Duncan Mark Brooks

Endovascular mechanical thrombectomy in large-vessel occlusion ischemic stroke presenting with low national institutes of health stroke scale: systematic review and meta-analysis

INTRODUCTION Mechanical thrombectomy has become the standard of care for management of most large vessel occlusion (LVO) strokes. When patients with LVO present with minor stroke symptomatology, no consensus on the role of mechanical thrombectomy exists. METHODS A systematic review and meta-analysis were performed to identify studies that focused on mechanical thrombectomy, either as a standalone treatment or with intravenous tissue plasminogen activator (IV tPA), in patients with mild strokes with LVO, defined as a baseline National Institutes of Health Stroke Scale score ≤5 at presentation. Data on methodology, quality criteria, and outcome measures were extracted, and outcomes were compared using odds ratio as a summary statistic. RESULTS Five studies met the selection criteria and were included. When compared with medical therapy without IV tPA, mechanical thrombectomy and medical therapy with IV tPA were associated with improved 90-day modified Rankin Scale (mRS) score. Among medical patients who were not eligible for IV tPA, those who underwent mechanical thrombectomy were more likely to experience good 90-day mRS than those who were not. There was no significant difference in functional outcome between mechanical thrombectomy and medical therapy with IV tPA, and no treatment subgroup was associated with intracranial hemorrhage or death. CONCLUSIONS In patients with mild strokes due to LVO, mechanical thrombectomy and medical therapy with IV tPA led to better 90-day functional outcome. Mechanical thrombectomy plays an important role in the management of these patients, particularly in those not eligible for IV tPA.

The 100 most cited articles in the endovascular management of intracranial aneurysms

Introduction Endovascular interventions for intracranial aneurysms have evolved substantially over the past several decades. A citation rank list is used to measure the scientific and/or clinical impact of an article. Our objective was to identify and analyze the characteristics of the 100 most cited articles in the field of endovascular therapy for intracranial aneurysms. Methods We performed a retrospective bibliometric analysis between July and August 2017. Articles were searched on the Science Citation Index Expanded database using Web of Science in order to identify the most cited articles in the endovascular therapy of intracranial aneurysms since 1945. Using selected key terms (‘intracranial aneurysm’, ‘aneurysm’, ‘aneurysmal subarachnoid’, ‘endovascular’, ‘coiling’, ‘stent-assisted’, ‘balloon-assisted’, ‘flow-diversion’) yielded a total of 16 314 articles. The top 100 articles were identified and analyzed to extract relevant information, including citation count, authorship, article type, subject matter, institution, country of origin, and year of publication. Results Citations for the top 100 articles ranged from 133 to 1832. All articles were cited an average of 27 times per year. There were 45 prospective studies, including 7 level–II randomized controlled trials. Most articles were published in the 2000s (n=53), and the majority constituted level III or level IV evidence. Half of the top 100 articles arose from the USA. Conclusion This study provides a comprehensive overview of the most cited articles in the endovascular management of intracranial aneurysms. It recognizes the contributions made by key authors and institutions, providing an important framework to an enhanced understanding of the evidence behind the endovascular treatment of aneurysms.

Endovascular Treatment of Wide-Necked Visceral Artery Aneurysms Using the Neurovascular Comaneci Neck-Bridging Device: A Technical Report.

IntroductionVisceral and renal artery aneurysms (VRAAs) are an uncommon clinical entity but carry a risk of rupture with associated morbidity and mortality. The rupture risk is particularly high when the aneurysms are large, of unfavourable morphology or in the setting of pregnancy and perioperative period. Endovascular approaches are now first line in the treatment of VRAA, but conventional techniques may be ineffective in excluding aneurysms with unfavourable anatomy such as those with wide necks or at arterial bifurcation points. The neurovascular Comaneci neck-bridging device is used to temporarily cover the neck of intracranial aneurysms without occluding forward arterial flow during endovascular coiling. We report the novel use of the Comaneci neck-bridging device for the treatment of complex peripheral VRAAs.Materials and MethodsWe describe the treatment of two patients with renal and splenic artery aneurysms demonstrating unfavourable anatomic morphology for conventional endovascular approaches.ResultsIn the first patient, the renal artery aneurysm was situated at the intrarenal bifurcation of the main renal artery in the setting of a solitary kidney. In the second patient, the splenic artery aneurysm was situated close to the splenic hilum at the distal splenic arterial bifurcation. The Comaneci neck-bridging device was successfully used in both cases to assist coil embolisation with visceral preservation.ConclusionsThe Comaneci neck-bridging device is potentially safe and effective for the treatment of peripheral VRAA with unfavourable anatomic characteristics that would have been deemed unsuitable for treatment using conventional techniques.Level of EvidenceLevel 4, Technical Report.

Percutaneous Placement of Permanent Metallic Stents in the Cystic Duct to Treat Obstructive Cholecystitis

This report presents a series of five patients unsuitable for surgery who had nonretrievable self-expanding metallic stents deployed along the cystic duct as treatment for benign and malignant causes of gallbladder obstruction. Techniques are described for draining cholecystitis, removing gallstones, bypassing gallbladder obstructions, and inserting metallic stents across the cystic duct to restore permanent antegrade gallbladder drainage in acute and chronic cholecystitis. Symptoms resolved in all cases, and stents remained patent for as long as 22 months. This procedure may be an effective alternative to cholecystectomy or long-term gallbladder drainage for patients in inoperable condition.

