Moyamoya disease is a chronic, progressive cerebrovascular disease involving occlusion or stenosis of the terminal portion of the internal carotid artery. We conducted an updated systematic review ...and meta-analysis to investigate clinical and angiographic outcomes comparing direct, combined, and indirect bypass for the treatment of moyamoya disease in adults.
Two independent authors performed Preferred Reporting Items for Systematic reviews and Meta-Analyses guided literature searches in December 2021 to identify articles reporting clinical/angiographic outcomes in adult moyamoya disease patients undergoing bypass. Primary end points used were ischemic and hemorrhagic strokes, clinical outcomes, and angiographic revascularization. Study quality was evaluated with Newcastle-Ottawa and the Oxford Center for Evidence-Based Medicine scales.
Four thousand four hundred fifty seven articles were identified in the initial search; 143 articles were analyzed. There were 3827 direct, 3826 indirect, and 3801 combined bypasses. Average length of follow-up was 3.59±2.93 years. Pooled analysis significantly favored direct (odds ratio OR, 0.62 0.48-0.79;
<0.0001; OR, 0.44 0.32-0.59;
<0.0001; OR, 0.56 0.42-0.74;
<0.0001; OR, 3.1 2.5-3.8;
=0.0001) and combined (OR, 0.53 0.41-0.69;
<0.0001; OR, 0.28 0.2-0.41;
<0.0001; OR, 0.41 0.3-0.56;
<0.0001; OR, 3.1 2.8-4.3;
=0.0001) over indirect bypass for early stroke, late stroke, late intracerebral hemorrhage, and favorable outcomes, respectively. Indirect bypass was favored over combined (OR, 3.1 1.7-5.6;
<0.0001) and direct (OR, 4.12 2.34-7.25;
<0.0001) for early intracerebral hemorrhage. The meta-analysis significantly favored direct (OR, 0.37 0.23-0.60;
<0.001; OR, 0.49 0.31-0.77;
=0.002) and combined (OR, 0.23 0.12-0.43;
<0.00001; OR, 0.30 0.18-0.49;
<0.00001) bypass over indirect bypass for late stroke and late hemorrhage, respectively. Combined bypass was favored over indirect bypass for favorable outcomes (OR, 2.06 1.18-3.58;
=0.01).
Based on combined meta-analysis (43 articles) and pooled analysis (143 articles), the existing literature indicates that combined and direct bypasses have significant benefits for patients suffering from late stroke and hemorrhage versus indirect bypass. Combined bypass was favored over indirect bypass for favorable outcomes. This is a strong recommendation based on low-quality evidence when utilizing the Grades of Recommendation, Assessment, Development, and Evaluation system. These findings have important implications for bypass strategy selection.
Wide-necked bifurcation aneurysms (WNBAs) make up 26-36% of all brain aneurysms. Treatments for WNBAs pose unique challenges due to the need to preserve major bifurcation vessels while achieving a ...durable occlusion of the aneurysm. Intrasaccular flow disruption is an innovative technique for the treatment of WNBAs. The Woven EndoBridge (WEB) device is the only United States Food and Drug Administration approved intrasaccular flow disruption device. In this review article we discuss various aspects of treating WNBAs with the WEB device, including indications for use, aneurysm/device selection strategies, antiplatelet therapy requirement, procedural technique, potential complications and bailouts, and management strategies for residual/recurrent aneurysms after initial WEB treatment.
The ability to discriminate between ruptured and unruptured cerebral aneurysms on a morphological basis may be useful in clinical risk stratification. The objective was to evaluate the importance of ...inflow-angle (IA), the angle separating parent vessel and aneurysm dome main axes.
IA, maximal dimension, height-width ratio, and dome-neck aspect ratio were evaluated in sidewall-type aneurysms with respect to rupture status in a cohort of 116 aneurysms in 102 patients. Computational fluid dynamic analysis was performed in an idealized model with variational analysis of the effect of IA on intra-aneurysmal hemodynamics.
