Flow diverters (FDs) have dramatically altered the treatment of intracranial aneurysms. Several literature studies have demonstrated the safety and effectiveness of individual devices. However, in clinical practice, different FDs are used, for different aneurysms, ruptured and unruptured.
Aim of Study
To assess the safety, long term angiographic and clinical outcomes in a real-world scenario.
Methods
We retrospectively analyzed data from all consecutive patients with intracranial aneurysms treated with FDs at our tertiary center between January 2010 and December 2019. Clinical presentations, intra- and perioperative complications, and clinical and angiographic outcomes were recorded, with long-term follow-up. Logistic regression analysis was performed to evaluate for possible variables associated with aneurysm occlusion, and early ischemic stroke after FD.
Results
A total 169 patients with 202 aneurysms were included. Seventeen aneurysms (8.4%) were ruptured. Technical success was achieved in 97.5% of cases. Aneurysm occlusion rates were 52.0% (64/123), 70.4% (88/125), and 81.5% (101/124) at 6 ,12 and 24-month follow-up, respectively. Intraprocedural complications occurred in 4.7% of patients, and postprocedural complications in 20.1%. The most frequent complication was ischemic stroke (14.9%), which was independently associated with older age and higher number of devices used.
Conclusion
Our series suggests that treatment with FD is feasible in a wide spectrum of cases, including aneurysms in different locations, sizes and morphology, ruptured and non-ruptured, reflecting a real-world scenario. Although available devices may differ, they seem to demonstrate comparable and adequate safety and effectiveness.
The safety and efficacy of bridging therapy with intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) in patients with large core infarct has not been sufficiently studied. In this study, we compared the efficacy and safety outcomes between patients who received IVT+MT and those treated with MT alone.This is a retrospective analysis of the Stroke Thrombectomy Aneurysm Registry (STAR). Patients with Alberta Stroke Program Early CT Score (ASPECTS) ≤5 treated with MT were included in this study. Patients were divided into two groups based on pre-treatment IVT (IVT, no IVT). Propensity score matched analysis were used to compare outcomes between groups.A total of 398 patients were included; 113 pairs were generated using propensity score matching analyses. Baseline characteristics were well balanced in the matched cohort. The rate of any intracerebral hemorrhage (ICH) was similar between groups in both the full cohort (41.4% vs 42.3%, P=0.85) and matched cohort (38.55% vs 42.1%, P=0.593). Similarly, the rate of significant ICH was similar between the groups (full cohort: 13.1% vs 16.9%, P=0.306; matched cohort: 15.6% vs 18.95, P=0.52). There was no difference in favorable outcome (90-day modified Rankin Scale 0-2) or successful reperfusion between groups. In an adjusted analysis, IVT was not associated with any of the outcomes.Pretreatment IVT was not associated with an increased risk of hemorrhage in patients with large core infarct treated with MT. Future studies are needed to assess the safety and efficacy of bridging therapy in patients with large core infarct.
Endoluminal reconstruction with flow diverter devices represents an innovative technique in the treatment of intracranial aneurysms.These new stents, self-expandable and of low porosity, are released through the microcatherization of the parent artery. The main goal of these systems is thereby rebuilding the vessel wall and excluding the aneurysmal formation of the arterial circulation.We show the preliminary results in treating 10 patients at Hospital de São José, Lisbon. These patients, with wide-necked (> 4 mm)or unfavorable dome/neck ratios (> 1.5) aneurysms, were treated with the PIPELINE® system, and angiographic control were made at three and six months. New control will be done at 12 months. The mean age of enrolled patients is 54.3 years; eight patients were female and two male. Aneurysms were incidentally discovered in two patients. The remaining patients were diagnosed during imaging investigation for headache (n = 3), visual field defect (n = 1), vertigo(n = 1) and at least one cranial palsy (n = 2). Only two patients had had prior subarachnoid hemorrhage and two patients underwent prior endovascular treatment with coils. The locations of aneurysms treated were the proximal segment of the middle cerebral artery(n = 1) and the paraophthalmic (n = 6), ophthalmic (n = 2) and cavernous (n = 4) internal carotid artery segments. Thirteen intracranial aneurysms were treated as three patients had multiple aneurysms. Control studies were conducted and shown an average degree of occlusion at three months of 74% and at six months of 86%. There was no reduction in size of one paraophthalmic artery aneurysm.The experience of this department is favorable to the use of flow-diverter devices to treat selected aneurysms. High occlusion rates were obtained given the existing challenges in the treatment of such aneurysms.
This review intends to systematize the diagnostic and treatment approach to cerebral venous thrombosis (CVT), highlighting key studies that have been recently published.