Contact Aspiration versus Stent-Retriever Thrombectomy for Distal Middle Cerebral Artery Occlusions in Acute Ischemic Stroke: Meta-Analysis

Purpose The evidence for endovascular therapy and choice of technique in distal middle cerebral artery (MCA) M2 segment occlusions in acute ischemic stroke remains controversial. We aimed to conduct a systematic review and meta-analysis primarily comparing reperfusion rates of stent-retrieval versus contact aspiration for M2 occlusions. Materials and Methods Study selection included cohorts of patients with distal MCA occlusions in acute ischemic strokes treated with an endovascular approach including stent-retrieval or contact aspiration. Twelve studies were selected for meta-analysis for a total of 835 cases. Meta-analysis by proportions was conducted on parameters including baseline and procedural characteristics, thrombolysis in cerebral infarction (TICI) 2b–3 outcomes, and 90-day modified Rankin scale (mRS) outcomes. Results Hypertension and hyperlipidemia were more prevalent in stent-retriever patients. Pooled baseline National Institute of Health Stroke Scale scores and Alberta Stroke Program Early Computed Tomography Score imaging scores were similar. Pooled time onset of symptoms to door arrival was higher for the stent-retrieval group (154 vs. 97.4 minutes, P=0.01), as was time to groin puncture (259.9 vs. 156.2 minutes, P=0.02), but there was no difference in procedure time. The TICI 2b–3 recanalization rate was similar (80.5% vs. 86.8%, P=0.168). The frequency of mRS 0–2 at 90-day was also similar (74.5% vs. 59.9%, P=0.120), and an excellent mRS 0–1 was lower for stent-retrievers (39.9% vs. 65.6%, P=0.003). A significant negative correlation was found between onset to groin puncture time and the proportion of patients with a good mRS (r=-0.71, P=0.048). Conclusion Both endovascular techniques achieved recanalization rates greater than 80% and 90-day outcomes of minimal disability with similar complication rates. The literature is skewed by aspiration cases being performed sooner after onset of stroke compared to stent-retriever cases.

E-132 Optimising resources for endovascular clot retrieval for acute ischaemic stroke using a discrete-event simulation model

Background Endovascular Clot Retrieval (ECR) is the standard of care for acute stroke due to a large vessel occlusion. It is a time critical and complex process involving many specialized care providers and resources. Maximizing patient benefit while minimizing cost of this service requires optimization of human and physical assets. The aim of this study was to develop a computer simulation of an ECR service designed to optimize resource allocation. Method Using Simmer-a Discrete Event Simulation (DES) software- as frequently employed in complex logistical operations, we have developed a comprehensive computational model that closely mimics the environment of an ECR service from presentation to emergency department to the angio suite. This model was tested using real data collected from a quaternary institution with ECR service. Results Our model assesses the impact of available services, and aids optimization of resource distribution and access, allowing comparison of various competing strategies. In this simulation, the numbers of different human or capital resources such as stroke physicians, neuro-interventionists, and angiography equipment can be varied to assess the impact on efficiency and availability of service delivery. Other factors and variables such as equipment breakdown, servicing or times taken during components of an individual stroke management pathway can also be integrated, to identify sources of systemic delay and cost-points, with a view to service improvement. Conclusion A novel computer simulation is proposed to assess resource allocation, directed at optimizing the timely, effective and equitable application of human and physical resources. This model can provide clinically important data to help existing ECR services, in targeting optimum service delivery and best patient outcomes. Disclosures S. Huang: None. J. Maingard: None. H. Kok: None. C. Barras: None. V. Thijs: None. R. Chandra: None. D. Brooks: None. H. Asadi: None.

Renal Embolization and Urothelial Sclerotherapy for Recurrent Obstructive Urosepsis and Intractable Haematuria from Upper Tract Urothelial Carcinoma

Management of intractable haematuria and obstructive urosepsis from upper tract urothelial carcinoma can be problematic in patients not suitable for surgery, chemotherapy or radiotherapy. Interventional radiology techniques provide alternative approaches in this setting, such as complete kidney embolization to cease urine output, percutaneous nephrostomy, antegrade injection of sclerotherapy agents and sterilisation of the upper collecting system. Related approaches have been successfully employed to sclerose renal cysts, lymphoceles, chyluria and intractable lower tract haemorrhage. No reports of percutaneous, antegrade sclerotherapy in the upper urinary tract have previously been published. We present a case of recurrent haematuria and obstructive urosepsis caused by invasive upper tract urothelial carcinoma in a non-operative patient, which was treated with renal embolisation and percutaneous upper tract urothelial sclerotherapy.

Retrieval of marrow and tumor embolus from inferior vena cava filter following internal fixation of metastatic long bone tumor: a case study.

inferior phrenic, or renal arteries (1). There can also be multiples of each adrenal artery branch. This is further complicated by the frequent occurrence of variant anatomy of the renal arteries. Variant renal artery anatomy is divided into early-dividing renal arteries and supernumerary renal arteries. The prevalence of variant renal artery anatomy is generally between 28% and 30% (4). The anatomic variant described in the present case makes a thorough diagnostic angiogram critical before adrenal embolization, as it was in this case. The most common complications of adrenal artery embolization are flank pain and low-grade fever in the 48 hours following the procedure. In summary, an adrenal myelolipoma is a benign lesion that can lead to retroperitoneal hematoma spontaneously or following trauma. In this case, adrenal artery embolization was an effective alternative to adrenalectomy, which was not performed in view of the patient’s cardiovascular risk profile. Further prospective data are needed to determine the long-term safety and efficacy of adrenal embolization of hemorrhagic adrenal lesions in patients who are unsuitable for surgery.