Initial Clinical Experience of Repeat Thrombectomy with a Retrieval Stent (RTRS) with Continuous Proximal Flow Arrest by Balloon Guide Catheter for Acute Intracranial Carotid Occlusion

Background. Balloon guide catheters (BGCs) have good performance in terms of radiological outcomes in acute ischemic thrombectomy. It is not uncommon for BGCs to be blocked by thrombi, especially in cases with acute intracranial internal carotid artery (ICA) occlusion. Our initial experience using repeat thrombectomy with a retrieval stent (RTRS) with continuous proximal flow arrest by BGC for acute intracranial ICA occlusion is presented. Methods. In patients with acute intracranial ICA occlusion treated with RTRS, clinical data, including the National Institutes of Health Stroke Scale (NIHSS) score at admission and modified Rankin Scale (mRS) score at 90 days, and procedural data, including the Extended treatment in Cerebral Infarction (eTICI) score, procedural time, and complications, were analyzed. Results. Thirty-two consecutive patients (12 men (37.5%); mean age: 73 years) were treated with RTRS using a BGC. The median NIHSS score was 19. The median puncture-to-reperfusion time was 46 minutes (range: 22-142 minutes). All patients were successfully revascularized; eTICI 2c or better recanalization was achieved in 30 (93.8%) patients. No procedure-related complications or symptomatic intracranial hemorrhage occurred. Two cases (6.3%) had distal emboli, but none had emboli to the anterior cerebral artery. Fourteen patients (43.8%) achieved a good outcome with an mRS score of 0–2 at 90 days, and 8 patients (25.0%) died. Conclusions. In patients with intracranial ICA occlusion, RTRS with proximal flow arrest by BGC is effective and safe, achieving good clinical and angiographic outcomes. This method may reduce the incidence of distal emboli in thrombectomy with stent retrievers.

Download Full-text

Ballast and NeuronMax in stroke thrombectomy

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2020-016039 ◽

2020 ◽

pp. neurintsurg-2020-016039

Author(s):

Bradley A Gross ◽

Jaydevsinh Dolia ◽

Daniel A Tonetti ◽

Jeremy Stone ◽

Merritt Brown ◽

...

Keyword(s):

Scale Score ◽

Comparative Evaluation ◽

National Institutes Of Health ◽

Initial Experience ◽

Modified Rankin Scale ◽

Transfemoral Approach ◽

Significant Difference ◽

Tissue Plasminogen ◽

Procedural Time ◽

Procedural Outcomes

BackgroundComparative evaluation of long sheath performance in stroke thrombectomy has not been performed.ObjectiveTo review an initial experience with the new Ballast 6F long sheath compared with the NeuronMax, to evaluate comparative benchmarks in trackability, navigability, and procedural outcomes.MethodsA prospectively maintained thrombectomy database was evaluated over a 6-month period to compare procedural and angiographic results between a cohort of patients treated with the historical institutional standard long sheath (NeuronMax) and another with the new Ballast long sheath via a transfemoral approach.ResultsOf 156 stroke thrombectomy cases, 69 were performed using NeuronMax and 40 using Ballast via a transfemoral approach; the remainder of cases employed alternative long sheaths or were performed via initial radial access. There was no significant difference in patient age, medical history, baseline National Institutes of Health Stroke Scale score, Alberta Stroke Program Early CT Score, arch type, tissue plasminogen activator use, and clot location between the two groups. Single-pass case frequency (41% for NeuronMax vs 44% for Ballast, p=0.84), and final successful revascularization (TICI 2b or greater) were similar between the two cohorts (91% vs 98%, p=0.42). Good 90-day outcome (modified Rankin Scale score 0–2) was also similar (33% for NeuronMax, 43% for Ballast, p=0.41). Excluding tandem occlusions, mean procedural time was 31 min for NeuronMax and 25 min for Ballast (p=0.09). Puncture to long sheath access and angiography in the base target vessel was faster for Ballast than NeuronMax (6.5 min vs 9.2 min, p=0.04).ConclusionAmong a cohort of practitioners with historical, preferential experience with NeuronMax for stroke thrombectomy, faster procedural times were achieved with Ballast with similar final angiographic results.

