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Distal transradial artery access (dTRA) has received increasing consideration for performing diagnostic cerebral angiography and neurointerventional procedures. In this meta-analysis, we aim to evaluate the safety and efficacy of dTRA compared to conventional transradial access (cTRA) for cerebral angiography and neurointerventions.A systematic review and meta-analysis were conducted on studies investigating outcomes of dTRA and cTRA in neurointerventions. The primary outcome was technical success rates. Secondary outcomes included access site complication rates, crossover rates to alternative vessels, fluoroscopy time, and contrast volume. The random effects model was used to calculate the mean difference (MD) and odds ratios (OR) with 95% confidence intervals (Cl).Eight retrospective observational studies with a total of 1477 patients who underwent 1175 diagnostic cerebral angiography and 516 neurointerventional procedures using 546 dTRA and 1164 cTRA approaches were included in our meta-analysis. The technical success rate was similar between dTRA and cTRA groups (95.8% vs 91.4%; OR:1.65; 95% Cl: 0.52 to 5.22; P = 0.40). Similarly, no difference was seen in dTRA and cTRA regarding access site complications (2% vs 1.4%; OR: 1.31; 95% CI: 0.47 to 3.61; P = 0.61) and access site crossover (2.1% vs 5.3%; OR: 0.55; 95% Cl: 0.28 to 1.05; P = 0.07). After resolving heterogeneity among included studies, dTRA was associated with a shorter fluoroscopy time (MD: −0.91 min; 95% CI: −1.74 to −0.09; P = 0.03) and lower contrast volume (MD: −8.32 mL; 95% CI = −14.7 to −1.94; P = 0.011).Our findings suggest that the dTRA approach is a safe and effective alternative to the cTRA approach in patients undergoing cerebral angiography and neurointerventions. [ABSTRACT FROM AUTHOR]

Larger microcatheters are being used with increasing frequency in routine neurovascular procedures. Navigating catheters safely and effectively to the target intracranial vessels can be a challenge when using conventional 0.014″ microwires. A new family of 0.024″ Aristotle 24 microwires (Scientia Vascular, West Valley City, UT) specifically designed for intracranial navigation were recently introduced. These microwires offer significant technical advantages over the standard 0.014″ microwires, including a reduced ledge gap, improved torquability and support, and overall safety. This video case series contains several illustrative cases to demonstrate the features of the novel Aristotle 24 microwire for use in endovascular neurointervention. [ABSTRACT FROM AUTHOR]

As Comprehensive Stroke Centers (CSCs) strive to improve neuro-intervention (NIR) times, process improvements are put in place to streamline workflows. Our prior publication (VISIION) demonstrated improvements in key performance indicators (KPIs). The purpose VISIION-S was to analyze whether those results were sustainable. Consecutive Direct Arriving LVO (DALVO) and telemedicine transfer LVO (BEMI) stroke NIR cases were assessed, including subgroups of DALVO-OnHours, DALVO-OffHours, BEMI-OnHours, and BEMI-OffHours. We analyzed times for the original 6 months pre (6/10/20-1/15/21) and compared them to a 17 month post-implementation period (1/16/21- 6/25/22) to evaluate for sustainability. Mann-Whitney U was utilized. 150 NIR cases were analyzed pre (n = 47) v. post (n = 103) implementation (DALVO-OnHours 7 v. 20, DALVO-OffHours 10 v. 25, BEMI-OnHours 13 v. 20, BEMI-OffHours 17 v. 38). For Door-to-groin (DTG), improvement was noted for DALVO-OffHours 39%(157 min,96 min;p < 0.001), DALVO-ALL 25%(127 min,95 min;p = 0.006), BEMI-OffHours 46%(45 min,25 min;p = 0.023), and BEMI-ALL 40%(42 min,25 min;p = 0.005). Activation-to-groin (ATG), door-to-device (DTD), and door-to-recanalization (DTR) also showed statistical improvements. For DALVO-OffHours, there were reductions in door to CT (DTC) 80%(26 min,5 min;p < 0.001), ATG 32%(90 min,61 min;p = 0.036), DTG 39%(157 min,96 min;p < 0.001), DTD 31%(178 min,123 min;p = 0.002), and DTR 32%(197 min,135 min;p = 0.003). We noted sustainability over a 17 month period with sustained reduction in KPIs for even more NIR time interval comparisons. In the greatest opportunity subgroup (DALVO-OffHours), we noted a reduction in all 5 time interval metrics. Our sustainability finding is important to show that process improvements continued even after the immediate period, adding credibility to the results. Models such as this could be useful for other centers striving to optimize workflow and improve times. [ABSTRACT FROM AUTHOR]

PurposeWe investigated whether a 3D overlay roadmap using monoplane fluoroscopy offers advantages over a conventional 2D roadmap using biplane fluoroscopy during endovascular aneurysm treatment.Materials and MethodsA retrospective chart review was conducted for 131 consecutive cerebral aneurysm embolizations by three neurointerventionalists at a single institution. Allowing for a transition period, the periods from January 2012 to August 2012 (Time Period 1) and February 2013 to July 2013 (Time Period 2) were analyzed for radiation exposure, contrast administration, fluoroscopy time, procedure time, angiographic results, and perioperative complications. Two neurointerventionalists (Group 1) used a conventional 2D roadmap for both Time Periods, and one neurointerventionalist (Group 2) transitioned from a 2D roadmap during Time Period 1 to a 3D overlay roadmap during Time Period 2.ResultsDuring Time Period 2, Group 2 demonstrated reduced fluoroscopy time (p

Since the 3rd WIN meeting in 1982 more than 500 participants join the meeting in Val D'Isere every year [1]. One of our authors has attended the meeting more than 10 times. He experienced many physical illnesses while travelling from South Korea to Val D'Isere in France, which is located in the Alps mountain near the border between France and Italy. In order to get there, it is necessary to take airplane, train, and/or bus with a heavy suitcase. During the trip which usually takes more than 15 hours, he experienced headache, gastrointestinal trouble, sleep disturbance and other additional physical illnesses. Therefore, we reviewed the itinerary to Val D'Isere and presented physical illnesses which occurred during a long trip for an academic activity by specialized professionals such as university hospital professors. In addition, we discussed the mechanism of such illnesses and offered possible solutions including medical treatment.

