome (modified rankin scale [mRS] 0-2) at day 90. Secondary outcomes were, among others, modified shift analyses at day 90. Safety outcome was symptomatic intracranial hemorrhage (sICH) as defined by the European Cooperative Acute Stroke Study (ECASS) II and mortality at day 90. Results: Compared to n/r-MT (n=220), patients with i-MT (n=80) were younger (65.3+/-13.5 vs. 69.5+/-14.1, p=0.021), had more often atrial fibrillation (44.8% vs. 28.2%, p=0.012), higher baseline NIHSS (4, 0-5 vs. 3, 0-5, p=0.005), more MCA-M1 (41.3% vs. 21.9%) and less MCA-M2 (28.8% vs. 49.3%, p=0.016) occlusions. The adjusted odds ratio for good outcome was 3.1 95% CI: 1.4-6.9 favoring i-MT. In the matched analysis, there was a 14.4% absolute difference in good outcome (84.4% vs. 70.1%, p=0.03) and a significant modified mRS shift (OR 2.29, 95% CI: 1.05-4.98) at day 90 favoring i-MT. There were no safety concerns. Conclusions and Relevance: The observed benefit-safety profile favors immediate MT in patients with milder symptoms and LVO.

Одонтологическая характеристика антропологической серии из могильника раннего железного века Верх-Сузун-5 с территории Новосибирского Приобья

Purpose. The article is devoted to the discussion of the results that was obtained from the anthropological study of the materials from the burial mound Verkh-Suzun-5. The burial ground is located in the Novosibirsk Ob area, 4.5 km South-West from the village Verkhniy Suzun. The main goal of the work is to reveal the genesis of the studied population and the measure of influence on its formation of various migration processes. This article is devoted to the study of the odontological series, which was studied according to the standard odontological program developed by A. A. Zubov and also according to the program of archaic dental markers, developed by A. V. Zubova. Results. The series from the Verkh-Suzun-5 burial ground is characterized by the average frequencies of shoveling I1, low frequencies of six-tubercle M1 and deflecting wrinkle M1, high frequencies of the Carabelli’s trait M1, average frequencies of four-tubercle M2. A similar combination of features in earlier epochs is found in the Okunevo, Andronovo and Karasuk populations of the Khakas-Minusinsk basin, where there is a complex with average frequencies of shoveling I1, high frequencies of six-tubercule M1, lack of M1 gracilization and average frequencies of deflecting wrinkle M1. The Okunevo series differs from the Verkh-Suzun group by the high frequencies of the distal trigonid crest, but during Andronovo time the percentage of this trait in the Khakas-Minusinsk basin drops sharply. Feature combinations are similar to those observed in Verkh-Suzun are traced in Andronovo groups from Orak burial grounds, Solenoye Ozero-1 and some others, and also in Karasuk groups. In the Early Iron Age, a similar combination of characters is found in the UyukSaglyn population of Tuva (burial ground of Dogee-Baary II). This complex characterizes by high frequencies of the Carabelli’s trait M1, the lack of M1 gracilization and the high degree of M2 gracilization, and also the average frequencies of the deflecting wrinkle M1 is traced here. The series from Dogee-Baary II differs from the series from Verkh-Suzun-5 by the absence of six-tubercle forms of M1 and high frequencies of the distal trigonid crest M1. Also a comparative intergroup analysis was carried out by the method of analysis of the principal components, which also showed us the convergence of the series from the Verkh-Suzun-5 cemetery with the Okunev population of the Khakas-Minusinsk basin and the Scythian population of Tuva. Proceeding from this, it can be concluded that the basis of the composition of the studied population is the autochthonous component, which fixes in the earlier epoch of the Okunev population. In this case, the general component of these two populations is expressed in the high frequencies of the Carabelli’s trait M1, the absence of M1 gracilisation, and the average frequencies of deflecting wrinkle M1. This component is typical for Okunev groups; he occupies an intermediate position between the races of the first order (in this case, the Mongoloid and the Caucasoid). Conclusion. As a result of the study, it was concluded that the composition of the group from Verkh-Suzun-5 was predominant in the local ancient component that occurs in the earlier epoch of the Okunev population of the Khakas-Minusinsk basin, and also this component marks Southern Eurasian Anthropological Formation.