Download Full-text

Longer stent retrievers enhance thrombectomy performance in acute stroke

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2018-013918 ◽

2018 ◽

Vol 11 (1) ◽

pp. 6-8 ◽

Cited By ~ 12

Author(s):

Diogo C Haussen ◽

Alhamza R Al-Bayati ◽

Jonathan A Grossberg ◽

Mehdi Bouslama ◽

Clara Barreira ◽

...

Keyword(s):

Primary Outcome ◽

Internal Carotid ◽

Multivariable Analysis ◽

National Institutes Of Health ◽

First Line ◽

Guide Catheter ◽

First Pass ◽

Tissue Plasminogen ◽

Stent Retrievers

BackgroundLonger stent retrievers have recently become available and have theoretical advantages over their shorter counterparts. We aim to evaluate whether stent retriever length impacts reperfusion rates in stroke thrombectomy.MethodsThis was a retrospective analysis of a prospectively collected thrombectomy database in which equal diameter (4 mm) stent retrievers were used as the first-line strategy for intracranial internal carotid or middle cerebral artery M1 or M2 occlusions along with a balloon guide catheter from June 2011 to March 2017. The population was dichotomized into long (Trevo 4×30 mm/Solitaire 4×40 mm) or short (Trevo 4×20 mm/Solitaire 4×20 mm) retrievers. The primary outcome was first-pass modified Thrombolysis in Cerebral Infarction (mTICI) 2b/3 reperfusion.ResultsOf 1126 thrombectomies performed within the study period, 420 were included. Age, gender, National Institutes of Health Stroke Scale, ASPECTS, IV tissue plasminogen activator use, stroke etiology, occlusion site, time from last-known-normal to puncture, distribution of Trevo and Solitaire, and the use of newer generation local thromboaspiration devices were comparable between the long and short retrievers. The short retriever group had more frequent hypertension, dyslipidemia, and atrial fibrillation. First-pass mTICI 2b/3 reperfusion was more common in the long retriever group (62% vs 50%; P=0.01). Parenchymal hematomas type 2, subarachnoid hemorrhage, 90-day modified Rankin Scale score 0–2, and mortality were comparable. Multivariable analysis indicated that long retriever (OR 2.2; 95% CI 1.3 to 3.6; P=0.001), radiopaque device (OR 2.1; 95% CI 1.2 to 3.4; P=0.003), and adjuvant local aspiration (OR 2.4; 95% CI 1.3 to 4.3; P=0.003) were independently associated with first-pass reperfusion.ConclusionsThe use of longer stent retrievers is an independent predictor of first-pass mTICI 2b/3 reperfusion. First-pass reperfusion was also associated with the use of radiopaque devices and adjuvant local aspiration.

Download Full-text

The golden 35 min of stroke intervention with ADAPT: effect of thrombectomy procedural time in acute ischemic stroke on outcome

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2017-013040 ◽

2017 ◽

Vol 10 (3) ◽

pp. 213-220 ◽

Cited By ~ 18

Author(s):

