COVID-19 has impacted neurosurgical care around the world. But reports describing patient admission trends during the pandemic have provided limited time frames and diagnoses. The purpose of this ...paper was to analyze the impact of COVID-19 on neurosurgical care provided to our emergency department during the outbreak.
Patient admission data were collected based on a list of 35 ICD-10 codes, which were placed into 1 of 4 categories: head and spine trauma (“Trauma”), head and spine infection (“Infection”), degenerative spine (“Degenerative”), and subarachnoid hemorrhage/brain tumor (“Control”). Emergency department (ED) consultations to the Neurosurgery Department were collected from March 2018 to March 2022, representing 2 years before COVID and 2 years of pandemic. We hypothesized that Control cases would remain stable throughout the 2 time periods while Trauma and Infection would decrease. Because of widespread clinic restrictions, we postulated Degenerative (spine) cases presenting to the ED would increase.
During the first 2 years of the COVID pandemic, Neurosurgical Trauma and Degenerative ED patients decreased compared with prepandemic levels, while Cranial and Spinal infections increased and continued to do so during the pandemic period studied. Brain tumors and subarachnoid hemorrhages (Control cases) did not change in a significant way throughout the 4-year analysis.
The COVID pandemic significantly altered the demographics of our Neurosurgical ED patient population and continues to do so.
The use of periprocedural dual antiplatelet therapy (DAPT) has significantly evolved along with innovations in the endovascular management of intracranial aneurysms. Historically, aspirin and ...clopidogrel have been the most commonly employed regimen due to its safety and efficacy. However, recent studies highlight the importance of tailoring DAPT regimens to individual patient characteristics which may affect clopidogrel metabolism, such as genetic polymorphisms. In the present report, a systematic review of the literature was performed to determine optimal antiplatelet use with flow diverting stents, intracranial stents, intrasaccular devices, and stent-assisted coiling. Studies were analyzed for the number of aneurysms treated, DAPT regimen, and any thromboembolic complications. Based on inclusion criteria, 368 studies were selected, which revealed the increasing popularity of alternative DAPT regimens with the aforementioned devices. Thromboembolic or hemorrhagic complications associated with antiplatelet medications were similar across all medications. DAPT with ticagrelor, tirofiban, or prasugrel are effective and safe alternatives to clopidogrel and do not require enzymatic activation. Further clinical trials are needed to evaluate different antiplatelet regimens with various devices to establish highest-level evidence-based guidelines and recommendations.
BackgroundFlow diversion (FD) embolization of intracranial cerebral aneurysms is an increasingly common modality where treatment success depends on adequate vessel wall apposition of the device. This ...study aimed to investigate off-label use of the Comaneci device for augmenting vessel wall apposition in post-deployed flow diversion stents (FDS).MethodsOver a 20- month period, all FD cases for the treatment of internal carotid artery (ICA) aneurysms were reviewed. Cases in which the Comaneci device was used to augment vessel wall apposition were analyzed. Data including patient demographics, case characteristics, and procedural outcomes were collected and analyzed as counts.ResultsFrom a total of 74 ICA FD cases, the Comaneci device was used to improve vessel wall apposition in 22 cases (29.7%) . Of these cases, 91% were female with a mean patient age of 64.9±11.3 years, and an average aneurysm size of 4.5±2.5 mm. Comaneci device deployment and retrieval was successful in all (100%) cases, with an average fluoroscopy time of 27.3±7.8 min, an average contrast usage of 25.8±13.2 mL, and an average radiation exposure of 915.1±320.8 mGy. Only two cases (9%) required subsequent balloon angioplasty after Comaneci deployment to improve vessel wall apposition throughout the FDS.ConclusionOur experience with this technique demonstrates the feasibility of using the Comaneci device for augmentation of FDS vessel wall apposition with 100% success in the deployment and retrieval of the Comaneci device.
Superbore 0.088″ catheters provide a platform for optimizing aspiration efficiency and flow control during stroke mechanical thrombectomy procedures. New superbore catheters have the distal ...flexibility necessary to navigate complex neurovascular anatomy while providing the proximal support of traditional 8F catheters. The safety and feasibility of Zoom 88™ superbore angled-tip catheters in the middle cerebral artery (MCA) segments smaller than the catheter diameter have not been previously described.