Background In response to the COVID-19 pandemic, many centers altered stroke triage protocols for the protection of their providers. However, the effect of workflow changes on stroke patients receiving mechanical thrombectomy (MT) has not been systematically studied. Methods A prospective international study was launched at the initiation of the COVID-19 pandemic. All included centers participated in the Stroke Thrombectomy and Aneurysm Registry (STAR) and Endovascular Neurosurgery Research Group (ENRG). Data was collected during the peak months of the COVID-19 surge at each site. Collected data included patient and disease characteristics. A generalized linear model with logit link function was used to estimate the effect of general anesthesia (GA) on in-hospital mortality and discharge outcome controlling for confounders. Results 458 patients and 28 centers were included from North America, South America, and Europe. Five centers were in high-COVID burden counties (HCC) in which 9/104 (8.7%) of patients were positive for COVID-19 compared with 4/354 (1.1%) in low-COVID burden counties (LCC) (P<0.001). 241 patients underwent pre-procedure GA. Compared with patients treated awake, GA patients had longer door to reperfusion time (138 vs 100 min, P=<0.001). On multivariate analysis, GA was associated with higher probability of in-hospital mortality (RR 1.871, P=0.029) and lower probability of functional independence at discharge (RR 0.53, P=0.015). Conclusion We observed a low rate of COVID-19 infection among stroke patients undergoing MT in LCC. Overall, more than half of the patients underwent intubation prior to MT, leading to prolonged door to reperfusion time, higher in-hospital mortality, and lower likelihood of functional independence at discharge.
OBJECTIVE Clinical outcome in nontraumatic subarachnoid hemorrhage (SAH) is multifactorial and difficult to predict. Diffusion tensor imaging (DTI) findings are a prognostic marker in some diseases such as traumatic brain injury. The authors hypothesized that DTI parameters measured in the subacute phase of SAH can be associated with a poor clinical outcome. METHODS Diffusion tensor imaging was prospectively performed in 54 patients at 8–10 days after nontraumatic SAH. Logistic regression analysis was performed to evaluate the association of fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values with a poor clinical outcome (modified Rankin Scale score ≥ 3) at 3 months. RESULTS At 8–10 days post-SAH, after adjusting for other variables associated with a poor outcome, an increased ADC at the frontal centrum semiovale was associated with a poor prognosis (OR estimate 1.29, 95% CI 1.04–1.60, p = 0.020). Moreover, an increase of 0.1 in the FA value at the corpus callosum at 8–10 days after SAH corresponded to 66% lower odds of having a poor outcome (p = 0.002). CONCLUSIONS Decreased FA and increased ADC values in specific brain regions were independently associated with a poor clinical outcome after SAH. This preliminary exploratory study supports a potential role for DTI in predicting the outcome of SAH.
The objectives of this study were to determine the incidence of Postoperative Delirium and to identify specific perioperative risk factors in patients undergoing Vascular Surgery. Other goals were to study its impact in hospital length of stay and to create an algorithm to deal with patients under suspicion of Postoperative Delirium.A total of 56 consecutive vascular surgery patients were prospectively evaluated. Exclusion criteria were age less than 18, dementia, abnormal level of consciousness, psychiatric disorder and visual or hearing impairment. Mini Mental State Examination were applied during pre-anesthetic visit. In patients with clinical indicators of delirium the Confusion Assessment Method was applied. Patients were assessed during 5 days after surgery.The overall incidence of delirium was 12,5%, developped mostly by the second to fifth postoperative day. Patients with delirium presented moderate to severe pain. Patients who received combined general and regional anesthesia didn't develop delirium. The median hospital length of stay was 21 in patients with delirium and 7 days in patients without (p 0.001).The overall incidence of postoperative delirium was lower than previously reported. The incidence of delirium was higher in ICU patients and pain was associated with postoperative delirium suggesting the opportunity to control postoperative factores. The development of delirium in the second and fifth day indicated the need for early and more prolonged preventive and diagnosing measures. Clinical and costly considerations of prolonged hospital stay shown in this cohort warrant strong debate strategies to be applied.
The appropriateness of rheumatic mitral valve repair remains controversial due to the risks of recurrent mitral dysfunction and need for reoperation. The aims of this study were to determine the overall short- and long-term outcomes of pediatric rheumatic mitral valve surgery in our center.Single-center, observational, retrospective study that analyzed the results of rheumatic mitral valve surgery in young patients, consecutively operated by the same team, between 1999 and 2014.We included 116 patients (mean age = 12.6 ± 3.5 years), of which 66 (57%) were females. A total of 116 primary surgical interventions and 22 reoperations were performed. Primary valve repair was possible in 86 (74%) patients and valve replacement occurred in 30 (26%). Sixty percent of the patients were followed up beyond three months after surgery (median follow-up time = 9.2 months [minimum = 10 days; maximum = 15 years]). Long-term clinical outcomes were favorable, with most patients in New York Heart Association functional class I (89.6%) and in sinus rhythm (85%). Freedom from reoperation for primary valve repair at six months, five years, and ten years was 96.4% ± 0.25%, 72% ± 0.72%, and 44.7% ± 1.34%, respectively. Freedom from reoperation for primary valve replacement at six months, five years, and ten years was 100%, 91.7% ± 0.86%, and 91.7% ± 0.86%, respectively. Mitral stenosis as the primary lesion dictated early reintervention.Despite the greater rate of reoperation, especially when the primary lesion was mitral stenosis, rheumatic mitral valve repair provides similar clinical outcomes as compared with replacement, with the advantage of avoiding anticoagulation.
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