PurposeDay-care management of unruptured intracranial aneurysms can shorten hospital stay, reduce medical cost and improve outcome. We present the process, outcome and duration of hospital stay for the management of unruptured intracranial aneurysms via a neurointervention clinic in a single center during the past four years.Materials and MethodsWe analyzed 403 patients who were referred to Neurointervention Clinic at Asan Medical Center for aneurysm evaluation between January 1, 2011 and December 31, 2014. There were 141 (41%) diagnostic catheter angiographies, 202 (59%) neurointerventional procedures and 2 (0.6%) neurointerventional procedures followed by operation. We analyzed the process, outcome of angiography or neurointervention, and duration of hospital stay.ResultsThere was no aneurysm in 58 patients who were reported as having an aneurysm in MRA or CTA (14 %). Among 345 patients with aneurysm, there were 283 patients with a single aneurysm (82%) and 62 patients with multiple aneurysms (n=62, 18%). Aneurysm coiling was performed in 202 patients (59%), surgical clipping in 14 patients (4%), coiling followed by clipping in 2 patients (0.6%) and no intervention was required in 127 patients (37%). The hospital stay for diagnostic angiography was less than 6 hours and the mean duration of hospital stay was 2.1 days for neurointervention. There were 4 procedure-related adverse events (2%) including 3 minor and 1 major ischemic strokes.ConclusionOur study revealed that day-care management of unruptured intracranial aneurysms could be performed without an additional risk. It could enable rapid patient flow, shorten hospital stay and thus reduce hospital costs.

Navigating a large-caliber catheter into the intracranial artery may generate a "ledge effect," which disturbs successful neurointervention. Particularly, navigation of a large-lumen aspiration catheter is often required to achieve fast recanalization in acute ischemic stroke cases. Occasionally, the aspirator cannot be passed through the ophthalmic artery origin because of the ledge effect. Here, we report a new technique for mitigation of the ledge effect that involves the use of double micro-guidewires (MGWs). We refer to this technique as the "beanstalk method." We evaluated the efficacy of our idea using a silicon vascular model. Two 0.014" MGWs are used for navigation of a 0.068" aspirator. After one guidewire is navigated to the distal portion, another MGW is advanced along with the former guidewire, in a spiral fashion, similar to the growth of a beanstalk. The aspirator can then pass with the coaxial double-guidewire, although there is a severe gap in the vessel. We performed an in vitro study to demonstrate the effectiveness of the beanstalk method. The beanstalk method was very useful, even under challenging conditions that did not allow for passage of a conventional coaxial catheter or buddy-wire. The beanstalk method effectively decreases the ledge effect because of the shape of the two wires just ahead of the catheter, which contrasts with the hardness of the spiral wires. In cases involving challenging vasculature, the beanstalk method achieves smoother catheter navigation than the conventional coaxial method or buddy-wire technique. [ABSTRACT FROM AUTHOR]

Objective: The Woven EndoBridge (WEB) device is an intrasaccular flow disruptor designed for wide-necked bifurcation aneurysms. These aneurysms may require the use of a concomitant stent. The objective of this study was to determine the clinical and radiological outcomes of patients undergoing stent-assisted WEB treatment. In addition, the authors also sought to determine the predictors of a concomitant stent in aneurysms treated with the WEB device., Methods: The data for this study were taken from the WorldWideWEB Consortium, an international multicenter cohort including patients treated with the WEB device. Aneurysms were classified into two groups based on treatment: stent-assisted WEB and WEB device alone. The authors compared clinical and radiological outcomes of both groups. Univariable and multivariable binary logistic regression analyses were performed to determine factors that predispose to stent use., Results: The study included 691 intracranial aneurysms (31 with stents and 660 without stents) treated with the WEB device. The adequate occlusion status did not differ between the two groups at the latest follow-up (83.3% vs 85.6%, p = 0.915). Patients who underwent stenting had more thromboembolic (32.3% vs 6.5%, p < 0.001) and procedural (16.1% vs 3.0%, p < 0.001) complications. Aneurysms treated with a concomitant stent had wider necks, greater heights, and lower dome-to-neck ratios. Increasing neck size was the only significant predictor for stent use., Conclusions: This study demonstrates that there is no difference in the degree of aneurysm occlusion between the two groups; however, complications were more frequent in the stent group. In addition, a wider aneurysm neck predisposes to stent assistance in WEB-treated aneurysms.