Twenty consecutive cases of acute MCA mechanical thrombectomy were retrospectively identified from the senior authors' prospectively maintained Institutional Review Board-approved database, in which the Zoom 88 (Imperative Care, Campbell, CA) catheter was successfully navigated to at least the M1 segment. Patient demographics, procedural details, and periprocedural information were analyzed. Rates and averages (standard errors) are generally reported.
The average National Institutes of Health Stroke Scale at presentation and age were 15 ± 2 and 73 ± 3 years, respectively. The M1 and M2 occlusions were evenly distributed. The average M1 measurements before thrombectomy ranged from 2.36 ± 0.07 mm proximally to 2.00 ± 0.11 mm distally, and after thrombectomy, they ranged from 2.34 ± 0.07 mm proximally to 1.97 ± 0.10 mm distally. First-pass modified thrombolysis in cerebral infarction (mTICI) 2C/3 recanalization was achieved in 40% of cases, and final mTICI 2C/3 recanalization was achieved in 90% of cases. A single case of mild vasospasm was managed with verapamil. No hemorrhagic or periprocedural complications were noted.
Superbore 0.088″ catheters with flexible distal segments can be safely navigated to the MCA to augment mechanical thrombectomy even when the MCA segment is smaller than the catheter.
Introduction
Recent literature continues to demonstrate the successful role large‐bore aspiration catheters have in thrombus ingestion during mechanical thrombectomy. However, the ledge gap, or step ...off, between the catheter and the microwire can make navigating to distal vasculature difficult. A new 035” micro‐guidewire reduces the step off for 035” aspiration catheters (Aristotle 35 Colossus Guidewire, Scientia Vascular, West Vale City, UT) while maintaining torquability and softness. We report here our early experience in 6 mechanical thrombectomy cases.
Methods
We reviewed and analyzed a prospectively maintained database of the senior authors to identify cases utilizing a 035” micro‐guidewire with 035” aspiration catheters in mechanical thrombectomy.
Results
Six consecutive cases of 035” microwire use for mechanical thrombectomy were identified. Four (67%) patients were female with an average age of 77±5.3 years (range 56‐97). Average presenting NIHSS was 11±3. Thrombus locations included 50% (n=3) in the M2, 33% (n=2) in the M1, and 17% (n=1) in the P1. Radial access was performed in 1 case (17%), with remaining via femoral access (n=5, 83%). An 088” ID aspiration catheter was navigated to at least the M1 segment in all anterior circulation cases and the basilar in the posterior circulation case. The 035” wire was placed proximal to the occlusion in all cases allowing coaxial 035” and 071” catheter aspiration passes. The average number of passes was 2±0.3. TICI 2C/3 was achieved in 83% of cases (5/6) and 2b in the remaining case. There were no catheter‐related dissections, perforations, or hemorrhagic complications noted for the cases.
Figure 1. (A) AP angiography demonstrating a thrombus in the right M2 superior division (white). (B) 035” (yellow), 071” (orange), and 088” (red) aspiration catheters over the Colossus 35 micro‐guidewire (black) at the level of the thrombus without crossing it.
Conclusion
The Colossus 035” micro‐guidewire may offer advantages over its narrower counterparts by reducing ledge effect and the need to cross the thrombus. Further comparative studies against currently available microwires are needed in various anatomies to confirm this perceived performance advantage.
Introduction
Placement of 088” aspiration catheters in the internal carotid artery (ICA) for aspiration in mechanical thrombectomy (MT) has been previously described. However, the use and safety of ...088” aspiration catheters beyond the ICA has not been established. Here, we report the utilization and early safety outcomes of 088” catheter placement in the M1 segment for MT.
Methods
We reviewed a prospectively maintained IRB‐approved database of the senior author to identify consecutive cases where the 088” catheter was navigated to the MCA for use in mechanical thrombectomy.
