Reade De Leacy

Predictors of treatment failure following coil embolization of intracranial aneurysms

We present a retrospective review of 357 consecutive patients with 419 aneurysms treated with coil embolization. Although incomplete occlusion and recurrence of intracranial aneurysms following coil embolization is a well-known problem, the factors that influence and predict treatment failure are still debated. For this study, we excluded non-coiling endovascular techniques (flow diversion) and non-saccular aneurysms (fusiform). The modified Raymond-Roy occlusion classification (MRRC) was used to grade the aneurysms. Treatment failure was defined as filling of the aneurysm dome (MRRC Class IIIa or IIIb) at the first angiographic follow-up (average 8 months). Univariate statistical tests were employed to select variables for incorporation into a multivariable logistic regression model. Multivariate analysis identified greater aneurysm volume (p<0.001), packing density (PD) less than 31% (p=0.007) and initial MRRC Class IIIb (p<0.001) as predictors of treatment failure. Incomplete neck coverage with coils was associated with treatment failure in univariate but not multivariate analysis. Class IIIb status was more predictive of treatment failure compared to all Class III (odds ratio 168 versus 14.4). Clinical outcomes were similar in both groups except that there were more retreatments in the treatment failure group (p<0.001). Aneurysm volume, PD and initial occlusion class are associated with angiographic outcome, consistent with prior literature. The MRRC is a powerful predictor of treatment failure. These results will be useful in the effort to both prevent and predict treatment failure after coil embolization, however, they should be verified in a prospective study.

Angiographic outcome of intracranial aneurysms with neck remnant following coil embolization.

Background The degree of aneurysm occlusion following coil embolization has an impact on aneurysm recanalization. Objective To explain the natural history of intracranial aneurysms with neck remnant, Raymond–Roy Occlusion Classification (RROC) class II. Methods A single-center, retrospective study of 198 patients with 209 aneurysms treated with coil embolization that were initially either RROC class I or II. The angiographic outcomes at short- and long-term follow-up were compared as well as the complication/re-treatment rates. Atypical aneurysms and those that had been previously treated were excluded. Results Ninety-nine class I aneurysms were compared with 110 class II aneurysms. There was no difference in recanalization rate between the groups (class I 3.3% vs class II 8.5%, p=0.478) at short-term follow-up (8.2 months) and at subsequent follow-ups (21.7 and 52.1 months). There was also no difference in re-treatment rates (class I 3.3% vs class II 8.5%, p=0.196) or complication rates (class I 9.1% vs class II 4.6%, p=0.12). There were no aneurysm ruptures after treatment in either group. Conclusions The angiographic outcome of aneurysms with neck remnant following coil embolization is similar to that of completely occluded aneurysms in that most remain stable and few recanalize. This understanding could potentially help the interventional neurosurgeon avoid complications such as coil herniation, vessel compromise, and stroke in selected cases. Further investigation with a larger patient population is warranted.

Endovascular management of fusiform aneurysms in the posterior circulation: the era of flow diversion

Fusiform aneurysms are uncommon compared with their saccular counterparts, yet they remain very challenging to treat and are associated with high rates of rebleeding and morbidity. Lack of a true aneurysm neck renders simple clip reconstruction or coil embolization usually impossible, and more advanced techniques are required, including bypass, stent-assisted coiling, and, more recently, flow diversion. In this article, the authors review posterior circulation fusiform aneurysms, including pathogenesis, natural history, and endovascular treatment, including the role of flow diversion. In addition, the authors propose an algorithm for treatment based on their practice.

Factors associated with successful revascularization using the aspiration component of ADAPT in the treatment of acute ischemic stroke