Neurointervention is a subspecialty of neurosciences which offers a minimally invasive therapy for the vascular lesions of the central nervous system. The resources, techniques, and indications of neurointervention therapy are rapidly expanding and becoming diverse. With the support of robust scientific data, neurointervention has established itself as a first line therapy for many neurovascular diseases. This article provides an overview about the various material used in neurointervention, basic steps followed in some common neurointerventional procedures, and its related complications. In the era of 21st century, any young physician or surgeon as well as residents-in-training dealing with neurovascular cases should have some insight into these basic concepts so as to provide better care to their patients. [ABSTRACT FROM AUTHOR]

Because neurointerventional surgery is a minimally invasive technique does not mean that it is qualified for complication-free procedures. Rather working about 2 m away from the three-dimensional (3D) target lesion and looking at two-dimensional (2D) images makes it one of the most complication-prone subspecialties. Advancement in hardwares, techniques, and technologies with continuous ability to learn and modify accordingly can only keep the complication rate low as compared with traditional vascular neurosurgery. [ABSTRACT FROM AUTHOR]

Purpose: A complicated course of the femoral route for neurointervention can prevent approaching the target. Thus, we determined whether transcervical access in the hybrid angiosuite is applicable and beneficial in real practice.Methods: From January 2014 to March 2017, this approach was used in 17 of 453 (3.75%) cases: 11 cerebral aneurysms (4 ruptured, 7 unruptured), 4 acute occlusions of the large cerebral artery, 1 proximal internal carotid artery (ICA) stenosis, and 1 direct carotid cavernous fistula (CCF).Results: All patients were elderly (mean age, 78.1 years). The main cause was severe tortuosity of the supra-aortic course or the supra-aortic and infra-aortic courses (eight and five cases, respectively), orifice disturbance (three cases), and femoral occlusion (one case). Through neck dissection, 6-8Fr guiding catheters were placed via subcutaneous tunneling to enhance device stability and support. All cerebral aneurysms were embolized (eight complete and three neck remnants) using the combination of several additional devices. Mechanical stent retrieval with an 8Fr balloon guiding catheter was successfully achieved in a few runs (mean, 2 times; range, 1-3) within the proper time window (mean skin to puncture, 17 ± 4 min; puncture to recanalization, 25 ± 4 min). Each stent was satisfactorily deployed in the proximal ICA and direct CCF without catheter kick-back. All puncture sites were closed through direct suturing without complications.Conclusions: In the hybrid angiosuite, transcervical access via direct neck exposure is feasible in terms of device profile and support when the femoral route has an unfavorable anatomy. [ABSTRACT FROM AUTHOR]

The aim of this study was to describe our experience in the treatment of various pathological conditions of the cranial and spinal blood vessels and hypervascularized lesions using dual lumen balloon catheters. Twenty-five patients were treated with endovascular techniques: two with vasospasm of cerebral blood vessels caused by subarachnoid hemorrhage, one with a hypervascularized metastasis in the vertebral body, two with spinal dural fistula, four with cerebral dural fistula, three with cerebral arteriovenous malformations, and 13 with aneurysms. The dual lumen balloon catheters were used for remodeling of the coil mesh, injection of various liquid embolic agents, particles and nimodipine, for the prevention of reflux and deployment of coils and stents. The diameter of catheterized blood vessels varied from 0.7 mm to 4 mm. Two complications occurred: perforation of an aneurysm in one case and gluing of the tip of balloon catheter by embolic material in another case. All other interventions were uneventful, and therapeutic goals were achieved in all cases except in the case with gluing of the tip of balloon catheter. The balloons effectively prevented reflux regardless of the type of the embolic material and diameter of blood vessel. The results of our study show that dual lumen balloon catheters allow complex interventions in the narrow cerebral and spinal blood vessels where the safe use of two single lumen catheters is either limited or impossible. [ABSTRACT FROM AUTHOR]

Background: Intra-arterial thrombectomy is the gold standard treatment for large artery occlusive stroke. However, the evidence of its benefits is almost entirely based on trials delivered by experienced neurointerventionists working in established teams in neuroscience centres. Those responsible for the design and prospective reconfiguration of services need access to a comprehensive and complementary array of information on which to base their decisions. This will help to ensure the demonstrated effects from trials may be realised in practice and account for regional/local variations in resources and skill-sets. One approach to elucidate the implementation preferences and considerations of key experts is a Delphi survey. In order to support commissioning decisions, we aimed using an electronic Delphi survey to establish consensus on the options for future organisation of thrombectomy services among physicians with clinical experience in managing large artery occlusive stroke.Methods: A Delphi survey was developed with 12 options for future organisation of thrombectomy services in England. A purposive sampling strategy established an expert panel of stroke physicians from the British Association of Stroke Physicians (BASP) Clinical Standards and/or Executive Membership that deliver 24/7 intravenous thrombolysis. Options with aggregate scores falling within the lowest quartile were removed from the subsequent Delphi round. Options reaching consensus following the two Delphi rounds were then ranked in a final exercise by both the wider BASP membership and the British Society of Neuroradiologists (BSNR).Results: Eleven stroke physicians from BASP completed the initial two Delphi rounds. Three options achieved consensus, with subsequently wider BASP (97%, n = 43) and BSNR members (86%, n = 21) assigning the highest approval rankings in the final exercise for transferring large artery occlusive stroke patients to nearest neuroscience centre for thrombectomy based on local CT/CT Angiography.Conclusions: The initial Delphi rounds ensured optimal reduction of options by an expert panel of stroke physicians, while subsequent ranking exercises allowed remaining options to be ranked by a wider group of experts within stroke to reach consensus. The preferred implementation option for thrombectomy is investigating suspected acute stroke patients by CT/CT Angiography and secondary transfer of large artery occlusive stroke patients to the nearest neuroscience (thrombectomy) centre. [ABSTRACT FROM AUTHOR]

