Interventional Neuroradiology Research Articles

Reimagining Cryptogenic Stroke Care: Collaborative Care and Inpatient Insertable Cardiac Monitors for Detection of Atrial Fibrillation

BACKGROUND Atrial fibrillation (AF) is a known risk factor of ischemic stroke, and AF‐related stroke is twice more likely to be fatal. Long‐term cardiac rhythm monitoring using insertable cardiac monitors (ICMs) has greater diagnostic yield compared with conventional monitoring in detecting AF, and the clinical utility of ICMs is established in cryptogenic stroke, strokes attributable to large‐artery atherosclerosis, and strokes attributable to small‐vessel disease. A registry‐based study was conducted to evaluate the inpatient implantation of ICMs and the feasibility of vascular and interventional neurologists as implanters using novel collaborative clinical care pathway for cryptogenic stroke. METHODS Multiyear data from a hospital‐based registry at a comprehensive stroke center were reviewed to evaluate inpatient ICM implantation and test feasibility of vascular and interventional neurologists as implanters of ICMs together with cardiology using a novel collaborative care pathway. Reviewed data included the number of ICMs, implantation trend, inpatient versus outpatient setting, time to ICM implantation, inpatient workflow, including defined roles of team members, and AF detection rate. RESULTS A total of 290 ICMs for cryptogenic stroke were implanted when patients were in the hospital and 78 as outpatients after discharge during the study period of 3 years. Most inpatient ICM implants were performed by vascular and interventional neurology (n = 181), and ICM use for cryptogenic stroke increased by 130%. The average time to inpatient ICM implant was 4.1 days, with 77% in 5 days and 95.5% within 10 days poststroke. The average time to out‐patient ICM placement was 57 days. AF detection rate of 36.5% was noted at 24 months with a collaborative care pathway. CONCLUSION Inpatient implantation of ICMs is feasible and was performed safely and efficiently by vascular and interventional neurology together with cardiology using a collaborative care pathway. An increase in use of ICMs and higher AF detection rates were noted. Findings support innovative efforts to improve access and close the gaps in the delivery of cryptogenic stroke care to ultimately reduce the secondary stroke burden.

Celebrating 30 Years of the Korean Society of Interventional Neuroradiology.

Celebrating 30 Years of the Korean Society of Interventional Neuroradiology.

Mechanical thrombectomy by stent retriever for the treatment of arterial ischemic stroke in a pediatric patient with acute lymphoblastic leukemia: A case report

Introduction: Arterial ischemic stroke (AIS) caused by occlusion of large vessels in childhood is a devastating rare condition that can contribute to long-term disabilities. Childhood leukemia is identified as a recognized risk factor for ischemic strokes. Mechanical thrombectomy is standard of care for large vessel occlusions in adults. However, there are still no definite recommendations regarding application and outcomes of endovascular thrombectomy and the devices used for pediatric patients with arterial ischemic stroke. Case presentation: We report a 13-year-old female with acute lymphoblastic leukemia who developed AIS due to thrombosis in the left internal carotid and proximal middle cerebral artery in the induction phase of treatment. The patient underwent successful mechanical thrombectomy via Solumbra by using “Embolus Retriever with Interlinked Cages (ERIC)” stent retriever and Sofia plus catheter which resulted in successful recanalization of ICA and MCA. Discussion: Selected pediatric patients with AIS due to large vessel occlusions can benefit from mechanical thrombectomy. Although the recently published literature demonstrated the efficacy and safety of MT in children, strong guideline recommendations are still absent. At present, the last AHA/ASA guidelines for early management of AIS recommends intravenous thrombolysis and endovascular therapy in adults, whereas controversy still exists in children. An urgent approach within the defined therapeutic time frame and a multidisciplinary team specialized in pediatric stroke with professional trained interventional neuroradiologist is essential for achieving optimal results. Conclusion: Mechanical thrombectomy provides promising results with high rates of arterial recanalization and favorable outcomes in pediatric patients with AIS.

Mechanical thrombectomy practices in Europe: Insights from a survey of European neuroradiologists from the ESMINT.