Translesional pressure gradient and leptomeningeal collateral status in symptomatic middle cerebral artery stenosis.

Leptomeningeal collateral (LMC) status governs the prognosis of large artery occlusive stroke, although factors determining LMC status are not fully elucidated. The aim was to investigate metrics affecting LMC status in such patients by using computational fluid dynamics (CFD) models based on computed tomography angiography (CTA). In this cross-sectional study, patients with recent ischaemic stroke or transient ischaemic attack attributed to atherosclerotic M1 middle cerebral artery (MCA) stenosis (50%-99%) were recruited. Demographic, clinical and imaging data of these patients were collected. Ipsilesional LMC status was graded as good or poor by assessing the laterality of anterior and posterior cerebral arteries in CTA. A CFD model based on CTA was constructed to reflect focal hemodynamics in the distal internal carotid artery, M1 MCA and A1 anterior cerebral artery. Pressure gradients were calculated across culprit MCA stenotic lesions in CFD models. Predictors for good LMC status were sought in univariate and multivariate analyses. Amongst the 85 patients enrolled (mean age 61.5 ± 10.9 years), 38 (44.7%) had good ipsilesional LMC status. The mean pressure gradient across MCA lesions was 14.8 ± 18.1 mmHg. Advanced age (P = 0.030) and a larger translesional pressure gradient (P = 0.029) independently predicted good LMCs. A lower fasting blood glucose level also showed a trend for good LMCs (P = 0.058). Our study suggested a correlation between translesional pressure gradient and maturation of LMCs in intracranial atherosclerotic disease. Further studies with more exquisite and dynamic monitoring of cerebral hemodynamics and LMC evolution are needed to verify the current findings.

Permeability Surface of Deep Middle Cerebral Artery Territory on Computed Tomographic Perfusion Predicts Hemorrhagic Transformation After Stroke.

Permeability surface (PS) on computed tomographic perfusion reflects blood-brain barrier permeability and is related to hemorrhagic transformation (HT). HT of deep middle cerebral artery (MCA) territory can occur after recanalization of proximal large-vessel occlusion. We aimed to determine the relationship between HT and PS of deep MCA territory. We retrospectively reviewed 70 consecutive acute ischemic stroke patients presenting with occlusion of the distal internal carotid artery or M1 segment of the MCA. All patients underwent computed tomographic perfusion within 6 hours after symptom onset. Computed tomographic perfusion data were postprocessed to generate maps of different perfusion parameters. Risk factors were identified for increased deep MCA territory PS. Receiver operating characteristic curve analysis was performed to calculate the optimal PS threshold to predict HT of deep MCA territory. Increased PS was associated with HT of deep MCA territory. After adjustments for age, sex, onset time to computed tomographic perfusion, and baseline National Institutes of Health Stroke Scale, poor collateral status (odds ratio, 7.8; 95% confidence interval, 1.67-37.14; P=0.009) and proximal MCA-M1 occlusion (odds ratio, 4.12; 95% confidence interval, 1.03-16.52; P=0.045) were independently associated with increased deep MCA territory PS. Relative PS most accurately predicted HT of deep MCA territory (area under curve, 0.94; optimal threshold, 2.89). Increased PS can predict HT of deep MCA territory after recanalization therapy for cerebral proximal large-vessel occlusion. Proximal MCA-M1 complete occlusion and distal internal carotid artery occlusion in conjunction with poor collaterals elevate deep MCA territory PS.