Following the success of recent endovascular trials, endovascular therapy has emerged as an exciting addition to the arsenal of clinical management of patients with acute ischemic stroke (AIS). In this paper, we present an extensive overview of intravenous and endovascular reperfusion strategies, recent advances in AIS neurointervention, limitations of various treatment paradigms, and provide insights on imaging-guided reperfusion therapies. A roadmap for imaging guided reperfusion treatment workflow in AIS is also proposed. Both systemic thrombolysis and endovascular treatment have been incorporated into the standard of care in stroke therapy. Further research on advanced imaging-based approaches to select appropriate patients, may widen the time-window for patient selection and would contribute immensely to early thrombolytic strategies, better recanalization rates, and improved clinical outcomes. [ABSTRACT FROM AUTHOR]

Objectives: Contextual data and local expertise are important sources of data that cannot be ignored in hospital-based health technology assessment (HTA) processes. Despite a lack of or unconvincing evidence in the scientific literature, technology can be recommended in a given context. We illustrate this using a case study regarding biplane angiography for vascular neurointervention.Methods: A systematic literature review was conducted, along with an analysis of the context in our setting. The outcomes of interest were radiation doses, clinical complications, procedure times, purchase cost, impact on teaching program, the confidence of clinicians in the technology, quality of care, accessibility, and the volume of activity. A committee comprising managers, clinical experts, physicians, physicists and HTA experts was created to produce a recommendation regarding biplane technology acquisition to replace a monoplane device.Results: The systematic literature review yielded nine eligible articles for analysis. Despite a very low level of evidence in the literature, the biplane system appears to reduce ionizing radiation and medical complications, as well as shorten procedure time. Contextual data indicated that the biplane system could improve operator confidence, which could translate into reduced risk, particularly for complex procedures. In addition, the biplane system can support our institution in its advanced procedures teaching program.Conclusions: Given the advantages provided by the biplane technology in our setting, the committee has recommended its acquisition. Contextual data were of utmost importance in this recommendation. Moreover, this technology should be implemented alongside a responsibility to collect outcome data to optimize clinical protocol in the doses of ionizing delivered. [ABSTRACT FROM AUTHOR]

Several recent reports of CorPath GRX vascular robot (Cordinus Vascular Robotics, Natick, MA) use intracranially suggest feasibility of neuroendovascular application. Further use and development is likely. During this progression it is important to understand endovascular robot feasibility principles established in cardiac and peripheral vascular literature which enabled extension intracranially. Identification and discussion of robotic proof of concept principals from sister disciplines may help guide safe and accountable neuroendovascular application.Summarize endovascular robotic feasibility principals established in cardiac and peripheral vascular literature relevant to neuroendovascular applicationSearches of PubMed, Scopus and Google Scholar were conducted under PRISMA guidelines 1 using MeSH search terms. Abstracts were uploaded to Covidence citation review (Covidence, Melbourne, AUS) using RIS format. Pertinent articles underwent full text review and findings are presented in narrative and tabular format.Search terms generated 1642 articles; 177, 265 and 1200 results for PubMed, Scopus and Google Scholar respectively. With duplicates removed, title review identified 176 abstracts. 55 articles were included, 45 from primary review and 10 identified during literature review. As it pertained to endovascular robotic feasibility proof of concept 12 cardiac, 3 peripheral vascular and 5 neuroendovascular studies were identified.Cardiac and peripheral vascular literature established endovascular robot feasibility and efficacy with equivalent to superior outcomes after short learning curves while reducing radiation exposure >95% for the primary operator. Limitations of cost, lack of haptic integration and coaxial system control continue, but as it stands neuroendovascular robotic implementation is worth continued investigation. [ABSTRACT FROM AUTHOR]

Aneurysms at the origin of the fetal posterior cerebral artery (fPCA) often show fPCA bifurcation from the aneurysm dome, impeding complete embolization and dense coil packing. The recanalization rate for fPCA aneurysms is therefore high. This study aimed to evaluate the efficacy and safety of stenting into fPCA for aneurysms with fPCA incorporated into the aneurysm to determine whether stenting can provide effective embolization results and prevent recanalization.A total of 19 consecutive coil embolization procedures between February 2012 and June 2022 for unruptured fPCA aneurysms with fPCA branching from the dome of the aneurysm were divided into two groups: non-stenting (NS) group (n = 11) and stenting into fPCA (PS) group (n = 8). Data were obtained retrospectively and compared regarding embolization results, complications, and recanalization.Compared with the NS group, the PS group achieved significantly higher complete occlusion rate and packing density (p < 0.001, p = 0.01, respectively). No symptomatic complications were observed in the PS group. Both immediately after stenting and at the 1-year follow-up, no stent kinking, stenosis, occlusion, or malposition were observed in any patients in the PS group. During 1-year follow-up, the cumulative minor and major recanalization-free rate after coil embolization for fPCA aneurysms were significantly higher in the PS group compared with the NS group (p = 0.022, 0.0024, respectively).Stenting into fPCA for aneurysms with fPCA incorporated into the aneurysm achieved high-density complete embolization without increasing complications, and prevented recanalization. The fPCA stent-assisted coil embolization can offer an alternative treatment for fPCA aneurysms. [ABSTRACT FROM AUTHOR]

Interventional neuroradiology (INR) has been a rapidly expanding and advancing clinical area during the past few decades. As the complexity and diversity of INR procedures increases, the demand for anesthesia also increases. Anesthesia for interventional neuroradiology is a challenge for the anesthesiologist due to the unfamiliar working environment which the anesthesiologist must consider, as well as the unique neuro-interventional components. This review provides an overview of the anesthetic options and specific consideration of the anesthesia requirements for each procedure. We also introduce the anesthetic management for interventional neuroradiology performed in our medical institution.