Mechanical thrombectomy (MT) has revolutionized the prognosis of acute ischemic stroke. Indications for MT are constantly expanding across countries, presenting healthcare professionals, and institutions with the challenge of offering MT to the entire population despite geographic constraints, while also training enough interventional neuroradiologists (INR) for this highly technical-level procedure. We aimed to provide an overview of current European MT practices and organizations in 2021. Members of the European Society of Minimally Invasive Neurological Therapy (ESMINT) were invited to complete two different online surveys from March to November 2021 to collect data on MT practice. A total of 240 individual responses from INR (from 33 European countries) were received. These included information from 56 thrombectomy-capable stroke centers (TCSC) data (across 26 European countries). The mean number of INR per center was 3.8 ± 1.43, median 4 (IQR, 3-4.5). Half of the centers (28/56, 50.00%) performed less than 150 MT per year. Most INR used a balloon guide catheter in less than 50% of cases (160/240, 66.67%), and limited the number of recanalization attempts to six passes to restore flow (209/240, 87.08%). Additionally, 37.92% of the respondents (91/240, 37.92%) indicated that they already performed MT for distal occlusions (M3, M4) as part of their routine practice. Other details of the MT procedure, anesthetic management, and patient selection are also presented and discussed. This European survey emphasizes the differences between TCSC and INR in modern thrombectomy practices. Even if most centers remain understaffed to meet current and future MT needs, most European TCSCs are actively training young INR.

WFITN 2024 - 17th Congress of World Federation of Interventional and Therapeutic Neuroradiology - October 6-10, 2024 - New York, USA.

WFITN 2024 - 17th Congress of World Federation of Interventional and Therapeutic Neuroradiology - October 6-10, 2024 - New York, USA.

The Los Angeles motor scale (LAMS) and ASPECTS score are independently associated with DSA ASITN collateral score.

Mechanical thrombectomy (MT) is the treatment standard in eligible patients with acute ischemic stroke (AIS) secondary to large vessel occlusions (LVO). Studies have shown that good collateral status is a strong predictor of MT efficacy, thus making collateral status important to quickly assess. The Los Angeles Motor Scale is a clinically validated tool for identifying LVO in the field. The aim of this study is to investigate whether admission LAMS score is also associated with the American Society of Interventional and Therapeutic Neuroradiology (ASITN) collateral score on digital subtraction angiography (DSA). We conducted a retrospective multicenter cohort study of consecutive patients presenting with AIS caused by LVO from 9/1/2017 to 10/1/2023 with diagnostically adequate DSA imaging. Demographic, clinical, and imaging data was collected through manual chart review. Both univariate and multivariate analysis were applied to assess associations. A p-value <0.05 was considered significant. A total of 308 patients (median age: 68, IQR: 57.5-77) were included in the study. On multivariate logistic regression analysis, we found that lower admission LAMS score (adjusted OR: 0.82, 95% CI: 0.68-0.98, p < 0.05) and higher ASPECTS score (adjusted OR: 1.21, 95% CI: 1.02-1.42, p < 0.05) were independently associated with good DSA ASITN collateral score of 3-4. Admission LAMS and ASPECTS score are both independently associated with DSA ASITN collateral score. This demonstrates the capability of LAMS to act as a surrogate marker of CS in the field.

Radiation dose analysis in interventional neuroradiology of unruptured aneurysm cases