THRIVE score predicts clinical and radiological outcome after endovascular therapy or thrombolysis in patients with anterior circulation stroke in everyday clinical practice.

Based on the data of several trials the Totaled Health Risks in Vascular Events (THRIVE) score has been shown to predict outcome after either intravenous thrombolysis (IVT) or endovascular therapy (ET) in acute stroke patients. It is unknown whether the THRIVE score can also predict outcome in everyday clinical practice. Using our prospectively obtained stroke database the utility of the THRIVE score to predict clinical and radiological outcome in everyday clinical practice was analysed. The relationships between THRIVE and good outcome (modified Rankin Scale≤2 at discharge), poor outcome (modified Rankin Scale 5-6), in-hospital death, symptomatic intracranial haemorrhage (SICH) as well as infarct size were examined in patients with distal intracranial carotid artery, M1 and M2 occlusions after either IVT or ET. From January 2008 to October 2016 a total of 546 patients were treated with IVT and 492 patients received ET with stent retrievers (with or without IVT). In both treatment groups the THRIVE score predicted clinical outcome (Mantel-Haenszel chi-squared tests for trend P<0.001 for good outcome, P<0.001 for poor outcome and P<0.001 for in-hospital death). In the ET group the THRIVE score remained an independent predictor of outcome after controlling for recanalization. The THRIVE score was associated with the infarct size after IVT or ET, whereas it did not predict SICH rates in either treatment group. In everyday clinical practice the THRIVE score strongly predicts clinical outcome and the extent of ischaemia after ET or IVT in patients with anterior circulation large vessel occlusions.

Internal Carotid Artery and the Proximal M1 Segment Are Optimal Targets for Mechanical Thrombectomy

Background and Purpose: Mechanical thrombectomy (MT) is an established treatment of acute anterior circulation stroke caused by large vessel occlusion (LVO). We compared the clinical outcome (3-month modified Rankin Scale, mRS) in hyperacute (<3h from the onset of symptoms) ischemic stroke between an MT and an intravenous thrombolysis (IVT) cohort in proximal (ICA and the proximal M1 segment of the middle cerebral artery) and distal (the distal M1 and the M2 segment) LVOs. Methods: We prospectively reviewed 67 patients who underwent MT with newer-generation stent retrievers. The IVT cohort consisted of 98 patients who received IVT without MT. We recorded baseline clinical, procedural and imaging variables, technical outcome, 24-h imaging outcome, and the clinical outcome. Differences between the groups were studied with theoretically appropriate statistical tests and binary logistic regression analysis. Results: The proportion of patients who had a proximal LVO and experienced good (mRS ≤2) or excellent (mRS ≤1) clinical outcome was significantly larger in the MT group (62 vs. 7%, p < 0.001; 47 vs. 3%, p < 0.001, respectively). In a regression model including relevant confounding variables, good clinical outcome was seen significantly more often among patients with proximal occlusions (OR = 6.0, CI 95% 1.9-18.3, p = 0.002). In a similar model, no statistically significant differences were observed in patients with more distal occlusions. Conclusions: MT is superior to IVT in achieving good clinical outcome in hyperacute anterior circulation stroke in the most proximal occlusions (ICA and proximal M1 segment). In the distal M1 and M2 segments neither of these therapies clearly outperforms the other.

Progression of Cerebral White Matter Hyperintensities and the Associated Sonographic Index.