Introduction The efficacy of the endovascular treatment of acute ischemic stroke has been substantiated by several recent randomized clinical trials. While intra-arterial therapy has significantly evolved in recent years, anatomic cerebrovascular variants and disease burden can present challenges to timely recanalization. We present the first reported case of anterior-to-posterior mechanical clot retrieval with use of a stent retriever. Case description A 53-year-old man presented with basilar artery thrombosis. Endovascular mechanical clot retrieval was performed. The typical, antegrade, access to the basilar artery thrombus was precluded by the findings of a hypoplastic left vertebral artery and an occluded proximal right vertebral artery. Given a number of factors including the patient’s worsening symptoms and the high morbidity and mortality associated with basilar stroke, cross-circulation—anterior-to-posterior—intra-arterial therapy was performed. Thrombectomy of the basilar thrombus was achieved via the right internal carotid artery and right posterior communicating artery. Conclusion To our knowledge, we report the first case of cross-circulation, anterior-to-posterior thrombectomy, with the use of a stent-retriever device. Cross-circulation stroke treatment may be beneficial in cases of proximal vessel occlusion or anatomical constraints. Larger studies will need to evaluate the safety and efficacy of these approaches. [ABSTRACT FROM AUTHOR]

Background Increased interest in radiation dose reduction in neurointerventional procedures has led to the development of a method called "spot fluoroscopy" (SF), which enables the operator to collimate a rectangular or square region of interest anywhere within the general field of view. This has potential advantages over conventional collimation, which is limited to symmetric collimation centered over the field of view. Purpose To evaluate the effect of SF on the radiation dose. Material and Methods Thirty-five patients with intracranial aneurysms were treated with endovascular coiling. SF was used in 16 patients and conventional fluoroscopy in 19. The following parameters were analyzed: the total fluoroscopic time, the total air kerma, the total fluoroscopic dose-area product, and the fluoroscopic dose-area product rate. Statistical differences were determined using the Welch's t-test. Results The use of SF led to a reduction of 50% of the total fluoroscopic dose-area product (CF = 106.21 Gycm2, SD = 99.06 Gycm2 versus SF = 51.80 Gycm2, SD = 21.03 Gycm2, p = 0.003884) and significant reduction of the total fluoroscopic dose-area product rate (CF = 1.42 Gycm2/min, SD = 0.57 Gycm2/s versus SF = 0.83 Gycm2/min, SD = 0.37 Gycm2/min, p = 0.00106). The use of SF did not lead to an increase in fluoroscopy time or an increase in total fluoroscopic cumulative air kerma, regardless of collimation. Conclusion The SF function is a new and promising tool for reduction of the radiation dose during neurointerventional procedures. [ABSTRACT FROM AUTHOR]

Background: In dural venous sinus thrombosis (DVST), the mortality ranges 5--30%. Deep venous system involvement and septic dural sinus thrombosis have a higher mortality rate. In acute occlusion, collateral flow may not be established, which may result in significant edema and mass effect. Endovascular interventions may be considered as a treatment option in appropriate high-risk patients with DVST. Materials and Methods: Eight patients with magnetic resonance imaging (MRI)-confirmed dural sinus thrombosis, who did not respond to the conventional standard medical treatment, were subsequently treated with mechanical thrombectomy using the Penumbra System®. In all cases, medical treatment including anticoagulants were continued following the procedure for a minimum period of 1 year. Results: Recanalization of the dural sinus thrombosis was achieved in all 8 cases. There were no immediate or late endovascular-related complications. One death occurred due to an unrelated medical event. At 6 months, there was notable improvement in the modified Rankin Score (mRS), with 5/8 (62%) patients achieving mRS of 2 or less. The follow-up ranged between 3 months and 26 months (mean: 14.5 months), and there were no new neurological events during the follow-up period. Conclusion: Cerebral venous sinus thrombosis is a rare but life-threatening condition that demands timely diagnosis and therapy. In cases of rapidly declining neurological status despite standard therapy with systemic anticoagulation and anti-edema measures, mechanical thrombectomy could be a lifesaving and effective option. In this study, good outcomes were observed in the majority of patients at long-term follow up. [ABSTRACT FROM AUTHOR]

Treatment guidelines of the neurointerventional procedures are continuously updated. However, these guidelines differ between countries and even medical societies within the same country because of the differing interests and patient groups. The differences between guidelines are confusing to many neurointerventionalists. Recently "Clinical Research Center for Stroke" in Korea updated "Clinical Practice Guidelines for Stroke" for the patients in Korea. So we introduce those guidelines and compare several recent guidelines of international medical societies for neurointerventionalists.

The term neurological nihilism stemmed from the deep seated belief that neurological disease could be diagnosed, but not cured. Today, the scenario has been transformed. Neurophysicians, like cardiologists, are more aggressive at interventions than ever before. The prognosis of victims with neurological ailments has undergone a remarkable transformation.