This study aimed to evaluate the radiation doses (peak skin dose (PSD) and bilateral lens dose) for each interventional neuroradiology procedure. A direct measurement system consisting of small radiophotoluminescence glass dosimeter chips and a dosimetry cap made of thin stretchable polyester was used for radiation dosimetry. The mean PSDs for each procedure were 1565 ± 590 mGy (simple technique coil embolization (STCE) cases), 1851 ± 825 mGy (balloon-assisted coil embolization (BACE) cases), 2583 ± 967 mGy (stent-assisted coil embolization (SACE) cases), 1690 ± 597 mGy (simple flow-diverter stenting (FDS) cases), and 2214 ± 726 mGy (FDS + coiling cases). The mean PSD was higher in SACE cases than in STCE, BACE, and simple FDS cases. Moreover, the PSD exceeded 2000 mGy and 3000 mGy in 46 (67.6%) and 19 (27.9%) SACE cases, respectively. The left lens doses for each procedure were 126 ± 111 mGy (STCE cases), 163 ± 152 mGy (BACE cases), 184 ± 148 mGy (SACE cases), 144 ± 60 mGy (simple FDS cases), and 242 ± 178 mGy (FDS + coiling cases). The left lens dose in SACE cases was higher than that in STCE cases and exceeded 500 mGy in 3 (4.4%) patients. In FDS + coiling cases, the mean PSD and left lens dose were 2214 ± 726 mGy and 242 ± 178 mGy, respectively. The left lens dose was higher than that in the STCE and BACE cases, with two (15.4%) patients receiving doses >500 mGy in FDS + coiling cases. The detailed data obtained in this study are expected to contribute to the promotion of radiation dose optimization.

Deep learning for efficient reconstruction of highly accelerated 3D FLAIR MRI in neurological deficits.

To compare compressed sensing (CS) and the Cascades of Independently Recurrent Inference Machines (CIRIM) with respect to image quality and reconstruction times when 12-fold accelerated scans of patients with neurological deficits are reconstructed. Twelve-fold accelerated 3D T2-FLAIR images were obtained from a cohort of 62 patients with neurological deficits on 3T MRI. Images were reconstructed offline via CS and the CIRIM. Image quality was assessed in a blinded and randomized manner by two experienced interventional neuroradiologists and one experienced pediatric neuroradiologist on imaging artifacts, perceived spatial resolution (sharpness), anatomic conspicuity, diagnostic confidence, and contrast. The methods were also compared in terms of self-referenced quality metrics, image resolution, patient groups and reconstruction time. In ten scans, the contrast ratio (CR) was determined between lesions and white matter. The effect of acceleration factor was assessed in a publicly available fully sampled dataset, since ground truth data are not available in prospectively accelerated clinical scans. Specifically, 451 FLAIR scans, including scans with white matter lesions, were adopted from the FastMRI database to evaluate structural similarity (SSIM) and the CR of lesions and white matter on ranging acceleration factors from four-fold up to 12-fold. Interventional neuroradiologists significantly preferred the CIRIM for imaging artifacts, anatomic conspicuity, and contrast. One rater significantly preferred the CIRIM in terms of sharpness and diagnostic confidence. The pediatric neuroradiologist preferred CS for imaging artifacts and sharpness. Compared to CS, the CIRIM reconstructions significantly improved in terms of imaging artifacts and anatomic conspicuity (p < 0.01) for higher resolution scans while yielding a 28% higher SNR (p = 0.001) and a 5.8% lower CR (p = 0.04). There were no differences between patient groups. Additionally, CIRIM was five times faster than CS was. An increasing acceleration factor did not lead to changes in CR (p = 0.92), but led to lower SSIM (p = 0.002). Patients with neurological deficits can undergo MRI at a range of moderate to high acceleration. DL reconstruction outperforms CS in terms of image resolution, efficient denoising with a modest reduction in contrast and reduced reconstruction times.

Remote Teleproctoring with the TEGUS System for Mechanical Thrombectomy in aNon-Comprehensive Stroke Center: Initial Preliminary Data On Clinical Experience.