Ali Alawieh ◽

Alyssa K Pierce ◽

Jan Vargas ◽

Aquilla S Turk ◽

Raymond D Turner ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

National Institutes Of Health ◽

Modified Rankin Scale ◽

Nihss Score ◽

Good Outcome ◽

First Pass ◽

Procedural Time

IntroductionIn acute ischemic stroke (AIS), extending mechanical thrombectomy procedural times beyond 60 min has previously been associated with an increased complication rate and poorer outcomes.ObjectiveAfter improvements in thrombectomy methods, to reassess whether this relationship holds true with a more contemporary thrombectomy approach: a direct aspiration first pass technique (ADAPT).MethodsWe retrospectively studied a database of patients with AIS who underwent ADAPT thrombectomy for large vessel occlusions. Patients were dichotomized into two groups: ‘early recan’, in which recanalization (recan) was achieved in ≤35 min, and ‘late recan’, in which procedures extended beyond 35 min.Results197 patients (47.7% women, mean age 66.3 years) were identified. We determined that after 35 min, a poor outcome was more likely than a good (modified Rankin Scale (mRS) score 0–2) outcome. The baseline National Institutes of Health Stroke Scale (NIHSS) score was similar between ‘early recan’ (n=122) (14.7±6.9) and ‘late recan’ patients (n=75) (15.9±7.2). Among ‘early recan’ patients, recanalization was achieved in 17.8±8.8 min compared with 70±39.8 min in ‘late recan’ patients. The likelihood of achieving a good outcome was higher in the ‘early recan’ group (65.2%) than in the ‘late recan’ group (38.2%; p<0.001). Patients in the ‘late recan’ group had a higher likelihood of postprocedural hemorrhage, specifically parenchymal hematoma type 2, than those in the ‘early recan’ group. Logistic regression analysis showed that baseline NIHSS, recanalization time, and atrial fibrillation had a significant impact on 90-day outcomes.ConclusionsOur findings suggest that extending ADAPT thrombectomy procedure times beyond 35 min increases the likelihood of complications such as intracerebral hemorrhage while reducing the likelihood of a good outcome.

Download Full-text

Abstract P33: Blind Exchange With the Mini-Pinning Technique Using Tron Fx Retriever for M2 Occlusion Thrombectomy

Stroke ◽

10.1161/str.52.suppl_1.p33 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Takeshi Yoshimoto

Keyword(s):

Stent Retriever ◽

National Institutes Of Health ◽

Modified Rankin Scale ◽

Target Vessel ◽

Stroke Patients ◽

Technical Improvement ◽

Vessel Size ◽

Blind Navigation ◽

First Pass ◽

Stent Retrievers

Introduction: Technical improvement to enhance M2 occlusion thrombectomy is desirable. Tron FX® is the only stent-retriever that can be deployed through 0.0165-inch microcatheters. Here we report outcomes of blind exchange with mini-pinning (BEMP) technique using Tron stent-retrievers. Methods: Consecutive stroke patients with M2 occlusion treated with 2 x15 mm or 4 x 20 mm Tron stent-retrievers using the BEMP technique were included. The technique involves the deployment of a Tron stent-retriever through a 0.0165-inch microcatheter followed by microcatheter removal and blind navigation of a 3/4MAX aspiration catheter over the bare Tron delivery wire until the aspiration catheter reaches the clot,. Tron stent-retriever was inserted into aspiration catheter like corkscrew, and subsequently pulled as a unit. A first pass effect (FPE), modified FPE (mFPE) and modified Rankin Scale (mRS) score at 90 days were assessed as outcomes. Results: Fifteen M2 vessels were treated in 13 patients (5 women, median 81 years of age, and median National Institutes of Health Stroke Scale score 18 [11–25]). BEMP technique was successful in all cases. Whether to use 3MAX or 4MAX was determined according to the target vessel size while proceeding with the procedure (3MAX, n=8; 4MAX, n=5). Final mTICI 2b–3 was achieved in 92% (12/13). FPE and mFPE rates were 50% and 64%, respectively. Six patients (46%) were achieved in mRS score 0–2 at 3 months. Conclusions: Tron stent-retriever was successfully and safely used in the BEMP technique for M2 occlusion

Download Full-text

What predicts poor outcome after successful thrombectomy in early time window?

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2021-017946 ◽

2021 ◽

pp. neurintsurg-2021-017946

Author(s):

Jean-Marc Olivot ◽

Jeremy J Heit ◽

Mikael Mazighi ◽

Nicolas Raposo ◽

Jean François Albucher ◽

...

Keyword(s):

Internal Carotid ◽

Time Window ◽

Independent Predictor ◽

Early Time ◽

National Institutes Of Health ◽

Multivariable Logistic Regression Analysis ◽

Modified Rankin Scale ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Poor Outcome