The 14th International Symposium on Thrombolysis, Thrombectomy and Acute Stroke Therapy (TTST) took place in Houston, Texas on 21–22 October 2018. Attended by 150+ invited global experts, the objectives of TTST 2018 were to explore the changing landscape of acute ischemic stroke therapy and to address current controversies in thrombolysis and thrombectomy, including expanding access and systems of care with global relevance. This article summarizes the proceedings of TTST 2018. The key points of each session are listed below, the full text of presentations and discussion are available in the online supplement, and the full list of contributing authors appear in the Appendix at the end of this article. [ABSTRACT FROM AUTHOR]

PurposeThere have been few reports regarding same-day discharge following uncomplicated procedures such as cerebral angiography and neurointervention. We present same-day experience with cerebral angiography and neurointervention during the past three years.Materials and MethodsFour hundred and fifty-three patients underwent cerebral angiography or neurointervention at Asan Medical Center between January 2009 and December 2011. Of these patients, 249 (55%) underwent diagnostic catheter cerebral angiography and 204 patients (45%) underwent neurointerventional procedures as same-day procedures. We analyzed any complications, the modified patient-care process, the yearly trend in patient increases, disease categories, and the additional duration of admission for these procedures.ResultsThe number of overall patients increased by an average of 51% annually. The disease categories included aneurysm (51%), atherosclerosis (11%) and arteriovenous malformation (10%), etc. for which the patient underwent angiography, and aneurysm (42%), venous malformation (28%), and arteriovenous malformation (17%), etc. for which patients underwent neurointervention. Same-day care patients were admitted to the intermediary care unit in the angiosuite. Neurointervention patients were sent to the neurology intensive unit after the procedure. The same-day care patients stayed in angiosuite for six hours following the transfemoral procedure. The mean admission duration for neurointervention was 2.4 days. There were no reported complications for the same-day care procedures.ConclusionOur study revealed an increasing tendency toward same-day care for patients who require angiography and neurointervention. Further studies will be required to better define the cost-minimization effects of outpatient practice as well as the patient perception of this fast-tracking method. We propose that outpatient angiography and neurointervention will undoubtedly continue to increase over the next decade.

Methods for assessing platelet function in patients with neurovascular disease remain controversial and poorly studied. This study aimed to assess associations between thromboelastography 6s (TEG6s) measurements and postoperative ischemic complications in patients with unruptured intracranial aneurysms (UIAs) treated by coil embolization. Eighty-four patients with UIAs taking a combined aspirin and clopidogrel protocol were retrospectively reviewed from January 2021 to May 2022. Blood samples were obtained for TEG6s to assess platelet function on the day of coil embolization. To identify acute ischemic complications, diffusion-weighted imaging (DWI) was performed within 24 h after coil embolization. Multivariate logistic regression analysis was conducted to identify potential risk factors for postoperative positive DWI (DWI (+)) lesions. Forty-three of the 84 patients (51%) with DWI (+) lesions were identified. Compared with patients without DWI (+) lesions, Adenosine diphosphate (ADP)-induced platelet-fibrin clot strength (MA ADP) was significantly higher (53.6 mm [Interquartile range (IQR): 48.3–58.3 mm] vs 46.7 mm [IQR: 36.8–52.2 mm]; p=0.001) and ADP inhibition rate (ADP%) was significantly lower (19% [IQR: 11–31%] vs 31% [IQR: 21–44%]; p=0.001) in DWI (+) patients. Multivariate analysis identified MA ADP , ADP%, and procedure time as significant independent predictors of subsequent DWI (+) lesions (odds ratios: 1.07, 0.96, and 1.02, respectively). Based on receiver operating characteristic curve analysis, MA ADP >50.9 mm and ADP% <28.8% were associated with postoperative DWI (+) lesions in patients undergoing coil embolization for UIAs. MA ADP and ADP% as assessed by TEG6s can offer reliable parameters to predict postoperative ischemic complications after coil embolization of UIAs. Lower MA ADP values and higher ADP% may decrease the risk of postoperative ischemic complications. [ABSTRACT FROM AUTHOR]

Transradial access (TRA) has increased popularity among neurointerventionalists during a short time period but until recently there have been no devices designed especially for radial use. Consecutive neurointerventional procedures with an intention to perform TRA with the Rist radial access guide catheter between April 2021 and May 2022 were retrospectively reviewed. Possible access site complications, other procedure-related complications and information on successful catherization of the target vessel as well as whether the procedure had been successful were collected. Information from 100 patients was included in the study. The most general procedure was flow diversion (29%) followed by WEB embolization (20 %). Four patients (4%) needed conversion to femoral access. The triaxial system was used in 76% of the procedures. Four patients (4%) experienced access site or device related complications, none of those were serious. Six patients had clinically relevant procedure related complications. It is concluded that the Rist device can be used safely for a large variety of neurointerventions with a short learning curve. [ABSTRACT FROM AUTHOR]

Objective: To investigate the efficacy of neurointervention combined with intravenous thrombolysis in ischemic stroke patients and the risk factors affecting cognitive function recovery., Methods: A total of 114 patients with acute ischemic stroke (AIS) treated in Baoji People's Hospital from January 2017 to December 2020 were retrospectively selected and divided into an observation group and a control group according to different treatment methods. The observation group was treated with neurointervention + intravenous thrombolysis (n = 64), and the control group underwent intravenous thrombolysis (n = 50). The efficacy, recanalization rate, incidence of adverse events, National Institutes of Health Stroke Scale (NIHSS) score, Mini-Mental State Examination (MMSE) score and modified Rankin Scale (mRS) score were evaluated and compared between the two groups. Patients were further divided into a cognitive dysfunction group and a non-disorder group according the MMSE score after treatment, and logistics regression was used to analyze the risk factors of cognitive dysfunction., Results: The overall response rate and the total recanalization rate of the observation group were significantly higher than those of the control group (both P < 0.05). Compared with those before operation, the NIHSS score at 7 d after operation and the mRS score 3 months after operation decreased, while the MMSE score increased in both groups (P < 0.05). The postoperative NIHSS score and mRS score were lower and MMSE score was higher in the observation group than those in the control group (P < 0.05). No significant difference was identified in the incidence of adverse events between the two groups (P > 0.05). Logistics regression analysis revealed that age, diabetes mellitus, hyperlipidemia and lesions at critical sites were independent risk factors for cognitive impairment in patients with AIS., Conclusion: Interventional thrombectomy combined with intravenous thrombolysis is effective in the treatment of cerebral infarction. This regimen can reduce neurological deficits and improve the recanalization rate. In addition, age, diabetes, hyperlipidemia and lesions at critical sites are independent risk factors for the development of cognitive impairment in AIS patients., Competing Interests: None., (AJTR Copyright © 2023.)