Mechanical thrombectomy (MT) is typically performed by experienced neurointerventional radiologists. However, logistical and geographic limitations often hinder access to rapid MT. This study reports the first clinical experience using TEGUS teleproctoring to support MT conducted by general interventional radiologists (IR) at non-comprehensive stroke centers, compared to on-site proctoring outcomes. The Arnau de Vilanova Hospital in Spain used to transfer stroke patients requiring MT to acomprehensive Stroke Center 160 km away. To overcome COVID-19 mobility restrictions, the Tegus Teleproctoring System was installed. Before teleproctoring, the general interventional radiologist underwent six months of neurointerventional training at aprimary stroke center. From April 2021 to May 2023, general IR conducted MT either with on-site proctor supervision or teleproctoring support. We aim to compare clinical outcome of patients receiving MT according to proctoring method. During the study, 49MTs were performed: 15 with TEGUS teleproctoring and 34with on-site proctoring. Both groups had similar baseline characteristics, except for NIHSS scores (Tegus 9 [IQR 6-20] vs 18 [IQR 12-22], p = 0.034). No significant differences were found in door-to-revascularization time (82 ± 28.2 vs 84 ± 26.4) min, p = (0.895). The final mTICI distribution and 90-day mRS scores were comparable after adjusting by stroke severity. There were no reports of symptomatic intracranial hemorrhage in either group. This study shows the feasibility of Tegus remote teleproctoring during emergent cases of MT in aremote hospital. It could improve the learning curve of interventional radiologists with limited experience in MT, and lower the territorial inequity associated to MT.

Comparison of safety of lumbar drain versus external ventricular drain in symptomatic hydrocephalus following aneurysmal subarachnoid hemorrhage.

Cerebrospinal fluid (CSF) diversion is typically performed with an external ventricular drain (EVD) for symptomatic hydrocephalus (HCP) following subarachnoid hemorrhage (SAH). Lumbar drain (LD) has also been studied to reduce the incidence of vasospasm after SAH but not HCP. We performed a single center retrospective analysis to evaluate the safety of LD versus EVD for symptomatic HCP following aneurysmal SAH in a naturally randomized patient population. Patients admitted for aneurysmal SAH who developed symptomatic HCP were treated with EVD or LD depending on neurosurgeon on call. Of the 10 neurosurgeons on call, five would place EVD in all patients while the other five would request LD be placed by interventional neuroradiology; however, the distribution on call was not evenly distributed. We retrospectively compared these two groups for drain complications and outcomes with Modified Rankin Scale (mRS). From 2018 to 2021, there were a total of 77 patients with aneurysmal SAH requiring CSF diversion for HCP. There were 56 cases of EVD placement and 21 cases of LD placement. Overall drain complications were 32.0% of cases with EVD and 9.5% with LD, p = .0773. EVD versus LD complications consisted of hemorrhage (1.8% vs 0%, p = 1.0000), infection (7.1 vs 0%, p = .5698), clogged (25% vs 0%, p = .008), dislodgement (1.8% vs 4.6%, p = .4737) and replacement (16% vs 4.8%, p = .2698). No case of cerebellar tonsillar herniation occurred. mRS between EVD versus LD obtained at baseline (0.3 vs 0.3, p = .3943), discharge (3.8 vs 2.7, p = .047), 90 days (2.9 vs 2.0, p = .060), and 1 year (2.6 vs 1.6, p = .081). One year mortality rates between EVD versus LD (26.8% vs 19.0%, p = .483). Symptomatic HCP after aneurysmal SAH can be effectively and safely treated with LD. LD had lower overall complications than EVD with no hemorrhage, infection or malfunction. Further prospective randomized control study may be helpful in elucidating optimal CSF diversion for patients with symptomatic HCP.

Medical malpractice claims and state medical board complaints among United States neurointerventionalists

BackgroundSurgeons are at high risk for malpractice claims, which can significantly impact physician quality of life and risk of burnout. There are few published data reporting the incidence, outcomes, and...

Part 1: Pushing the boundaries of neurointerventional surgery: A historical review of the work of Dr Gerard Debrun.