Results
We identified 13 cases with placement of an 088” aspiration catheter in the MCA segment (all cases performed in 2023). Average patient age was 71±4 years (range 56‐97 years), with 10 (77%) females, presenting NIHSS was 12±2.1, and 3 (23%) patients received tPA. Location of the thrombus includes 7 (54%) in the M1 and 6 (46%) in the M2. In 13 (100%) cases, the Zoom88 (OD = 2.7 mm, Imperative Care, Campbell, CA) catheter was advanced to at least the M1 segment, and it was used with a coaxial Zoom71 catheter. The average M1 diameter prior to MT was 2.5±0.2mm, 2.3±0.2mm, and 2.2±0.1 in the proximal, mid, and distal M1‐segment, respectively. After MT, the average M1 diameter was 2.4±0.1mm, 2.2±0.1mm, and 2.1±0.2mm in the proximal, mid, and distal M1‐segment, respectively. 85% (n=11) of cases used one or more stentrievers including a Tigertriever, Solitaire, and Trevo. Average number of passes was 1.9±0.2. There were no vessel perforations, catheter‐related dissections, or hemorrhagic complications noted in any case. TICI 2C/3 recanalization was achieved in 100% of cases. The average mRS on discharge was 1.2±0.4.
Figure 1. (A) AP angiography demonstrating an M1 branch occlusion (orange). (B) Native view, 088” catheter under aspiration in the MCA (green). (C) Post‐thrombectomy final angiography demonstrating TICI 3 reperfusion.
Conclusion
The use of large‐bore 088” aspiration catheters in the MCA may offer a safe strategy for direct clot ingestion during mechanical thrombectomy in MCA vasculature that is smaller than the 8‐Fr aspiration catheter.
Introduction
Middle meningeal artery (MMA) embolization for the treatment of chronic subdural hematomas (cSDH) is becoming an alternative to surgical intervention. Recent literature suggests distal ...embolic penetration beyond visible MMA branches achieves optimal cSDH devascularization. Here, we report the mid‐term radiographic follow‐up of a hyper‐dilution glue technique for enhanced embolization of non‐visible dural vasculature.
Methods
A prospectively maintained IRB‐approved institutional database of the senior authors was retrospectively reviewed to identify and analyze cSDHs managed with 10:1 glue hyper‐dilution (TRUFILLTM n‐BCA liquid embolic) paradigm.
Results
Over a 5‐month study period (September 2022 to February 2023), 46 cases of 10:1 glue hyper‐dilution for MMA embolization were identified in 23 patients. 56% of the cases were female with an average age of 70±1.59 years. Average admission cSDH thickness was 9.3±0.8 mm with an average midline shift of 3.5±0.5 mm. Bilateral embolization was performed in 91% (n=21) of patients. Technical success was achieved in all cases without need for periprocedural rescue surgery. One postprocedural complication (2.2%), a unilateral partial facial nerve palsy (House‐Brackmann 2), was identified. All patients were discharged at their mRS baseline. Nine patients (40%) had radiographic follow‐up (mean 42±6.7 days; range 1 to 194 days). Complete resolution of the cSDH was achieved in 67% of those with follow‐up imaging (n=9) cases. In those with residual cSDH, average followup thickness was 7.2±0.8mm.
Conclusion
Mid‐term radiographic results of 10:1 glue hyper‐dilution for MMA embolization for enhanced non‐visible dural vasculature demonstrates a favorable safety profile compatible with the literature and encouraging resolution of cSDH. Further follow‐up and comparative studies are warranted.
Abstract only
Introduction
Middle meningeal artery (MMA) embolization has emerged as an adjunctive treatment in the management of chronic subdural hematomas (cSDH). After surgical cSDH evacuation, ...embolization offers enhanced resorption of cSDH fluid by infarcting the neomembranes at the capillary level. MMA embolization is typically performed on the side ipsilateral to the cSDH, but in the setting of recent surgical evacuation, the ipsilateral meningeal circulation is oftentimes disrupted and/or collateralized. In this situation, penetration of the membranes via an over‐the‐top contralateral injection may provide additional MMA occlusion and efficacy.
Methods
Consecutive cases of unilateral cSDH surgery with contralateral liquid embolic injection were retrospectively identified from a prospectively maintained database of the senior authors.
Results
Eight consecutive cases of recurrent cSDH after surgery were identified (average age = 76±3.5 years, all male). Five subjects (63%) had a previous craniotomy and 3 (38%) had previous burr holes. All subjects had a contralateral MMA embolization in addition to an ipsilateral MMA embolization with regards to their previous index surgery. Average recurrent cSDH thickness was 9.8±1.4mm, midline shift of 1.8±0.9mm. MMA branches embolized included both anterior and posterior (n=5, 63%) anterior only (n=2, 25%), and posterior only (n=1, 12.5%). The falx was penetrated in the contralateral MMA embolization in 3 (38%) cases. Injection of glue across the midline to previously non‐penetrated dura on the index surgery side was successfully achieved in all 8 cases. There were no periprocedural complications encountered.