Purpose To evaluate the relationship between penetrating arterial pulsation and the progression of white matter hyperintensities (WMHs) by using the sonographic resistance index (RI) along the M1 segment of the middle cerebral artery (MCA). Materials and Methods The study design was approved by the institutional review board of Seoul National University Hospital. The study included 450 individuals who had undergone initial transcranial Doppler (TCD) sonography and magnetic resonance imaging, with follow-up imaging performed within 34-45 months, and who had no stenosis of 30% or more in the internal carotid artery or MCA or a history of stroke other than an old lacunar infarction. MRIR was defined as distal RI divided by proximal RI, where the distance between proximal MI and distal M1 was approximately 20 mm based on TCD evaluation. WMH progression was quantitatively evaluated by subtracting WMH volume at baseline from WMH volume at follow-up. Results At baseline, mean MRIR was 0.974 ± 0.045 (standard deviation), and mean WMH volume was 9.66 mL ± 14.54. After a mean of 38.3 months ± 3.4, the WMH volume change was 4.06 mL ± 7.35. WMH volume change was linearly associated with MRIR (r = 0.328, P < .001), along with the baseline WMH volume (r = 0.433, P < .001) and mean MCA pulsatility index (r = 0.275, P = .037). MRIR values greater than or equal to 1.000 were associated with a greater increase in WMH volume (P < .001). Conclusion MRIR might reflect the pulsation of penetrating arteries and is independently associated with WMH progression. © RSNA, 2017 Online supplemental material is available for this article.

Alberta Stroke Program Early CT Score Infarct Location Predicts Outcome Following M2 Occlusion.

Although it is generally thought that patients with distal middle cerebral artery (M2) occlusion have a favorable outcome, it has previously been demonstrated that a substantial minority will have a poor outcome by 90 days. We sought to determine whether assessing the Alberta Stroke Program Early CT Score (ASPECTS) infarct location allows for identifying patients at risk for a poor 90-day outcome. We retrospectively analyzed patients with isolated acute M2 occlusion admitted to a single academic center between January 2010 and August 2012. Infarct regions were defined according to ASPECTS system on the initial head computed tomography. Discriminant function analysis was used to define specific ASPECTS regions that are predictive of the 90-day functional outcome as defined as a modified Rankin Scale score of 3-6. In addition, logistic regression was used to model the relationship between each individual ASPECT region with poor outcome; for evaluation and comparison, odds ratios, c-statistics, and Akaike information criterion values were estimated for each region. Ninety patients with isolated M2 were included in the final analysis. ASPECTS score ≤6 predicted poor outcome in this cohort (sensitivity = 0.591, specificity = 0.838, p < 0.001). Using multiple approaches, we found that infarction in ASPECTS regions M3 and M6 were strongly associated with poor functional status by 90 days. Infarction in ASPECTS regions M3 and M6 are key predictors of functional outcome following isolated distal M2 occlusion. These findings will be helpful in stratifying outcomes if validated in future studies.

Abstract WP18: Cerebral Mechanical Thrombectomy Simulator Using Hydrogel Polymers and 3D Printing Technology

Introduction: While stroke remains a leading cause of death and disability, recent advances in endovascular technology an important opportunity to make a significant impact in clinical outcomes. However, training opportunities are rare, preventing dissemination of these techniques. Hands-on training is further complicated by the critical time to therapy associated with stroke treatment. This physical simulator was built for neurosurgical residents and fellows to practice mechanical thrombectomy. Methods: A simplified virtual model of the anterior cerebral circulation was created based on patient imaging. This luminal model was 3D printed using flexible filament and attached to a guide catheter at the proximal carotid to provide endovascular access and an IV tube at the distal M2 branches to permit outflow. A 7Fr sheath was also connected at the anterior cerebral artery to permit placement of a simulated clot model and simulate a proximal M1 occlusion. This entire construct was placed into a container of polyvinyl alcohol (PVA) and after crosslinking the flexible print was removed. Results: Using 3D printing technology and polymer hydrogels, a low-cost, high fidelity stroke model was achieved. Despite its simplified anatomy, the model permitted realistic wire and catheter navigation through the different segments of the internal carotid and middle cerebral arteries. The ACOM sheath provided a convenient method to reliably place an embolism and created a life-like proximal M1 occlusion. Recanalization was performed using the solumbra technique, which is used in live-patient cases. Conclusions: This model demonstrated proof of concept for a mechanical thrombectomy simulation. The angiographic profile and response to endovascular tools created a training experience similar to live endovascular procedures. As the model is perfected visually and mechanically, next steps are to perform validation studies and create a training curriculum.