French-American neurointerventionalist and pioneer, Dr Gerard Debrun, laid the groundwork for treatments which have become irreplaceable in neurointerventional surgery today. This article aims to outline the career of Dr Debrun while highlighting his accomplishments and contributions to the field of neurointerventional surgery. We selected relevant articles from PubMed authored or co-authored by Dr Debrun between 1941 and 2023. All included articles discuss the accomplishments and contributions of Dr Debrun. Dr Debrun began his career in France by investigating neurointerventional techniques, most notably the intravascular Detachable Balloon Catheter (DBC). His work was recognized by renowned neurosurgeon Dr Charles Drake, who recruited him to London, Ontario. Dr Debrun created the foundation for homemade manufacturing of DBCs, building on one of the largest series for use of DBCs in cerebrovascular disease. Dr Debrun spent time as faculty at Massachusetts General Hospital (MGH) and Johns Hopkins Hospital, before arriving at the University of Illinois Chicago (UIC) where he remained until his retirement. Dr Debrun's subsequent contributions included the calibrated-leak balloon catheter, pioneering of glue embolization, setting the foundation for preoperative AVM embolizations, and as an early adopter of the Guglielmi detachable coil (GDC), including mastering the balloon remodeling technique for wide neck aneurysms. Dr Debrun established the first integrated neurointerventional surgery program at UIC, establishing a well sought-after fellowship program. Dr Debrun lectured extensively and was a prolific writer on neurointerventional surgery throughout this career. His contributions established the foundation for several techniques which have since become standard practice in present-day neurointerventional surgery.

Reducing Motion Artifacts in Craniocervical Background Subtraction Angiography with Deformable Registration and Unsupervised Deep Learning

Abstract Background In clinical practice, digital subtraction angiography (DSA) often suffers from misregistration artifact due to voluntary, respiratory, and cardiac motion during acquisition. Most prior efforts to register the background DSA mask to subsequent post-contrast images rely on key point registration using iterative optimization, which has limited real-time application. Purpose Leveraging state-of-the-art, unsupervised deep learning, we aim to develop a fast, deformable registration model to substantially reduce DSA misregistration in craniocervical angiography without compromising spatial resolution or introducing new artifacts. Methods We extend HyperMorph, an open source deep learning deformable registration framework, to reduce motion artifacts in DSA. Novel image similarity loss functions with vessel layer estimation were introduced to optimize background registration, making it robust to the variable presence of intravascular iodinated contrast. Results A total of 516 studies with 5,240 angiographic series were collected and divided into training (5046 series) and hold-out test (194 series) sets. Blinded algorithm rankings and Likert scores on five-point scales (1 = worst, 5 = best) were generated by three practicing interventional neuroradiologists using 50 series randomly selected from the hold-out test set. Compared to traditional DSA, our learning-based background subtraction angiography (BSA) significant improved vascular fidelity (2.4 ± 0.6 for DSA vs. 3.6 ± 0.5 for BSA), subtraction artifacts (2.0 ± 0.4 for DSA vs. 3.9 ± 0.3 for BSA), and overall quality (2.1 ± 0.5 for DSA vs. 3.9 ± 0.4 for BSA) (p &amp;lt; 0.0001). Learning-based BSA also significantly outperformed affine registration-based BSA (p &amp;lt; 0.0001). The average inference time for learning-based BSA was 30 milliseconds per frame on our hardware. Conclusion The results demonstrate that deep learning deformable registration, combined with an appropriate loss function, can significantly reduce the motion artifacts that degrade DSA.

Multidisciplinary Approach to Patent Foramen Ovale Closure for Cryptogenic Stroke: Brain-Heart Board Experience.

Patent foramen ovale (PFO) is present in approximately 25% of adult population. The prevalence of PFO is high in patients with cryptogenic stroke suggesting paradoxical embolism. PFO closure in carefully selected patients is an effective secondary preventive strategy in these patients. We report predictors of management recommendations by the multidisciplinary Board and their impact on outcomes. Brain-Heart Board comprises vascular and interventional neurology and cardiology subspecialties (structural, electrophysiology, and cardiac imaging). Adult patients referred to the Board for consideration of PFO closure between October 2017 to March 2021 were included in this retrospective cohort analysis. Demographics, comorbid conditions, risk of paradoxical embolism (RoPE) score, event frequencies (transient ischemic attack [TIA] or stroke, intracranial hemorrhage [ICH], post-PFO closure cardiac arrhythmias), and modified Rankin Scale (mRS) at 1 year were compared between the groups (PFO closure vs medical management). Multivariable logistic regression was used to identify factors associated with management recommendation and chi-square tests to test differences in outcomes for patients according to management. Two hundred seventy patients (229 stroke; 41 TIA) were discussed by the Board for PFO closure. 119 (44.0%) patients were recommended for PFO closure of which 117 (98.3%) had evidence of ischemic infarct on imaging. In univariate analysis, age was similar (50 ± 11.9 vs 52 ± 12.8, p = 0.17), but RoPE score was higher in closure as compared with the medical management group (6 [IQR 5-7] vs 5 [IQR 4-7], p < 0.05). In multivariable analysis, TIA as the index event was an independent predictor of Board recommendation against PFO closure (OR 0.05, 95% CI 0.01-0.19, p < 0.05). Event frequency was low in both cohorts (5.9% vs 4.8%, p > 0.05) and comprised cardiac arrhythmias (6 cases of atrial fibrillation and 1 ICH in closure group; 1 TIA and 1 recurrent stroke in medical management group). Excellent functional outcome (mRS 0-1) was similar in both cohorts (66.3% vs 70.7%, p > 0.05) at 1 year. Multidisciplinary Brain-Heart Board provides a clinical practice model of collaborative care to ensure proper patient selection for PFO closure. TIA as the index event is associated with recommendation of medical management by the multidisciplinary Brain-Heart Board.