Introduction ADAPT (a direct aspiration first pass technique) has been shown to be fast, cost-effective, and associated with excellent angiographic and clinical outcomes in the treatment of acute ischemic stroke (AIS). Objective To identify any and all preoperative factors that are associated with successful revascularization using aspiration alone. Methods A retrospective review of 76 patients with AIS treated with thrombectomy was carried out. Cohort 1 included cases in which aspiration alone was successful (Thrombolysis in Cerebral Infarction 2b or 3). Cohort 2 included cases in which aspiration was unsuccessful or could not be performed despite an attempt. Results There was no difference between cohorts in gender, race, medications, National Institute of Health Stroke Scale score, IV tissue plasminogen activator, site or side of the occlusion, dense vessel sign, aortic arch type, severe stenosis, clot length, operator years of experience, and guide/aspiration catheters used. Patients in cohort 1 were on average younger (66.5 vs 74.1 years, p=0.025). There was a trend for more patients in cohort 2 to have atrial fibrillation/arrhythmias (62.5% vs 45.5%, p=0.168) and have a cardiogenic stroke etiology (78.1% vs 56.8%, p=0.086). There was also a trend for more reverse curves (2.3 vs 1.7, p=0.107), larger vessel diameter (3.26 mm vs 2.88 mm, p=0.184), larger vessel-to-catheter ratio (2.09 vs 1.87, p=0.192), and worse clot burden score (5.38 vs 6.68, p=0.104) in cohort 2. Conclusions Aspiration success was associated with younger age. Our findings suggest that ADAPT can be used for the vast majority of patients but it may be beneficial to use a different method first in the elderly.

The burden of neurothrombectomy call: a multicenter prospective study

Introduction Neurothrombectomy frequency is increasing, and a better understanding of the neurothrombectomy call burden is needed. Methods Neurointerventional physicians at nine participating stroke centers prospectively recorded time requirements for all neurothrombectomy (NT) consultations over 30 consecutive 24 hour call periods. Results Data were collected from a total of 270 days of call. 214 NT consultations were reported (mean 0.79 per day), including 130 ‘false positive’ consultations that ultimately did not lead to thrombectomy (mean 0.48 per day). 84 NT procedures were performed at the nine centers (0.32 per day, or 1 every 3 days). Most (59.8%) consultations occurred between 5pm and 7am. 30% of thrombectomy procedures resulted in delays in scheduled cases; treating physicians had to emergently travel to the hospital for 51.2% of these cases. A median of 27 min was spent on each false positive consultation and 171 min on each thrombectomy. Overall, the median physician time spent on NT responsibilities per 24 hour call period was 69 min (mean 85 min; IQR 16–135 min). Conclusions NT consultations are frequent and often disrupt physician schedules, requiring physicians to commute in from home after hours in the majority of cases. As procedural and consultation volumes increase, it is crucial to understand the significant burden of call on neurointerventional physicians and develop strategies that reduce the potential for burnout. Importantly, this study was performed prior to the completion of the DAWN and DEFUSE3 trials; NT consultations are expected to continue to increase in the future.

Mobile Interventional Stroke Teams Lead to Faster Treatment Times for Thrombectomy in Large Vessel Occlusion

Background and Purpose— Endovascular recanalization treatment for acute ischemic stroke is a complex, time-sensitive intervention. Trip-and-treat is an interhospital service delivery model that has not previously been evaluated in the literature and consists of a shared mobile interventional stroke team that travels to primary stroke centers to provide on-site interventional capability. We compared treatment times between the trip-and-treat model and the traditional drip-and-ship model. Methods— We performed a retrospective analysis on 86 consecutive eligible patients with acute ischemic stroke secondary to large vessel occlusion who received endovascular treatment at 4 hospitals in Manhattan. Patients were divided into 2 cohorts: trip-and-treat (n=39) and drip-and-ship (n=47). The primary outcome was initial door-to-puncture time, defined as the time between arrival at any hospital and arterial puncture. We also recorded and analyzed the times of last known well, IV-tPA (intravenous tissue-type plasminogen activator) administration, transfer, and reperfusion. Results— Mean initial door-to-puncture time was 143 minutes for trip-and-treat and 222 minutes for drip-and-ship (P<0.0001). Although there was a trend in longer puncture-to-recanalization times for trip-and-treat (P=0.0887), initial door-to-recanalization was nonetheless 79 minutes faster for trip-and-treat (P<0.0001). There was a trend in improved admission-to-discharge change in National Institutes of Health Stroke Scale for trip-and-treat compared with drip-and-ship (P=0.0704). Conclusions— Compared with drip-and-ship, the trip-and-treat model demonstrated shorter treatment times for endovascular therapy in our series. The trip-and-treat model offers a valid alternative to current interhospital stroke transfers in urban environments.