BackgroundHalf of the patients with large vessel occlusion (LVO)-related acute ischemic stroke (AIS) who undergo endovascular reperfusion are dead or dependent at 3 months. We hypothesize that in addition to established prognostic factors, baseline imaging profile predicts outcome among reperfusers.MethodsConsecutive patients receiving endovascular treatment (EVT) within 6 hours after onset with Thrombolysis In Cerebral Infarction (TICI) 2b, 2c and 3 revascularization were included. Poor outcome was defined by a modified Rankin scale (mRS) 3–6 at 90 days. No mismatch (NoMM) profile was defined as a mismatch (MM) ratio ≤1.2 and/or a volume <10 mL on pretreatment imaging.Results187 patients were included, and 81 (43%) had a poor outcome. Median delay from stroke onset to the end of EVT was 259 min (IQR 209–340). After multivariable logistic regression analysis, older age (OR 1.26, 95% CI 1.06 to 1.5; p=0.01), higher National Institutes of Health Stroke Scale (NIHSS) (OR 1.15, 95% CI 1.06 to 1.25; p<0.0001), internal carotid artery (ICA) occlusion (OR 3.02, 95% CI 1.2 to 8.0; p=0.021), and NoMM (OR 4.87, 95% CI 1.09 to 22.8; p=0.004) were associated with poor outcome. In addition, post-EVT hemorrhage (OR 3.64, 95% CI 1.5 to 9.1; p=0.04) was also associated with poor outcome.ConclusionsThe absence of a penumbra defined by a NoMM profile on baseline imaging appears to be an independent predictor of poor outcome after reperfusion. Strategies aiming to preserve the penumbra may be encouraged to improve these patients’ outcomes.

Download Full-text

Abstract WP53: Safety and Efficacy of Mechanical Thrombectomy in Acute Stroke Patients on New Oral Anticoagulants

Stroke ◽

10.1161/str.51.suppl_1.wp53 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Nurose Karim ◽

Alicia C Castonguay ◽

Hisham Salahuddin ◽

Julie Shawver ◽

Syed Zaidi ◽

...

Keyword(s):

Mechanical Thrombectomy ◽

Oral Anticoagulants ◽

National Institutes Of Health ◽

New Oral Anticoagulants ◽

Limited Data ◽

Stroke Patients ◽

Safety And Efficacy ◽

Nihss Score ◽

Symptomatic Intracerebral Hemorrhage ◽

Symptomatic Intracranial Hemorrhage

Background: Limited data exists on the benefits of mechanical thrombectomy (MT) in acute ischemic stroke patients on new oral anticoagulants (NOAC). The aim of our study is to examine the safety and efficacy of MT in NOAC patients at our center. Methods: A retrospective review of our prospective MT database was performed for this study. Baseline characteristics, National Institutes of Health Stroke Scale (NIHSS) score, revascularization rate, symptomatic intracranial hemorrhage rate (sICH), and 90-day mortality and favorable outcomes were compared in MT patients on NOAC (MT-NOAC) versus those who were not on NOAC (MT). Results: From July 2012 to December 2018, 553 AIS patients underwent treatment with MT, with 36 patients on NOAC (6.5%). Median age was similar (73 versus 74), with 52.8% and 52.0% (p=0.8) female in the MT-NOAC and MT groups, respectively. Median baseline NIHSS score (17 IQR10-21 versus 17 IQR 12-21, p=0.75) and ASPECTS (9 IQR 8-9, p=0.80) were similar between the groups. Atrial fibrillation was more prevalent in the MT-NOAC group (80.6% versus 37.7%, p=<0.0001). No difference was seen in occlusion site between the group, with M1 occlusions the most common site (44.4% versus 43.3%, p=0.9). Median onset to revascularization times did not differ between the cohorts (146 minutes versus 206, p=0.61). Successful revascularization (mTICI≥2b) was 87.5% and 81.8% in the MT NOAC and MT groups, respectively. Rates of symptomatic intracerebral hemorrhage per ECASS III criteria were similar between the two groups (5.5% versus 4.6%, p=0.68). No difference was seen in 90-day favorable outcomes (mRS 0-2) (48.3% versus 41.1%, p=0.44) or mortality (27.6% versus 27.1%, 0.95). Conclusion: MT in patients on NOAC appears to be safe and efficacious. As our study is limited by sample size, larger prospective studies are needed to understand the safety and efficacy of MT in AIS patients on NOAC.

Download Full-text

Who Is Classified as Untestable on Brief Cognitive Screens in an Acute Stroke Setting?