The 100 highest-cited original articles in large vessel occlusions: A bibliometric analysis.

Large vessel occlusions (LVO) are a common etiology of morbidity and mortality. The current literature lacks a synthesis of the landscape and trends in research. We aimed to conduct a bibliometric analysis of the 100 most cited original articles on LVOs to assess the current state of research. Scopus database was queried from inception to December 2022 to identify the most cited original articles from 4506 retrieved records on LVOs. Publication year, country of origin, total and average annual citation count, and type of study were collected for each article. The journal impact factor (JIF) was obtained from the Journal Citation Reports database. The articles were published between 1994 and 2021, with most (n = 82) published during the 2011-2020decade. The median total citation count was 108.5, with an interquartile range (IQR) of 81-149.5. The median (IQR) average annual citation count was 15.9 (11.5-22.9). Half of the articles were published in Stroke (n = 35) and Journal of NeuroInterventional Surgery (n = 15), with JIFs ranging from 1.8 to 202.7. The USA was the leading country in contributing to LVO research (n = 45). Most studies focused on the treatment (n = 63) and diagnosis (n = 22) of LVOs. Most articles were published during the past decade, highlighting the impact of the clinical trials of endovascular treatment on the discipline. With several ongoing clinical trials on the horizon, continued growth of the field is anticipated in the upcoming decades.

Association of radiation-induced epilation and interventional neuroradiology procedures.

The aim of this study is to quantify the association of temporary epilation following interventional neuroradiology (INR) procedures and compare the peak skin dose (Dskin,max) threshold to published values. Gold Coast University Hospital (GCUH) is a major centre for INR with over 500 primarily interventional procedures performed every year. Dskin,max is calculated when the reference air kerma (Ka,r) exceeds 3 Gy. If the Dskin,max exceeds 3 Gy, the patient is followed up for any skin effects. An audit was undertaken of these results over a 2-year period. From January 2020 to December 2021, 140 patients who underwent INR procedures had a Ka,r > 3 Gy, 66 resulted in a calculated Dskin,max >3 Gy, and 45 were successfully followed up. Twenty patients (44%) reported no skin effects and 25 (56%) reported skin effects, which were almost exclusively epilation. The mean (range) Dskin,max for patients with no reported skin effects and those with observed skin effects was 4.6 Gy (3.0-11.1 Gy) and 4.2 Gy (3.0-7.0 Gy), respectively. These results demonstrate that temporary epilation was observed in 56% of patients, in a cohort of 45 patients who underwent an INR procedure with calculated Dskin,max >3 Gy and successful follow-up. The results support evidence in the literature that suggests the approximate threshold for temporary epilation reported by the International Commission on Radiological Protection (ICRP) may be too high for incidence of this effect, specifically on the scalp, when Dskin,max is calculated from Ka,r (using commonly used corrections and assumptions in the calculation).