Abstract 186: IV tPA Recanalization Rates by Site of Occlusion and Time After tPA Bolus- Main Results Of The Interrsect Multinational Multicenter Prospective Cohort Study

Introduction: Decisions to transport patients from primary to comprehensive stroke centre would be influenced by info on likelihood/timing of spontaneous or IV tPA recanalization (recan). We examined recan rates by time for a wide range of occlusion sites in the INTERRSeCT multicenter prospective cohort study. Methods: Acute stroke patients consented/enrolled at 12 centers/5 countries if intracranial occlusion present on baseline CTA; eGFR≥60 ml/min. CTA was repeated 2-6 hrs later for recan unless patient taken for EVT (first run of angio used instead). Primary outcome was successful recan (rAOL scale score 2b/3) interpreted by central core lab. Results: 619 patients enrolled, 81.6% received IV tPA. 59.9% recan by follow-up CTA and 40.1% by first run angio. Median baseline NIHSS 14 (IQR 11); mean age 70.1 yrs (SD 13); median onset to baseline CTA 115 mins (IQR 108). Recan assessment imaging median 162 mins (IQR 198) from IV tPA bolus or baseline CTA (if no IV tPA). Successful recan (rAOL 2b-3) rates comparing baseline to repeat imaging shown in Figure 1a (IV tPA red; no IV tPA blue). IV tPA had much higher recan than non-IV tPA group (30.5% vs 11%, p&lt;0.0001). Successful recan rates by occlusion site and by time from IV tPA bolus shown in Figure 1b. Site of occlusion, tPA administration, time from tPA to recan assessment and baseline residual flow were the only independent predictors of recan (all p&lt;0.0001). Distal M1 MCA had highest recan [RR 4.12; 95% CI 1.91-8.86 vs. ICA]. Conclusions: Early recan rates were low across all occlusion sites. Beyond 6 hrs post tPA, recan rates approached EVT levels except for ICA. Imaging factors such as residual flow may further refine transport/triage decisions.

Opercular Index Score: a CT angiography-based predictor of capillary robustness and neurological outcomes in the endovascular management of acute ischemic stroke

BackgroundMany CT angiography (CTA) collateral scoring systems are either subjective or complex and time consuming.ObjectiveTo evaluate the correlation between a CTA collateral scoring system—the Opercular Index Score (OIS)—with neurological outcomes...

Flow Diverters in the Treatment of Pediatric Cerebrovascular Diseases.

There is very limited data concerning utilization of flow diverters in children. Our aim is to report results for the treatment of complex intracranial aneurysms and carotid cavernous fistulas by using flow diverters in children. Retrospective review of children (17 years of age or younger) treated with flow diverters between May 2011 and July 2014 was performed. Clinical and laboratory data and angiographic findings were extracted. Seven patients (6 males, 1 female; mean age, 12.7 years; range, 3-16 years) were included. Two presented with posttraumatic fistulas. The remaining patients presented with traumatic aneurysms of the cavernous carotid artery or fusiform aneurysms of the distal vertebral artery, M1, or A2 segments. All patients were premedicated with clopidogrel (75 mg daily for patients with body weights of >45 kg, 37.5 mg daily for 1 small child with a body weight of <45 kg) and aspirin (300 mg daily for ≥45 kg, 100 mg daily for smaller children). VerifyNow and Multiplate Analyzer values were higher than expected. No clinical complications were noted. Imaging performed at 7-52 months after the procedure (mean/median, 22.3/14 months) revealed occlusions of all aneurysms and fistulas. One patient had an asymptomatic occlusion of the parent artery; otherwise, no hemodynamically significant parent artery restenosis was observed. There were no clinically significant neurologic events during follow-up. Although flow-diverter placement appears to be safe and effective on midterm follow-up in children, longer follow-up is critical. The current sizes of flow diverter devices and delivery systems cover the pediatric size range, obviating developing flow diverters specific to children.

