Rescue Intracranial Stenting in acute Ischemic Stroke v1

Background In acute ischemic stroke (AIS) caused by intracranial large vessel occlusion, rescue intracranial stenting (RIS) has been recently a treatment option to achieve recanalization in patients with the failure of mechanical thrombectomy (MT). Nevertheless, there are few studies supporting this beneficial treatment in two cerebral circulations. We aimed to analyze whether the use of RIS would improve prognosis “non-poor” of patients at 3 months. Methods and Findings This was a interventional, single-arm study in patients with AIS who were treated with rescue stenting at Can Tho S.I.S hospital. Inclusion criteria consisted of: evidence of intracranial large vessel occlusion, absence of intracranial hemorrhage and severe stenosis or reocclusion after MT. Tandem lesion, loss to follow-up after discharge and a severe or fatal combined illness before AIS were excluded. The primary outcome was the “non-poor” outcome rate at 3 months and postprocedural symptomatic intracerebral hemorrhage (sICH). The study is registered with ClinicalTrials.gov, NCT04986774.Between August 2019 and May 2021, 85 eligible patients were comprised of 82 (96.5%) successful recanalization and 4 (4.7%) sICH. “Non-poor” outcome comprising of good (mRS 0 - ≤ 2) and fair (mRS 3). “Non-poor” outcome at 3 months occurred 47 (55.3%), in which there were 35 (41.2%) good outcome. DAPT was associated with new infarcts (RR = 0.1; 95%CI 0.01 - 0.7, NNT = 2) and sICH (RR = 0.1; 95%CI 0.01 - 0.9; NNT = 2). MRI 3 Tesla evaluated diagnostic occlusive lesions with sensitivity (Se) = 98.5%, positive Likelihood Ratio (LR+) = 3.5. The pc-ASPECTS < 6 points was associated with poor outcome (RR = 2.1, 95% CI 1.2- 3.7). Many predictors from demographic, history, time onset, dysphagia, imaging of MRI 3 Tesla, preprocedure, procedure and postprocedure were demonstrated the influence on poor outcome after RIS significantly (all RR > 1, all p < 0.05). The main limitations of the study was conducted in a single center, these results from clinical symptoms to imaging of MRI 3 Tesla could not only be influenced by selection bias but also not generalize to other countries in Asia. Conclusions The RISIS trial suggests that RIS could be an important alternative and additional treatment afterfailureMT despite low proportion of postprocedural sICH. Trial registration Clinicaltrials.gov, Identifier:NCT04986774.

A novel intracranial exchange guidewire improves the navigation of various endovascular devices: An in vitro study of challenging situations

Objective Neuroendovascular procedures rely on successful navigation and stable access to the target vessel. The Stabilizer is a 300 cm long exchange wire with a 0.014 diameter and a soft, flexible stent at the distal end designed to assist with navigation and device delivery. This study aims to assess the efficacy of the Stabilizer for navigation in a variety of challenging environments. Methods The efficacy of the Stabilizer was evaluated using three challenging vascular models: a giant aneurysm model, a severe tortuosity model, and an M1 stenosis model. The Stabilizer was compared with a conventional wire during navigation in each model. Results In the giant aneurysm model, there was no significant difference of success during straightening of a looped wire and significantly higher success rates when advancing an intermediate catheter with the Stabilizer beyond the aneurysm neck compared to a conventional guidewire. The Stabilizer also significantly increased success rates when advancing an intermediate catheter through a model with severe tortuosity compared to a conventional guidewire, as well as exchange maneuver for intracranial stenting in a stenosis model compared to an exchange wire. Conclusions In our experimental model, the Stabilizer significantly improved navigation and device delivery in a variety of challenging settings compared to conventional wires.

Abstract 1122‐000185: Rescue Intracranial Stenting in Acute Ischemic Stroke

Introduction : Rescue treatment for failed thrombectomy in patients with acute ischemic stroke (AIS) from large vessel occlusion (LVO) remains controversial. We report our institutional experience with using intracranial stenting of occlusion refractory to aspiration and stent retriever thrombectomy. Methods : We performed a retrospective review of our prospectively maintained thrombectomy database to identify the LVO AIS patients who underwent intracranial stenting during endovascular thrombectomy at our comprehensive stroke center between January 2015 and July 2021. Modified Rankin scale (mRS) at 90 days was used as primary outcome. A good neurologic outcome was defined as mRS 0–3, and a poor neurologic outcome is defined as mRS score between 4–6. Secondary outcomes included symptomatic intracerebral hemorrhage (sICH) based on ECASS criteria, and in‐hospital mortality. Results : We identified 52 acute ischemic stroke patients who underwent intracranial stenting acutely. Thirty‐three patient (63.4%) are males. Median age was 64 years (Interquartile range (IQR 57–74), median baseline mRS was 0 (IQR 0–1), median NIHSS score was 13 (IQR 7–18), and median ASPECTS was 9 (IQR 8–10). Thirty six percent of the patients had a vertebrobasilar occlusion, 34% had a middle cerebral occlusion (M1 segment), and 14% had an M2 segment occlusion. The median number of thrombectomy passes prior to stenting was 3 (IQR 2–4). In 48% of patients, a combination of aspiration and stent retriever techniques were used prior to intracranial stenting. The Enterprise stent was the most commonly used stent (51.9%), followed by Wingspan stent (25%), and Neuroform Atlas stent (21.5%). Majority of the patients (93%) were loaded with anti‐thrombotics intraoperatively, with rectal Aspirin and intravenous Integrilin being the most commonly used agents. Successful recanalization (TICI 2 B or better) was achieved in 96% of the patients, while the remaining 2 patients were graded as TICI 2A recanalization. Fifty percent of the patients had good outcome at 90 days. A total of 4 patients (8%) developed a sICH, with a 90 day mortality of rate of 15.4% (8/52). Conclusions : Rescue intracranial stenting appears to be a safe and effective approach in patients with emergent large vessel occlusion refractory to thrombectomy. Larger studies are warranted to further establish the safety and efficacy of this approach.

