Faculty Bibliography

BACKGROUND:Recent studies have suggested that favorable venous outflow (VO) may be a promising imaging biomarker to predict clinical outcomes following reperfusion therapy in patients with acute ischemic stroke caused by large vessel occlusion (AIS-LVO). METHODS:A comprehensive literature search was conducted in PubMed, Scopus, WOS, and Cochrane to identify studies that evaluated VO profiles, assessed using the Cortical Vein Opacification Score (COVES). The risk ratio (RR) and 95% confidence interval (CI) for the outcomes, including functional independence, assessed by modified rankin scale at 90 days (mRS 0-2), hemorrhagic infarction, parenchymal hematoma, 90-day mortality, intracranial hemorrhage (ICH), and symptomatic ICH (sICH), were calculated and analyzed using the 'meta' package in R version 4.4.1. RESULTS:A total of six studies encompassing 2249 patients were included. Patients with favorable VO had a higher likelihood of achieving functional independence at 90 days (RR = 2.15; 95% CI: 1.35, 3.42; p = 0.01) and a lower incidence of 90-day mortality (RR = 0.39; 95% CI: 0.30, 0.51; p < 0.01), parenchymal hematoma (RR = 0.36; 95% CI: 0.27, 0.47; p < 0.01). Furthermore, sICH was less frequent in patients with favorable VO (RR = 0.39; 95% CI: 0.17, 0.89; p = 0.03). However, hemorrhagic infarction and any ICH did not differ significantly between the two groups (p-values: 0.06 and 0.32, respectively). CONCLUSION/CONCLUSIONS:VO is a promising imaging biomarker for predicting outcomes in patients with AIS-LVO following reperfusion therapy. Prospective clinical trials are warranted to investigate the predictive value of VO, assessed on multiphasic computed tomography angiography (CTA), as a prognostic marker in this patient population.

Imaging follow-up is an established component of intracranial aneurysm management that allows ongoing assessment of rupture risk and timely intervention to maintain protection from bleeding. Yet the frequency, duration, and imaging modality for follow-up vary widely. This review outlines contemporary imaging techniques and practice for follow-up of treated and untreated aneurysms, highlighting existing knowledge gaps and technical limitations that limit standardization. Updated evidence on the expected evolution and long-term outcome of common treatment strategies is presented to guide accurate reporting of radiological outcome after treatment and considerations regarding follow-up regimen.

Although the concept of treating cerebral aneurysms by filling the sac from the inside (endosaccular) started many years ago first with detachable balloons and then coils, the use of a single metallic resheathable device acting as a flow disruptor is a much more recent innovation. The most studied device among these is certainly the WEB, which became part of standard clinical practice for treatment of wide-neck bifurcation aneurysms. This study reviews the most important features of the WEB device with a short summary of the most important literature. A small section at the end reviews also other endosaccular devices.

Definitive endoluminal reconstruction, widely known as flow diversion, revolutionized treatment of brain aneurysms. A range of targets, by location, size, etiology, and acuity, can be cured with an excellent risk/benefit profile. Requirement for effective antiplatelet state is balanced with superior treatment durability. Implant and delivery system technology continue to evolve. Some aneurysm types/locations remain undertreated. Maximizing efficacy while minimizing risks requires deep understanding of flow diversion principles, pathologic anatomy, endoluminal implants, delivery systems, and clinical management.

This article looks at the current state of aneurysm risk modeling, exploring the limitations of linear measurement. It reviews articles using Food and Drug Administration (FDA)-approved artificial intelligence-driven volumetric measurement tools both for evaluating potential aneurysm growth in patients being managed conservatively as well as in assessing morphologic change prerupture and postrupture. The challenges of defining the aneurysm boundary are explored, and a novel definition of aneurysm/parent artery interface is proposed.