Endovascular Therapy of M2 Occlusion in IMS III: Role of M2 Segment Definition and Location on Clinical and Revascularization Outcomes.

Uncertainty persists regarding the safety and efficacy of endovascular therapy of M2 occlusions following IV tPA. We reviewed the impact of revascularization on clinical outcomes in 83 patients with M2 occlusions in the Interventional Management of Stroke III trial according to specific M1-M2 segment anatomic features. Perfusion of any M2 branch distinguished M2-versus-M1 occlusion. Prespecified modified TICI and arterial occlusive lesion revascularization and clinical mRS 0-2 end points at 90 days for endovascular therapy-treated M2 occlusions were analyzed. Post hoc analyses of the relationship of outcomes to multiple baseline angiographic M2 and M1 subgroup characteristics were performed. Of 83 participants with M2 occlusion who underwent endovascular therapy, 41.0% achieved mRS 0-2 at 90 days, including 46.6% with modified TICI 2-3 reperfusion compared with 26.1% with modified TICI 0-1 reperfusion (risk difference, 20.6%; 95% CI, -1.4%-42.5%). mRS 0-2 outcome was associated with reperfusion for M2 trunk (n = 9) or M2 division (n = 42) occlusions, but not for M2 branch occlusions (n = 28). Of participants with trunk and division occlusions, 63.2% with modified TICI 2a and 42.9% with modified TICI 2b reperfusion achieved mRS 0-2 outcomes; mRS 0-2 outcomes for M2 trunk occlusions (33%) did not differ from distal (38.2%) and proximal (26.9%) M1 occlusions. mRS 0-2 at 90 days was dependent on reperfusion for M2 trunk but not for M2 branch occlusions. For M2 division occlusions, good outcome with modified TICI 2b reperfusion did not differ from that in modified TICI 2a. M2 segment definition and occlusion location may contribute to differences in revascularization and good outcome between Interventional Management of Stroke III and other endovascular therapy studies.

TREVO and Capture LP have equal technical success rates in mechanical thrombectomy of proximal and distal anterior circulation occlusions

PurposeMechanical thrombectomy (MT) is a proven method to treat large vessel occlusions in acute anterior circulation stroke. We compared the technical, imaging, and clinical outcomes of MT performed with either...

The feasibility of detecting cerebral blood flow direction using the indocyanine green video angiography

The intraoperative confirmation of blood flow direction is necessary in cerebral vascular surgery. Using indocyanine green video angiography (ICG-VAG) with the FLOW 800 system, we examined the transit time of the blood vessel of interest and semiquantitatively evaluated the delay time (T1/2max) from indocyanine green (ICG) injection into the donor artery in reconstructive surgery and the middle cerebral artery (MCA) in aneurysmal surgery. The direction of cerebral blood flow (CBF), which can often be confirmed by ICG-VAG, may be more difficult to determine with faster blood flow. Here, we report our findings regarding the feasibility of detecting CBF direction using the FLOW 800 system. Twenty patients undergoing superficial temporal artery (STA) to MCA anastomosis for carotid occlusive disease and 13 patients with a small MCA aneurysm clipping were evaluated using the T1/2max, semiquantitative method with the FLOW 800 system. In STA-MCA anastomosis cases, the regions of interest (ROIs) included: the proximal donor STA and a region more than 10mm on the distal side of the donor STA near the anastomosis site. In MCA aneurysms, the ROIs included the proximal M1 and distal M2 sides of the MCA aneurysm. T1/2max was significantly shorter for the proximal sites compared to the distal sites for all subjects (ps < 0.01). T1/2max was shorter for all subjects in the proximal sites. The direction of CBF can be determined using the FLOW 800 system.