Cervical-petrous internal carotid artery pseudoaneurysm presenting with otorrhagia treated with endovascular techniques

Cervical–petrous internal carotid artery (CP-ICA) pseudoaneurysms are rare and have different etiologies, presentations, and treatment options. A middle-aged patient with a history of chronic otitis media presented with acute otorrhagia and was found to have a left-sided CP-ICA pseudoaneurysm. The patient was a poor surgical candidate with difficult arterial access. The pseudoaneurysm was treated with stand-alone coiling via a left brachial approach with persistent contrast filling seen only in the aneurysm neck at the end of the procedure. The patient re-presented 12 days later with repeat hemorrhage and rapid enlargement of the neck remnant, and was treated with a covered stent via a transcervical common carotid artery cut-down. A covered stent may provide a more definitive treatment for CP-ICA pseudoaneurysms compared with standalone coiling.

Novel and emerging technologies for endovascular thrombectomy

Endovascular thrombectomy device improvements in recent years have served a pivotal role in improving the success and safety of the thrombectomy procedure. As the intervention gains widespread use, developers have focused on maximizing the reperfusion rates and reducing procedural complications associated with these devices. This has led to a boom in device development. This review will cover novel and emerging technologies developed for endovascular thrombectomy.

A multicenter study evaluating the frequency and time requirement of mechanical thrombectomy

Introduction There are few published data evaluating the incidence of mechanical thrombectomy among stroke centers or the times at which they occur. Methods A multicenter retrospective study was performed to identify all patients undergoing emergent thrombectomy for acute ischemic stroke during a 3-month period (June through August 2016). Consultations that did not undergo thrombectomy were not included. Results Ten institutions participated in the study. During the 92-day study period, a total of 189 patients underwent mechanical thrombectomy. The average number of procedures per hospital over the study period was 18.9 (average of 0.2 cases per day per or 75.6 cases per year). This ranged from 0.09 cases per day at the lowest volume center to 0.49 cases per day at the highest volume center. Procedures were more common on weekdays (p<0.001) and during non-work hours (p<0.001). The most common period for thrombectomy procedures was between 20:00 and 21:00 hours. The median time from notification to groin puncture was 84 min (IQR 56–145 min) and from puncture to closure was 57 min (IQR 33–80 min). The median time from imaging completion to procedural start was 52 min longer for non-work hours than during work hours (p<0.001). There were no differences in procedural length based on day of the week or time of day. Conclusions These findings indicate that the majority of mechanical thrombectomy cases occur during non-work hours, with associated off-hours delays, which has important operational implications for hospitals implementing stroke call coverage.

The impact of evidence: evolving therapy for acute ischemic stroke in a large healthcare system.

Background With a recent surge of clinical trials, the treatment of ischemic stroke has undergone dramatic changes. Objective To evaluate the impact of evidence and a revamped stroke protocol on a large healthcare system. Methods A retrospective review of 69 patients with ischemic stroke treated with intra-arterial therapy was carried out. Cohort 1 included patients treated before implementation of a new stroke protocol, and cohort 2 after implementation. Angiographic outcome was graded using the Thrombolysis in Cerebral Infarction (TICI) score. Clinical outcomes were assessed using the National Institute of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS). Results Primary outcomes comparing cohorts demonstrated decreased arrival-to-puncture time (cohort 2: 104 vs cohort 1: 181 min, p<0.001), similar TICI 2b/3 rates (86.5% vs 81.3%, p=0.5530), and similar percentage of patients with discharge mRS 0–2 (18.9% vs 21.9%, p=0.7740). Notable secondary outcomes for cohort 2 included decreased puncture-to-first pass time (34 vs 53 min, p <0.001), increased TICI 3 rates (37.8% vs 18.8%, p=0.0290), a trend toward greater improvements in NIHSS on postoperative day 1 (6.8 vs 2.6, p=0.0980) and discharge (9.5 vs 6.7, p=0.1130), and a trend toward increased percentage of patients discharged with mRS 0–3 (48.6% vs 34.4%, p=0.3280 NS). There were similar rates of symptomatic intracerebral hemorrhage (10.8% vs 9.4%, p=0.9570) and death (10.8% vs 15.6%, p=0.5530). Conclusions An interdisciplinary and rapid response to the emergence of strong clinical evidence can result in dramatic changes in a large healthcare system.