Robotic-assisted technology has been used as a tool to enhance open and minimally invasive surgeries as well as percutaneous coronary and peripheral vascular interventions. It offers many potential ...benefits, including increased procedural and technical accuracy as well as reduced radiation dose during fluoroscopic procedures. It also offers the potential for truly "remote" procedures. Despite these benefits, robotic technology has not yet been used in the neuroendovascular field, aside from diagnostic cerebral angiography. Here, we report the first robotic-assisted, therapeutic, neuroendovascular intervention performed in a human. This was a stent-assisted coiling procedure to treat a large basilar aneurysm. All intracranial steps, including stent placement and coil deployment, were performed with assistance from the CorPath
GRX Robotic System (Corindus, a Siemens Healthineers Company, Waltham, MA, USA). This represents a major milestone in the treatment of neurovascular disease and opens the doors for the development of remote robotic neuroendovascular procedures.
Stenting of the intracranial venous sinuses is used as a treatment in certain cases of idiopathic intracranial hypertension (IIH). Interest in, and experience of, this technique is growing, ...particularly in recent years. We sought to provide an updated systematic review and meta-analysis of the use of venous stenting in these patients, examining clinical outcomes.
A literature search of venous stenting in IIH patients was performed. Using random-effects meta-analysis, we evaluated the following outcomes: clinical resolution of papilledema; headaches and pulsatile tinnitus; recurrence of symptoms after stenting; and complications.
Twenty articles from 18 different centers were included. In a total of 474 patients. 418 were female (88%). The mean age of the patients was 35, while the mean body mass index (BMI) was 35 kg/m
. Median follow-up was 18 months. The overall rate of improvement in papilloedema was 93.7% (95% CI 90.5% to 96.9%), while the overall rate of improvement or resolution of headache was 79.6% (95% CI 73.3% to 85.9%). Pulsatile tinnitus resolved in 90.3% (95% CI 83.8% to 96.70%), while the overall rate of recurrence of IIH symptoms after stenting was 9.8% (95% CI 6.7% to 13%). The rate of major complications was 1.9% (95% CI 0.07% to 3.1%).
Venous sinus stenting in patients with IIH who are refractory to medical therapy appears to have an excellent safety profile and is associated with significant improvements in headaches, pulsatile tinnitus, and papilledema.
Abstract
Over the past decade, flow diverter technology for endocranial aneurysms has seen rapid evolution, with the development of new devices quickly outpacing the clinical evidence base. However, ...flow diversion has not yet been directly compared to surgical aneurysm clipping or other endovascular procedures. The oldest and most well-studied device is the Pipeline Embolization Device (PED; Medtronic), recently transitioned to the Pipeline Flex (Medtronic), which still has sparse data regarding outcomes. To date, other flow diverting devices have not been shown to outperform the PED, although information comes primarily from retrospective studies with short follow-up, which are not always comparable. Because of this lack of high-quality outcome data, no reliable recommendations can be made for choosing among flow diversion devices yet. Moreover, the decision to proceed with flow diversion should be individualized to each patient. In this work, we wish to provide a comprehensive overview of the technical specifications of all flow diverter devices currently available, accompanied by a succinct description of the evidence base surrounding each device.
The purpose of this study was to evaluate safety and efficacy of the Solitaire FR device in the treatment of patients with acute ischemic stroke secondary to large artery occlusion.
We conducted a ...retrospective study of consecutive patients presenting with acute ischemic stroke treated with Solitaire FR as the first-line device to restore blood flow in 6 experienced European centers. This study was entirely funded and supported by Coviden Neurovascular. An independent Corelab determined modified Thrombolysis in Cerebral Infarction scores on the preprocedure and postprocedure angiograms. Complete revascularization was defined as modified Thrombolysis in Cerebral Infarction 2b or 3 post-Solitaire FR device use. Symptomatic intracranial hemorrhage was defined as parenchymal hemorrhage Type 2 associated with a decline of ≥ 4 points in the National Institutes of Health Stroke Scale score within 24 hours or causing death. Favorable functional outcome was considered as modified Rankin Scale score ≤ 2 at Day 90.
We studied 141 patients (mean age, 66 years; median National Institutes of Health Stroke Scale, 18); 74 patients received intravenous tissue-type plasminogen activator before endovascular treatment. Complete revascularization was achieved in 120 of 142 occlusion sites (85%) and good outcome in 77 of 141 (55%) patients. Good outcome was more frequent in patients treated with intravenous tissue-type plasminogen activator than in those without (66% versus 42%; P<0.01). Symptomatic intracranial hemorrhage was reported in 5 patients (4%) and 29 of 141 (20%) patients died or were lost during follow-up (3 cases).
This retrospective study with centralized evaluation shows that the use of Solitaire FR is safe and achieves good revascularization rates and functional outcomes in patients with acute ischemic stroke and large artery occlusion.
Vessel wall imaging (VWI) is emerging as a novel imaging tool for the management and risk stratification of patients with intracranial saccular aneurysms. Our objective was to compare the rates of ...wall enhancement in unstable (ruptured, growing, or symptomatic) and stable aneurysms and assess the ability of VWI with high-resolution magnetic resonance imaging to distinguish between these 2 entities.