Diagnostics ◽

10.3390/diagnostics9030095 ◽

2019 ◽

Vol 9 (3) ◽

pp. 95 ◽

Cited By ~ 3

Author(s):

Emma Elliott ◽

Bogna A. Drozdowska ◽

Martin Taylor-Rowan ◽

Robert C. Shaw ◽

Gillian Cuthbertson ◽

...

Keyword(s):

Cognitive Assessment ◽

Odds Ratio ◽

National Institutes Of Health ◽

Screening Tests ◽

Stroke Severity ◽

Modified Rankin Scale ◽

Cognitive Screening ◽

Dementia Diagnosis ◽

Nihss Score ◽

Test Completion

Full completion of cognitive screening tests can be problematic in the context of a stroke. Our aim was to examine the completion of various brief cognitive screens and explore reasons for untestability. Data were collected from consecutive stroke admissions (May 2016–August 2018). The cognitive assessment was attempted during the first week of admission. Patients were classified as partially untestable (≥1 test item was incomplete) and fully untestable (where assessment was not attempted, and/or no questions answered). We assessed univariate and multivariate associations of test completion with: age (years), sex, stroke severity (National Institutes of Health Stroke Scale (NIHSS)), stroke classification, pre-morbid disability (modified Rankin Scale (mRS)), previous stroke and previous dementia diagnosis. Of 703 patients admitted (mean age: 69.4), 119 (17%) were classified as fully untestable and 58 (8%) were partially untestable. The 4A-test had 100% completion and the clock-draw task had the lowest completion (533/703, 76%). Independent associations with fully untestable status had a higher NIHSS score (odds ratio (OR): 1.18, 95% CI: 1.11–1.26), higher pre-morbid mRS (OR: 1.28, 95% CI: 1.02–1.60) and pre-stroke dementia (OR: 3.35, 95% CI: 1.53–7.32). Overall, a quarter of patients were classified as untestable on the cognitive assessment, with test incompletion related to stroke and non-stroke factors. Clinicians and researchers would benefit from guidance on how to make the best use of incomplete test data.

Download Full-text

ADAPT FAST study: a direct aspiration first pass technique for acute stroke thrombectomy

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2014-011125.rep ◽

2018 ◽

Vol 10 (Suppl 1) ◽

pp. i4-i7 ◽

Cited By ~ 17

Author(s):

Aquilla S Turk ◽

Don Frei ◽

David Fiorella ◽

J Mocco ◽

Blaise Baxter ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Functional Outcomes ◽

National Institutes Of Health ◽

Nihss Score ◽

First Pass ◽

Procedural Complications ◽

Intracerebral Hemorrhages ◽

Stent Retrievers ◽

A New Technique

BackgroundThe development of new revascularization devices has improved recanalization rates and time, but not clinical outcomes. We report a prospectively collected clinical experience with a new technique utilizing a direct aspiration first pass technique with large bore aspiration catheter as the primary method for vessel recanalization.Methods98 prospectively identified acute ischemic stroke patients with 100 occluded large cerebral vessels at six institutions were included in the study. The ADAPT technique was utilized in all patients. Procedural and clinical data were captured for analysis.ResultsThe aspiration component of the ADAPT technique alone was successful in achieving Thrombolysis in Cerebral Infarction (TICI) 2b or 3 revascularization in 78% of cases. The additional use of stent retrievers improved the TICI 2b/3 revascularization rate to 95%. The average time from groin puncture to at least TICI 2b recanalization was 37 min. A 5MAX demonstrated similar success to a 5MAX ACE in achieving TICI 2b/3 revascularization alone (75% vs 82%, p=0.43). Patients presented with an admitting median National Institutes of Health Stroke Scale (NIHSS) score of 17.0 (12.0–21.0) and improved to a median NIHSS score at discharge of 7.3 (1.0–11.0). Ninety day functional outcomes were 40% (modified Rankin Scale (mRS) 0–2) and 20% (mRS 6). There were two procedural complications and no symptomatic intracerebral hemorrhages.DiscussionThe ADAPT technique is a fast, safe, simple, and effective method that has facilitated our approach to acute ischemic stroke thrombectomy by utilizing the latest generation of large bore aspiration catheters to achieve previously unparalleled angiographic outcomes.