Predictive value of early serum ACSL4 and ASITN/SIR grade for motor function recovery in patients with post-ischemic stroke lower limb neurological sequelae after modified constraint-induced movement therapy

BackgroundIschemic stroke accounts for over 85 % of all stroke types. Acyl-CoA synthetase long chain family member 4 (ACSL4) is considered to promote myocardial and cerebral ischaemia/ reperfusion. However, up to now, no study focused on the role of ACSL4 in patients with post-stroke lower limb neurological sequelae. ObjectiveThe present study aimed to investigate the predictive value of ACSL4 and collateral circulation for lower limb neurological sequelae of ischemic stroke patients after modified constraint-induced movement therapy (mCIMT). MethodsThis is a prospective cohort study which included 99 ischemic stroke patients with lower limb neurological sequelae who were admitted to our hospital during January 2021 to December 2022. All patients received mCIMT after the admission. Collateral circulation was evaluated by digital subtraction angiography (DSA) and graded by the American Society of Interventional and Therapeutic Neuroradiology/ Society of Interventional Radiology (ASITN/SIR) grading system. Enzyme linked immunosorbent assay (ELISA) was used to detect serum ACSL4. Basic characteristics were collected and lower limb motor function was measured by Fugl-Meyer score (FMS), modified Ashworth score (MAS) and Brunnstrom stage, as well as timed up and go (TUG) test, ten-Meter walk test (10MWT), and six-minute walk test (6MWT) before and after treatment. ResultsSerum ACSL4 and percentage of patients with ASITN/SIR 0–1 decreased significantly after treatment compared with the values before treatment. Patients with higher baseline serum ACSL4 values at admission showed significantly lower FMS scores, higher TUG and 10MWT, as well as lower 6MWT. Patients with ASITN/SIR grade 0–1 at admission only showed significantly higher TUG and 10MWT, as well as lower 6MWT. Receiver operating characteristic (ROC) curves showed ACSL4 and ASITN/SIR grade could be used to predict the prognosis. Logistic regression found only national institutes of health stroke scores (NIHSS) was the independent risk factor for post-treatment motor impairment after mCIMT. ConclusionHigher levels of ACSL4 and ASITN/SIR 0–1 are associated with poor recovery of motor functions of patients with post-stroke sequelae after mCIMT.

Visualization of intracranial aneurysms treated with Woven EndoBridge (WEB) devices using Ultrashort Echo Time Magnetic Resonance Imaging (UTE-MRI).

Assessing treatment success of intracranial aneurysms treated with Woven EndoBridge (WEB) devices using MRI is important in follow-up imaging. Depicting both the device configuration as well as reperfusion is challenging due to susceptibility artefacts. We evaluated the usefulness of contrast-enhanced 3D-Ultrashort Echo-Time (UTE) sequence in this setting. In this prospective study, 12 patients (9 female) with 15 treated aneurysms were included. These 12 patients underwent 18 MRI examinations. Follow-up UTE-MRI controls were performed on the same 3-Tesla scanner. We compared the visualization of device configuration, artifact-related virtual stenosis of the parent vessel and WEB occlusion scale in 3D isotropic UTE-MRI post-contrast with standard time-of-flight (TOF) MR-angiography with (CE) and without intravenous contrast as well as DSA. Two interventional neuroradiologists rated the images separately and in consensus. Visualization of the WEB device position and configuration was rated superior or highly superior using the UTE sequence in 17/18 MRIs compared to TOF-MRA. Artifact-related virtual stenosis of the parent vessel was significantly lower in UTE-MRI compared to TOF and CE-TOF. Reperfusion was visible in 8/18 controls in DSA. TOF was able to grade reperfusion correctly in 16 cases, CE-TOF in 16 cases and UTE in 17 cases. Contrast-enhanced UTE is a novel MRI sequence that shows benefit compared to standard sequences in non-invasive and radiation-free follow-up imaging of intracranial aneurysms treated using the WEB-device. ACoA = anterior communicating artery, BA = basilar artery, CEA = contrast enhanced angiography, ICA = internal carotid artery, MCA = middle cerebral artery, PCom = posterior communicating artery TOF-CE = contrast enhanced time-of-flight angiography, UTE = ultra-short echo time, WEB = woven endobridge.