Conclusion
The addition of contralateral MMA embolization for recurrent cSDH after previous surgery is a safe and potentially additive therapy that may increase the overall efficacy of MMA embolization in these challenging cases.
Introduction
There is increasing literature to support the efficacy of middle meningeal artery (MMA) embolization in the treatment of chronic subdural hematomas (cSDH). Techniques for optimal ...embolization of the MMA are yet to be elucidated. We hypothesized utilization of a novel 046” intermediate catheter within the proximal MMA trunk carry procedural advantages for multiple pedicle embolizations and ease of navigation to distal MMA vasculature.
Methods
We retrospectively reviewed and analyzed a prospectively maintained IRB‐approved database of the senior authors.
Results
Twenty‐one (21) consecutive cases of Vecta46 utilization with MMA embolization were identified (2023), in patients 69±13 years (range 49‐83 years), 4 (19%) women. Four (19%) patients were on antiplatelet/anticoagulants. At presentation, recurrent cSDH in 9 patients (43%) were previously managed with burr holes (n=2, 22%), craniotomy (n=3, 33%), or without drainage (n=4, 44%). Average admission cSDH thickness was 8.8±1.6mm, midline shift of 3±0.7mm. Access was performed through a 5‐ or 6‐French arteriotomy. Both anterior and posterior MMA branches were embolized in 16 (76%) cases, and adjunctive coiling of the proximal MMA trunk was performed in all cases. Vecta46 was successfully placed in the proximal MMA trunk in all cases. There were no vessel irregularities, vasospasm, or dissection noted along the course of the MMA Vecta46 placement. No immediate procedural complications were noted and all cases achieved complete distal MMA occlusion.
Figure 1: (A) Ophthalmic (black) and petrous (white) collaterals off the anterior and posterior MMA branches, respectively. (B) Contralateral (green) and falx (orange) penetration of the MMA branches. (C) Proximal coiling of the anterior and posterior MMA branches (black).
Conclusion
The Vecta46 intermediate catheter is a powerful tool for MMA embolization that allows the safe and effective placement of an intermediate catheter in the proximal MMA trunk. This allows for simple catheter exchange for multiple liquid embolic pedicle embolizations and significant support for navigating microcatheters to distal MMA branches.
Introduction
The latest FDA‐approved intermediate guide catheter, Vecta46, allows for a unique, mini‐triaxial access platform. The size of this catheter allows for 058” guide compatibility, ...intraluminal accommodation of an 027” microcatheter for flow diverter delivery, and angiographic procedural injections in an 070” guide catheter.
Methods
We retrospectively identified and analyzed patients who underwent Surpass Evolve flow diversion treatment utilizing the Vecta46 across the senior authors’ institutions.
Results
The use of the Vecta46 was identified for treatment of 9 aneurysms treated with the Surpass Evolve Flow Diverter (March to April 2023), in patient’s aged 61±3.5 years (range 40‐74 years) with 89% (n=8) female. Aneurysm average size of 4.3±0.47mm, aneurysms originating along the internal carotid artery (n=6) and MCA branches (n=4). Preoperative PRU measured 92 ± 21. Radial access was utilized in 2 cases. Mean Surpass Evolve utilized was 4.4±0.17mm (diameter) by 15.7±0.88mm (length). An 071” guide catheter (Armadillo, Q’Appel Medical) was used in 8 cases. Vecta46 was safely navigated to the supraclinoid ICA segment in all cases. Average fluoroscopy time was 24±3.1 minutes, radiation exposure was 756±259mGy, and verapamil was used in all cases. Technical success was achieved in all cases with adequate vessel wall apposition verified. There were no hemorrhagic complications nor parent vessel wall dissection or vasospasm in the region of the Vecta46 catheter on final control angiography in all 9 cases.
Conclusion
The new low‐profile Vecta46 intermediate catheter can be safely and effectively utilized in a 6‐French mini‐triaxial system for flow diverter delivery without compromising injection quality, support, or trackability.