Download Full-text

Longer procedural times are independently associated with symptomatic intracranial hemorrhage in patients with large vessel occlusion stroke undergoing thrombectomy

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2015-012157 ◽

2016 ◽

Vol 8 (12) ◽

pp. 1217-1220 ◽

Cited By ~ 16

Author(s):

Tareq Kass-Hout ◽

Omar Kass-Hout ◽

Chung-Huan Johnny Sun ◽

Taha A Kass-Hout ◽

Raul Nogueira ◽

...

Keyword(s):

Intracranial Hemorrhage ◽

Functional Outcomes ◽

Infarct Volume ◽

National Institutes Of Health ◽

Procedure Time ◽

Vessel Occlusion ◽

Procedural Time ◽

Symptomatic Intracranial Hemorrhage

BackgroundTime to reperfusion is an essential factor in determination of outcomes in acute ischemic stroke (AIS).ObjectiveTo establish the effect of the procedural time on the clinical outcomes of patients with AIS.MethodsData from all consecutive patients who underwent mechanical thrombectomy between September 2010 and July 2012 were analysed retrospectively. The variable of interest was procedural time (defined as time from groin puncture to final recanalization time). Outcome measures included the rates of symptomatic intracranial hemorrhage (sICH, defined as any parenchymal hematoma—eg, PH-1/PH-2), final infarct volume, 90-day mortality, and independent functional outcomes (modified Rankin Scale 0–2) at 90 days.ResultsThe cohort included 242 patients with a mean age of 65.5±14.2 and median baseline National Institutes of Health Stroke Scale score 20. 51% of the patients were female. The mean procedure time was significantly shorter in patients with a good outcome (86.7 vs 73.1 min, respectively, p=0.0228). Patients with SICH had significantly higher mean procedure time than patients without SICH (79.67 vs 104.5 min, respectively; p=0.0319), which remained significant when controlling for the previous factors (OR=0.974, 95% CI 0.957 to 0.991). No correlation was found between the volume of infarction and the procedure time (r=0.10996, p=0.0984). No association was seen between procedure time and 90-day mortality (77.8 vs 88.2 min in survivals vs deaths, respectively; p=0.0958).ConclusionsOur data support an association between the risk of SICH and a longer procedure time, but no association between procedural times and the final infarction volume or long-term functional outcomes was found.

Download Full-text

Stent Reconstruction of Carotid Tonsillar Loop Dissection Using Telescoping Peripheral Stents

Interventional Neurology ◽

10.1159/000486457 ◽

2018 ◽

Vol 7 (3-4) ◽

pp. 189-195 ◽

Cited By ~ 1

Author(s):

Benjamin M. Zussman ◽

Bradley A. Gross ◽

William J. Ares ◽

Cynthia L. Kenmuir ◽

Gregory M. Weiner ◽

...

Keyword(s):

Internal Carotid ◽

Treatment Options ◽

National Institutes Of Health ◽

Modified Rankin Scale ◽

Endovascular Techniques ◽

Aspiration Thrombectomy ◽

Patient Demographics ◽

Clinical Presentations ◽

Scale Scores

Background: Endovascular treatment options for internal carotid artery (ICA) dissection with tandem intracranial occlusion are evolving. We report 2 cases of stent reconstruction of carotid loop dissections. Methods: Two patients with symptomatic ICA dissections of true 360° tonsillar loops and tandem intracranial occlusions were treated with manual aspiration thrombectomy (MAT) and telescoping Zilver self-expanding peripheral stents. Patient demographics, clinical presentations, endovascular techniques, and clinical outcomes were reviewed. Results: In both cases, MAT achieved modified Treatment in Cerebral Ischemia scale 2B reperfusion, and complete endovascular reconstruction of the dissected extracranial loop was performed. Both patients had improved pre- to postintervention National Institutes of Health Stroke Scale scores (16 to 0 and 14 to 0), and both had modified Rankin scale scores of 1 at 3-month follow-up. Conclusions: Stent reconstruction of complex cerebrovascular anatomy is increasingly feasible with advancements in stent technology and catheter support system design. This technique may be of use to neuroendovascular surgeons who encounter variant ICA anatomy.

Download Full-text