This study was performed according to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines, and eligible studies were identified through a comprehensive literature review. A meta-analysis was conducted to examine the association between aneurysm wall enhancement and aneurysm instability with the use of a random effects model. The I2 statistic was used to assess for heterogeneity.
Six studies comprising 505 saccular aneurysms were included. Aneurysms that showed vessel wall enhancement had statistically significant higher odds of being unstable (odds ratio OR: 20; 95% confidence interval CI: 6.4–62.1; I2: 63.1%). The sensitivity, specificity, positive predictive value, and negative predictive value of VWI in identifying unstable aneurysms were 95.0% (90.4–97.8), 62.7% (57.1–67.9), 55.8% (52.2–59.4), and 96.2% (92.8–98.0), respectively.
There is a statistically significant association between vessel wall enhancement and aneurysm instability. Importantly, the lack of wall enhancement is a strong predictor of aneurysm stability. VWI could potentially provide new insights in the management of intracranial aneurysms.
•VWI with HR-MRI is a novel imaging tool for risk stratification of intracranial aneurysms.•Unstable aneurysms were defined as symptomatic, growing, or ruptured.•Unstable aneurysms had statistically significant higher odds for AWE.•The sensitivity and NPV of VWI were 95% and 96.2%, respectively.•Lack of wall enhancement is a strong predictor of aneurysm stability.
Robotically performed neurointerventional surgery has the potential to reduce occupational hazards to staff, perform intervention with greater precision, and could be a viable solution for ...teleoperated neurointerventional procedures.
To determine the indication, robotic systems used, efficacy, safety, and the degree of manual assistance required for robotically performed neurointervention.
We conducted a systematic review of the literature up to, and including, articles published on April 12, 2021. Medline, PubMed, Embase, and Cochrane register databases were searched using medical subject heading terms to identify reports of robotically performed neurointervention, including diagnostic cerebral angiography and carotid artery intervention.
A total of 8 articles treating 81 patients were included. Only one case report used a robotic system for intracranial intervention, the remaining indications being cerebral angiography and carotid artery intervention. Only one study performed a comparison of robotic and manual procedures. Across all studies, the technical success rate was 96% and the clinical success rate was 100%. All cases required a degree of manual assistance. No studies had clearly defined patient selection criteria, reference standards, or index tests, preventing meaningful statistical analysis.
Given the clinical success, it is plausible that robotically performed neurointerventional procedures will eventually benefit patients and reduce occupational hazards for staff; however, there is no high-level efficacy and safety evidence to support this assertion. Limitations of current robotic systems and the challenges that must be overcome to realize the potential for remote teleoperated neurointervention require further investigation.
Abstract
BACKGROUND:
The treatment of ruptured dissecting aneurysms of the intracranial vertebral artery (VA) with parent vessel preservation is a challenge for neurosurgeons and interventional ...neuroradiologists.
OBJECTIVE:
To propose an indication for flow-diverting treatment for reconstruction of a dissecting VA with acute subarachnoid hemorrhage.
METHODS:
Two male patients transferred after acute subarachnoid hemorrhage and dissecting aneurysm on the V4 segment of the dominant VA. An occlusion test was not performed because of their poor clinical state. A flow-diverting stent represented by the Pipeline embolization device was suggested to both patients.
RESULTS:
Three Pipeline embolization devices were deployed in each VA. One dissecting aneurysm was excluded immediately after 3 stents, and 1 patient had complete exclusion demonstrated at the 48-hour control. No morbidity directly related to the procedure was observed. No recanalization and no rebleeding occurred during the 3 months of follow-up.
CONCLUSION:
A flow-diverting stent may be considered an option to treat ruptured dissecting aneurysms of the VA, providing remodeling of the parent vessel and complete exclusion of the aneurysm.
Sporadic arteriovenous malformations of the brain, which are morphologically abnormal connections between arteries and veins in the brain vasculature, are a leading cause of hemorrhagic stroke in ...young adults and children. The genetic cause of this rare focal disorder is unknown.
We analyzed tissue and blood samples from patients with arteriovenous malformations of the brain to detect somatic mutations. We performed exome DNA sequencing of tissue samples of arteriovenous malformations of the brain from 26 patients in the main study group and of paired blood samples from 17 of those patients. To confirm our findings, we performed droplet digital polymerase-chain-reaction (PCR) analysis of tissue samples from 39 patients in the main study group (21 with matching blood samples) and from 33 patients in an independent validation group. We interrogated the downstream signaling pathways, changes in gene expression, and cellular phenotype that were induced by activating KRAS mutations, which we had discovered in tissue samples.
We detected somatic activating KRAS mutations in tissue samples from 45 of the 72 patients and in none of the 21 paired blood samples. In endothelial cell-enriched cultures derived from arteriovenous malformations of the brain, we detected KRAS mutations and observed that expression of mutant KRAS (KRAS
) in endothelial cells in vitro induced increased ERK (extracellular signal-regulated kinase) activity, increased expression of genes related to angiogenesis and Notch signaling, and enhanced migratory behavior. These processes were reversed by inhibition of MAPK (mitogen-activated protein kinase)-ERK signaling.
We identified activating KRAS mutations in the majority of tissue samples of arteriovenous malformations of the brain that we analyzed. We propose that these malformations develop as a result of KRAS-induced activation of the MAPK-ERK signaling pathway in brain endothelial cells. (Funded by the Swiss Cancer League and others.).
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