Background and Objective: Over the last few years, there has been considerable interest in the neurointervention community to use transradial approach for diagnostic and therapeutic neurointerventions. Distal radial approach has been postulated as an effective technique with reduced risk of hand ischemia. Our objective was to assess the safety and feasibility of distal transradial access (DTRA) to perform diagnostic cerebral angiography., Materials and Methods: A retrospective evaluation of 25 patients who were taken for DTRA through the anatomical snuff box from December 2021 to March 2022 was done., Results: Twenty-five diagnostic cerebral angiographies were attempted with DTRA in 25 patients (age, 23-70 years; mean age, 45.4 years; 10 (40%) females). The right distal radial artery mean diameter was 2.09 mm. The procedure was successful in 21 (84%) procedures. Failure was seen in four cases, with three being converted to the proximal transradial approach without any need for redraping and one was converted to the transfemoral approach. The reason for access conversion was a severe spasm in three cases and dissection in one case. Selective catheterization of the cranial vessels through a distal transradial approach was achieved in 92 (96.8%) of 95 vessels. No significant access site complications were seen in the study cohort., Conclusion: DTRA is a promising approach for diagnostic cerebral angiography. Interventionists should get accustomed to this approach by overcoming the initial learning curve., Competing Interests: None

Background: To evaluate factors that influence the successful cannulation of intracranial vessels using a transradial approach., Methods: A total of 61 transradial diagnostic angiograms were evaluated in a tertiary care center from July 2020 to December 2021. We evaluated the learning curve and aortic arch vessel factors that may influence the cannulation of intracranial major vessels using a transradial approach., Results: Learning curve for the procedure was established after 21 cases. We were successful in cannulating the supra-aortic arteries except in 4 cases where we were unable to cannulate the left VA (vertebral artery). Significant positive correlation was seen between time to Sim (Simmons curve) formation and aortic arch diameter ( p = .002). Significant positive correlation was also seen between left VA take-off angle and time to cannulate left VA ( p = .001) and negative correlation was noted between left CCA (common carotid artery) take-off angle and time to cannulate left CCA ( p = .001)., Conclusion: Transradial approach is a feasible and safe approach for performing cerebral angiography. Multiple factors can influence the procedure time and successful cannulation of intracranial vessels. With the availability of radial specific hardware in the future, procedural success and time taken to complete the procedure may improve.

Purpose: The purpose of the study is to describe carotid artery stenting (CAS) via distal transradial access (dTRA) facilitated by additional superficial temporal artery (STA) access, in a patient with complex aortic arch vessel anatomy., Technique: A 72-year-old woman with a prior history of complex cervical surgery and radiotherapy due to laryngeal malignancy, presented with a symptomatic 90% stenosis of the left internal carotid artery (ICA). Due to high cervical lesion, the patient was rejected from carotid endarterectomy. Angiography demonstrated 90% stenosis of the left ICA and a type III aortic arch. After failure of left common carotid artery (CCA) cannulation with appropriate catheter support via dTRA and transfemoral approaches, CAS was attempted a second time. After percutaneous ultrasound guided access to right dTRA and left STA, a 0.035 inch guidewire introduced to the left CCA from the contralateral dTRA was snared and externalized via left STA to improve wire support for guiding advancement. Thereafter, the left ICA lesion was successfully stented with a 7×30 mm self-expanding stent via right dTRA. All vessels involved were patent at 6-month follow-up., Conclusion: The STA may be a promising adjunctive access site to increase transradial catheter support for CAS or neurointerventional procedures in the anterior circulation., Clinical Impact: Transradial cerebrovascular interventions have been gaining popularity, however, unstable catheter access to distal cerebrovascular structures limits its widespread use. Guidewire externalization technique via additional STA access may improve transradial catheter stabilty and increase procedural success with possibly low access stie complication rate.

Aim: To save brain cells in acute cerebral infarction by injecting hemoglobin oxygen carrier (HBOC) into the blood vessel blockage of the cerebral infarction site through a microcatheter., Methods: 120 male rats were divided into four groups: control (CTRL), ischemia (I), ischemia + low perfusion (I + LP), and ischemia + high perfusion (I + HP). Perfusion groups (ischemia, I + LP, and I + HP) underwent MCAO surgery with intraluminal monofilament. These groups were subdivided into 6 h, 12 h, and 24 h ( n  = 10/group). RT-PCR, Western-Blot, immunohistochemistry, and apoptosis assays were used to detect apoptosis, hypoxia range and extent, and ischemia., Results: Compared with the I group, the neurological deficit sign scores of the I + HP group were statistically significant at 12 h. Compared with the I group, the neurological deficit sign scores of the I + LP group and the I + HP group were statistically significant at 24 h. At all time points, compared with the I group and the I + LP group, Caspase-3, HIF-1α, and Cytochrome C protein levels were significantly decreased in the I + HP group. Bcl-2 and BAX mRNA levels were also significantly decreased in the same group. TNF-α, IL-6, and IL-1β cytokines were significantly decreased in the I + HP group as well. The infarct size of rats in the I + HP group was smaller than that of the I + LP group, which was smaller than ischemia alone. Time of perfusion had an obvious effect as infarct size was smaller with longer perfusion. The number of Nissl stained cells in the I + HP group was increased compared with the ischemia and the I + LP group, and was proportional to the time of perfusion., Conclusion: Time- and rate-controlled perfusion of HBOC to acutely occluded cerebral vascular regions through microcatheters can effectively protect ischemic brain tissue in rats., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Gao, Peng, Yang, Li and Xiang.)