BACKGROUND AND OBJECTIVES/OBJECTIVE:The Silk Vista Baby (SVB) flow diverter (FD) stent (Balt SAS) is the first device designed for treating distally located brain aneurysms. It can be delivered through a 0.017-inch ID microcatheter, enabling access to small, distal vessels. The aim of this study was to evaluate the effectiveness, safety, technical success, occlusion rate, and clinical outcomes of the SVB device. METHODS:This retrospective, multicenter study included data from 18 centers from November 2023 to September 2024. Procedures were performed by experienced neurointerventionalists following institutional standards of care. Outcomes analyzed included effectiveness, safety, and aneurysm occlusion rates. Descriptive analyses and Pearson χ2 or Independent t-Test were used for statistical evaluation. RESULTS:A total of 95 patients, mean age 55.4 years, were included. A total of 31% of aneurysms were ruptured at admission. Most (58.3%) were located in the anterior circulation, and 45% had previous treatment, mainly coiling (69.4%). Complication rates were higher for ruptured aneurysms (24.1%) compared with unruptured ones (9.2%). Two deaths occurred, 1 (1.1%) related to the procedure. At discharge, 87% of patients had modified Rankin Scale ≤2. The latest follow-up showed overall complete/near-complete occlusion rates of 76.1%, with 81.14% for ruptured and 73.43% for unruptured aneurysms. Technical success was higher in unruptured cases (100% vs 93.1%). CONCLUSION/CONCLUSIONS:Our case series demonstrated the efficacy of the SVB with a high rate of technical success. The occlusion rates for ruptured cases are comparable with those of other FDs. However, the rates are lower for unruptured cases. This discrepancy is likely due to the characteristics of the aneurysms, particularly in the presence of side branches in bifurcation lesions. The SVB safety profile is similar to other FDs in unruptured cases, while the ruptured group presented more complications.

PURPOSE/OBJECTIVE:Treating small-caliber vessel aneurysms with flow diverters poses challenges due to narrow luminal diameters and tortuous vasculature, which complicate the navigation and deployment of conventional devices using standard microcatheters. The Silk Vista Baby (SVB, Balt, Montmorency, France) flow diverter was developed to treat intracranial aneurysms located in smaller vessels or more distal segments and is compatible with 0.017″ microcatheters. We present the largest multicenter analysis to date evaluating the outcomes of SVB use in unruptured distal anterior cerebral artery (DACA) aneurysms. METHODS:Retrospective data from 20 centers were reviewed for patients with unruptured DACA aneurysms treated with the SVB. Demographic information, clinical presentation, radiographic characteristics, complications, and outcomes were recorded. RESULTS:Seventy-nine patients (79 DACA aneurysms) were treated between January 2018 and December 2022; 59 were female (74.7%), and the median age was 61 years (IQR 53-67). Most aneurysms were saccular (89.9%), and 65.8% involved a branch. The median parent vessel diameter was 1.9 mm (IQR 1.7-2.1). A single stent was implanted in 97.5% of cases; 2.5% required two stents. The median imaging follow-up duration was 12 months (IQR 9.5-24). At the last follow-up, 76% of aneurysms showed complete or near-complete occlusion (O'Kelly-Marotta scale C or D, Raymond-Roy 1 or 2). Overall, thromboembolic or hemorrhagic complications occurred in 14% of patients, with two cases being symptomatic. The mortality rate was 0%, and the retreatment rate was 1.3%. CONCLUSION/CONCLUSIONS:In this multicenter series, the SVB flow diverter represented a valuable treatment option for distal anterior cerebral artery (DACA) aneurysms.

BackgroundLarger "macrowires" may facilitate microcatheter-free delivery of large-bore aspiration catheters (ACs) for intracranial endovascular mechanical thrombectomy. We examined the safety and efficacy of the Aristotle Colossus Guidewire for this use.MethodsIn this retrospective analysis of prospective data from 12 institutions, we identified anterior circulation endovascular mechanical thrombectomy cases involving the Aristotle Colossus guidewire over a 12-month period. The primary efficacy endpoint was successful delivery of the AC to the site without the use of adjunct devices. Multivariable logistic regression was performed with clinically relevant covariables.ResultsIn 122 patients (median age 74 years (interquartile range (IQR) 63-82)), most intracranial occlusions were in the M1 segment of the middle cerebral artery (95/122, 78.0%). The primary endpoint of microcatheter-free AC delivery was met in 87.7% (107/122) of patients; 93/122 (76.2%) patients underwent microcatheter-free delivery with successful reperfusion via contact aspiration (modified thrombolysis in cerebral infarction grade ≥ 2B). The median number of passes was 1 (IQR 1-2). Multivariable regression demonstrated that severe internal carotid artery tortuosity or cervical loop presence (odds ratio (OR): 0.09, 95% confidence interval (CI): 0.01-0.54, p = 0.01) and presence of intracranial atherosclerotic disease (OR: 0.15, 95% CI: 0.03-0.83, p = 0.03) were significantly associated with lower odds of successful AC delivery over the guidewire. Intraprocedural vasospasm occurred in 4.9% (6/122) of cases; there were no reports of vessel dissection or perforation.ConclusionsWe demonstrate the favorable performance of the Aristotle Colossus guidewire for anterior circulation ischemic stroke intervention. The macrowire appears to safely facilitate navigation of the neurovasculature by large-bore ACs without the need for microcatheter and/or stentriever.