Acute intracranial stenting with mechanical thrombectomy is safe and efficacious in patients diagnosed with underlying intracranial atherosclerotic disease

Objective To investigate whether significant differences exist in recanalization rates and primary outcomes between patients who undergo mechanical thrombectomy alone versus those who undergo mechanical thrombectomy with acute intracranial stenting. Methods Through the utilization of a prospectively collected endovascular database at a comprehensive stroke center between 2012 and 2020, variables such as demographics, co-morbid conditions, symptomatic intracerebral hemorrhage, mortality rate at discharge, and good/poor outcomes in regard to modified thrombolysis in cerebral infarction score and modified Rankin Scale were examined. The outcomes between patients receiving acute intracranial stenting + mechanical thrombectomy and patients that underwent mechanical thrombectomy alone were compared. Results There were a total of 420 acute ischemic stroke patients who met criteria for the study (average age 70.6 ± 13.01 years; 46.9% were women). Analysis of 46 patients from the acute stenting + mechanical thrombectomy group (average age 70.34 ± 13.75 years; 37.0% were women), and 374 patients from the mechanical thrombectomy alone group (average age 70.64 ± 12.92 years; 48.1% were women). Four patients (8.7%) in the acute stenting + mechanical thrombectomy group experienced intracerebral hemorrhage versus 45 patients (12.0%) in the mechanical thrombectomy alone group ( p = 0.506); no significant increases were noted in the median length of stay (7 vs 8 days; p = 0.208), rates of modified thrombolysis in cerebral infarction 2B-3 recanalization ( p = 0.758), or good modified Rankin Scale scores ( p = 0.806). Conclusion Acute intracranial stenting in addition to mechanical thrombectomy was not associated with an increase in overall length of stay, intracerebral hemorrhage rates, or any change in discharge modified Rankin Scale. Further research is required to determine whether mechanical thrombectomy and acute intracranial stenting in acute ischemic stroke patients is unsafe.

Augmented reality enhanced tele-proctoring platform to intraoperatively support a neuro-endovascular surgery fellow

Background Remote tele-proctoring has been conducted in neuro-endovascular surgery, however, evidence to support its use in the fellowship training is limited. We demonstrate a novel augmented reality tele-proctoring platform to enable a remote attending to guide a fellow. Methods A consecutive series of neuro-endovascular cases were performed by a neuro-endovascular fellow with remote guidance from an attending surgeon. The fellow and attending were connected using a commercially available cloud-based platform designed to capture and stream up to four live video feeds from a clinical environment to a remote user. In this setting, two video streams were obtained directly from the anteroposterior and lateral cameras on the biplane. Additional video of the operator from a telescopic camera was streamed live to the remote attending surgeon. The attending could provide immediate vocal feedback and also deploy the platform's augmented reality tools to communicate with the fellow in the angiography suite. Results A total of 10 cases were performed on eight patients utilizing the cloud-based tele-proctoring platform to facilitate instruction. The series included diagnostic angiograms and interventions such as intracranial balloon angioplasty, carotid stenting, and intracranial stenting. All cases were a technical success. No complications or deaths occurred. When compared to similar cohort of 10 cases prior to these which utilized a traditional instruction paradigm; we saw no differences in contrast use ( p = 0.38), fluoroscopy time ( p = 0.85), or technical success. Conclusions This study demonstrates successful use of an augmented reality tele-proctoring platform to guide a neuro-endovascular fellow through complex neuro-interventional procedures from a remote setting.

Intracranial Stenting: Angioplasty Basic Technique, Indications, and Sizing: 2-Dimensional Operative Video

Intracranial atherosclerotic disease (ICAD) is a common cause of stroke. Antiplatelet therapy is the mainstay for symptomatic ICAD treatment. Endovascular management with submaximal angioplasty and/or intracranial stenting is reserved for patients with repeated ischemic events despite optimal medical therapy. We demonstrate intracranial angioplasty and stenting technique, technique indications, and sizing of stent and target vessel diameter. Stenting and angioplasty have been described in the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis and Wingspan Stent System Post Market Surveillance trials.1,2 Submaximal angioplasty has also been described.3 This patient, who had been on dual antiplatelet therapy for several months, initially presented with occlusion of the left middle cerebral artery M2 inferior division and underwent mechanical thrombectomy with successful reperfusion. Postoperatively, the patient's symptoms did not improve. Medical management was optimized with heparin infusion. However, repeat stroke study demonstrated M2 inferior division reocclusion. A decision was made to proceed with intracranial angioplasty and stenting. P2Y12 levels were therapeutic. Under moderate conscious sedation, submaximal angioplasty of up to 80% of the normal M2 caliber was attempted. However, we observed persistent high-grade stenosis of the M2 inferior division. The major risk of crossing the lesion for angioplasty is vessel perforation. To safely perform this maneuver, we used a J-configured Synchro-2 microwire (Stryker). Because of the patient's recent thrombectomy, we also had prior tactile feedback about how much resistance was encountered while crossing the occlusion. We then deployed a balloon-mounted intracranial stent for optimal radial force across the stenotic area to restore perfusion. Postoperative computed tomography perfusion showed resolution of the previously noticed perfusion deficit. The patient gave informed consent for the procedures and video recording. Institutional review board approval was deemed unnecessary. Video. ©University at Buffalo Neurosurgery, September 2020. With permission.