“TIPS” and Technical Nuances for Digital Illustration in Neurointerventional Surgery

Medical illustrations represent a precious resource for learning surgical anatomy and surgical techniques, allowing preoperative and postoperative reviews. As traditional hand-drawn illustrations are difficult to use and expressing the area of neurointerventional surgery is time-consuming, we proposed methods for neurointerventional surgeons to create digital illustrations (DIs) for neurointerventional surgery using the iPad-exclusive Procreate application (Savage Interactive, Hobart, Australia). Dedicated "digital pens" were created and used for each endovascular device, creating straightforward representations of neurointerventional procedures and changes over time. DIs in neurointervention easily depict changes to highlighted surgical scenes for various devices with complex configurations and structures. DIs are also versatile, allowing easy intrainstitutional and interinstitutional sharing and discussion of technical tips on the manipulation of medical devices (coils, catheters, stents, etc.) among neurointerventional surgeons worldwide. DIs can be applied as educational tools not only in neurointerventional surgery, but also in craniotomy surgery and for surgical records from other specialties.

Safety and efficacy of stent retrievers plus contact aspiration in patients with acute ischaemic anterior circulation stroke and positive susceptibility vessel sign in France (VECTOR): a randomised, single-blind trial

Positive susceptibility vessel sign (SVS) in patients with acute ischaemic stroke has been associated with friable red blood cell-rich clots and more effective recanalisation using stent retrievers versus contact aspiration. We compared the safety and efficacy of stent retrievers plus contact aspiration (combined technique) versus contact aspiration alone as the first-line thrombectomy technique in patients with acute ischaemic anterior circulation stroke and SVS-positive occlusions. Adaptive Endovascular Strategy to the Clot MRI in Large Intracranial Vessel Occlusion (VECTOR) was a prospective, randomised, open-label study with blinded evaluation. Patients with SVS-positive anterior circulation occlusions on pretreatment MRI and arterial puncture within 24 h of symptom onset were enrolled from 22 centres in France. A centralised web-based method was used by interventional neuroradiologists for dynamic randomisation by minimisation. Patients were randomly assigned 1:1 to the combined technique or contact aspiration alone. The primary outcome was expanded Thrombolysis in Cerebral Infarction (eTICI) grade 2c or 3 reperfusion after three or fewer passes on post-treatment angiogram, adjudicated by a blinded independent central imaging core laboratory. The intention-to-treat population was used to assess the primary and secondary outcomes. This trial is registered with ClinicalTrials.gov (NCT04139486) and is complete. Between Nov 26, 2019, and Feb 14, 2022, 526 patients were enrolled, of whom 521 constituted the intention-to-treat population (combined technique, n=263; contact aspiration alone, n=258). The median age of participants was 74·9 years (IQR 64·4-83·3); 284 (55%) were female and 237 (45%) male. The primary outcome did not differ significantly between groups (152 [58%] of 263 patients for the combined technique vs 135 [52%] of 258 for contact aspiration; odds ratio [OR] 1·27; 95% CI 0·88-1·83; p=0·19). Procedure-related adverse events occurred in 32 (12%) of 263 patients in the combined technique group and 27 (11%) of 257 in the contact aspiration group (OR 1·14; 0·65-2·00; p=0·65). The most common adverse event was intracerebral haemorrhage (146 [56%] of 259 patients for the combined technique vs 123 [49%] of 251 for contact aspiration; OR 1·32; 0·91-1·90; p=0·13). All-cause mortality at 3 months occurred in 57 (23%) of 251 patients in the combined technique group and 48 (19%) of 247 in the contact aspiration group (OR 1·19; 0·76-1·86; p=0·45), none of which was treatment-related. The results of the VECTOR trial do not show superiority of the combined stent retriever plus contact aspiration technique over contact aspiration alone in patients with SVS-positive occlusion with respect to achieving eTICI 2c-3 within three passes. These findings support the use of either the combined technique or contact aspiration alone as the initial thrombectomy strategy in patients with acute anterior circulation stroke with SVS on pretreatment MRI. Cerenovus.