Purpose: The off-label use of flow diverting stents (FDS) for treating cerebral aneurysms in small distal vessels is increasing in clinical practice with encouraging results; however, data directly addressing the parent vessel size are still scarce. Our aim was to evaluate the safety and efficacy of FDS placement in anterior and posterior circulation aneurysms with parent arteries ≤ 2 mm in a real-world representative setting., Methods: We retrospectively reviewed patients treated with FDS at the three participating university hospitals between 2009 and 2021. The inclusion criteria were the placement of at least one FDS in a parent vessel with a maximum diameter of 2 mm or less. The primary clinical safety endpoint was the absence of death, major or minor symptomatic stroke, transient ischemic attack and procedure-related intracranial hemorrhage. Clinical outcome was assessed using the modified Rankin Scale (mRS) score at the follow-up visit at 1 year. The primary efficacy endpoint was defined as complete and near-complete occlusion at the 1‑year follow-up., Results: We identified 55 patients harboring 56 aneurysms. The primary clinical safety endpoint was obtained in 93% of cases. The hemorrhagic and thromboembolic complication rates were 4% and 9%, respectively. No patient died or had a relevant discrepancy (> 1 point) at the pre-mRS and post-mRS. The primary efficacy endpoint was reached in 80% of cases., Conclusion: The use of FDS in vessels < 2 mm is technically feasible with good aneurysm occlusion rates and an acceptable safety profile. Nevertheless, it is essential to be aware of the of the main complications associated when operating in small diameter vessels., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Background: Optimal antiplatelet inhibition is essential in patients undergoing neurointerventional procedures; however, variability in response to clopidogrel can contribute to thromboembolic and hemorrhagic complications. The present study evaluated the influence of diabetes mellitus and cigarette smoking on clopidogrel reactivity.Methods: Between 2011 and 2013, 71 consecutive patients underwent aneurysmal coil embolization (CE) or carotid artery stenting (CAS) and received clopidogrel (75 mg daily) and aspirin (100 mg daily) before the treatment. The patients were divided into 2 groups: CE (n = 31) and CAS (n = 40). The patients underwent prospective assessment of preoperative platelet function using VerifyNow assay and received adjunctive cilostazol (200 mg daily, triple antiplatelet therapy) in case of clopidogrel hyporesponse. Patients with clopidogrel hyper-response underwent clopidogrel dose reduction (clopidogrel, 12.5-50 mg daily).Results: Clopidogrel resistance was noted in 15 patients (37.5%) in the CAS group and in 4 patients (12.9%) in the CE group (P = .031). Clopidogrel hyper-response was noted in 2 patients (5%) in the CAS group and in 11 patients (54.8%) in the CE group (P < .001). There was a significant difference in the baseline clinical characteristics between the 2 groups. In the multivariate logistic regression analysis, diabetes and age were independent predictors of clopidogrel hyporesponse, whereas current smoker was an independent predictor of clopidogrel hyper-response.Conclusions: Significant differences in baseline clinical characteristics were present when comparing patients undergoing endovascular treatment of unruptured cerebral aneurysms and carotid artery stenosis. Diabetes mellitus and current smoker status were independent factors related to reactivity to clopidogrel. [ABSTRACT FROM AUTHOR]

Neurointervention which deals with neurovascular disease in brain, head-and-neck and spines are one of the rapidly evolving medical fields. Several indices representing neurointerventional activities are still increasing year-by-year in Korea. We review current trend in major neurovascular diseases requiring usage of specific medical devices and some issues related to administrative process of the government approval.

Purpose: Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor antagonist is often used to prevent thrombotic complications after endovascular stent placement. Most of the published experience surrounding DAPT after carotid stenting is with clopidogrel. Ticagrelor may be a promising alternative, especially in patients who may be considered nonresponders to clopidogrel. However, clinical outcomes utilizing DAPT with ticagrelor in a cohort with carotid stenting is lacking. In this case series, we describe our experience with systematic prescribing of ticagrelor after carotid stent placement in 18 patients. Methods: A retrospective review of 18 patients prescribed ticagrelor who underwent carotid stenting between November 2015 and January 2017 was performed. All eligible patients were included in the review. The primary end point of interest was any ischemic stroke or death within 30 days following the procedure. Intracranial hemorrhage was a secondary end point. Results and Conclusions: No patients experienced the primary end point of ischemic stroke or death within 30 days. No intracranial hemorrhages were observed. The use of ticagrelor after carotid stenting may be a reasonable alternative to clopidogrel after carotid stent placement. Randomized trials to support our findings are needed. [ABSTRACT FROM AUTHOR]

Stroke in children is common and is associated with long-term morbidity. The incidence of stroke is 13/100,000 in children above 1 month, with higher incidences in neonates and premature infants. It has to be differentiated from other diseases which have a similar presentation. We present a case of a 3-year-old female child with embolic stroke of right middle cerebral artery managed with endovascular clot retrieval done under general anesthesia. [ABSTRACT FROM AUTHOR]