BACKGROUND:Intravenous thrombolysis (IVT), utilizing the clot-dissolving medications alteplase (rt-PA) or tenecteplase (TNK), is the cornerstone in acute ischemic stroke (AIS) emergency intervention. However, the impact of prior antiplatelet therapy (APT) on post-IVT outcomes when utilizing alteplase remains controversial. We conducted a systematic review and meta-analysis to evaluate the effect of prior APT on the outcomes after using alteplase in AIS patients. METHODS:We conducted a systematic review and meta-analysis synthesizing studies, which were retrieved by systematically searching PubMed, Web of Science, SCOPUS, and Cochrane through June 30, 2024. We used the R language V. 4.3. to pool dichotomous data using odds ratio (OR) with a 95% confidence interval (CI). PROSPERO ID/UNASSIGNED:CRD42024495393. RESULTS:Thirty studies were included in our analysis, with 436,232 patients. Prior APT was significantly associated with increased odds of symptomatic intracranial hemorrhage (sICH) (OR, 1.78; 95%CI [1.48, 2.13]; P < 0.01), any ICH (OR, 1.44; 95%CI [1.16, 1.78]; P < 0.01), mortality (OR, 1.39; 95%CI [1.23, 1.58]; P < 0.01), and poor functional outcomes (modified Rankin Scale score of 3-6 [mRS 3-6]) (OR, 1.81; 95%CI [1.03, 3.19]; P = 0.04). Additionally, prior APT significantly reduced the odds of good functional outcome [mRS 0-2] (OR, 0.85; 95%CI [0.74, 0.97]; P = 0.02). CONCLUSION/CONCLUSIONS:Prior APT increased hemorrhagic complications, mortality, and poor functional outcome, while reducing the odds of good functional outcome after IV alteplase. Future research should focus on identifying adjunctive agents that may decrease hemorrhagic complications and investigate the impact of various APT regimens and alternative thrombolytics beyond alteplase in this specific population.

IntroductionFlow diversion with the pipeline embolization device (PED) is an effective endovascular treatment. However, the metal surface's thrombogenicity and need for dual antiplatelet therapy (DAPT) are notable limitations. Few prior studies have reported specifically on flow diverters' safety in patients with hemoglobinopathies, a population at increased risk of thrombotic and hemorrhagic complications.MethodsNatural language processing queried our institution's medical records for intracranial embolization procedures from 2014 to 2024, screening for "hemoglobinopathy," "thalassemia," and "sickle cell." Patient charts were retrospectively reviewed.ResultsSixteen procedures in 14 patients were identified in which a mean 2.0 PEDs per patient were used. Most patients were female (71.4%). Median age was 48.8 years. Five patients had sickle cell disease, two had sickle cell trait, two had sickle cell or hemoglobin C trait and alpha thalassemia minor, and five had alpha thalassemia minor. The 14 patients were treated for 20 aneurysms; four treatments covered two distinct aneurysms. Median dome size per treatment was 4.0 mm. Of the 16 aneurysm treatments, five (31.2%) treated an irregular aneurysm. Most (56.2%) treatments used multiple PEDs. All patients were discharged on DAPT after verifying effect with P2Y12 assays. Follow-up DSA, CTA, or MRA was obtained in 12/14 (85.7%) patients at a median 1.6 years. Complete occlusion was achieved in all aneurysms. Clinical follow-up was obtained in all patients at a median 2.2 years. There were no thromboembolic or hemorrhagic complications, neurological deficits, or mortalities.ConclusionPipeline embolization can safely and effectively treat patients with hemoglobinopathies.