Univariate analysis identified IA as significantly more obtuse in the ruptured subset (124.9 degrees+/-26.5 degrees versus 105.8 degrees+/-18.5 degrees, P=0.0001); similarly, maximal dimension, height-width ratio, and dome-neck aspect ratio were significantly greater in the ruptured subset; multivariate logistic regression identified only IA (P=0.0158) and height-width ratio (P=0.0017), but not maximal dimension or dome-neck aspect ratio, as independent discriminants of rupture status. Computational fluid dynamic analysis showed increasing IA leading to deeper migration of the flow recirculation zone into the aneurysm with higher peak flow velocities and a greater transmission of kinetic energy into the distal portion of the dome. Increasing IA resulted in higher inflow velocity and greater wall shear stress magnitude and spatial gradients in both the inflow zone and dome.
Inflow-angle is a significant discriminant of rupture status in sidewall-type aneurysms and is associated with higher energy transmission to the dome. These results support inclusion of IA in future prospective aneurysm rupture risk assessment trials.
Decompressive hemicraniectomy and duroplasty (DHCD) can improve survival in patients with severe cerebral edema. We present our clinical experience with DHCD for the treatment of refractory elevated ...intracranial pressure (ICP) in patients with aneurysmal subarachnoid hemorrhage (aSAH).
DHCD was performed in 16 patients (11 female; median age, 49.5 years) with aSAH (11 Hunt-Hess grade 4 to 5) for sustained ICP >250 mm H(2)O refractory to maximal medical treatment and cerebrospinal fluid drainage at a median of 2 days from admission. Half of the patients were treated with endovascular coiling and the other half with surgical clipping.
DHCD (mean flap size, 8536 mm(2)) reduced ICP from 350+/-157 to 147+/-124 mm H(2)O. Eleven patients survived (69%), and at latest follow-up (median, 450 days), 7 (64%) had a modified Rankin score of 0 to 3 and 4 (36%) a score of 4 to 5. Peak herniated brain volume was inversely associated with good outcome (P<0.005). Early craniectomy performed within 48 hours after the aSAH was associated with better outcome: 6 of 8 patients had good outcomes (75%) compared with 1 of 8 patients in whom late decompression was performed (P<0.01). Midline shift, Hunt-Hess grade, presence of hemorrhage, hematoma volume, craniectomy area, peak ICP, and relative ICP reduction were not associated with outcome in this patient population.
DHCD is a useful adjunct modality for management of refractory intracranial hypertension in patients with high-grade aSAH, even in the absence of large intraparenchymal hemorrhage. In our series, long-term outcome was better in patients who underwent early intervention.
A direct to angiography (DTA) treatment paradigm without repeated imaging for transferred patients with large vessel occlusion (LVO) may reduce time to endovascular thrombectomy (EVT). Whether DTA is ...safe and associated with better outcomes in the late (>6 hours) window is unknown. Also, DTA feasibility and effectiveness in reducing time to EVT during on-call vs regular-work hours and the association of interfacility transfer times with DTA outcomes have not been established.
To evaluate the functional and safety outcomes of DTA vs repeated imaging in the different treatment windows and on-call hours vs regular hours.
This pooled retrospective cohort study at 6 US and European comprehensive stroke centers enrolled adults (aged ≥18 years) with anterior circulation LVO (internal cerebral artery or middle cerebral artery subdivisions M1/M2) and transferred for EVT within 24 hours of the last-known-well time from January 1, 2014, to February 29, 2020.
Repeated imaging (computed tomography with or without computed tomographic angiography or computed tomography perfusion) before EVT vs DTA.
Functional independence (90-day modified Rankin Scale score, 0-2) was the primary outcome. Symptomatic intracerebral hemorrhage, mortality, and time metrics were also compared between the DTA and repeated imaging groups.
A total of 1140 patients with LVO received EVT after transfer, including 327 (28.7%) in the DTA group and 813 (71.3%) in the repeated imaging group. The median age was 69 (interquartile range IQR, 59-78) years; 529 were female (46.4%) and 609 (53.4%) were male. Patients undergoing DTA had greater use of intravenous alteplase (200 of 327 61.2% vs 412 of 808 51.0%; P = .002), but otherwise groups were similar. Median time from EVT center arrival to groin puncture was faster with DTA (34 IQR, 20-62 vs 60 IQR, 37-95 minutes; P < .001), overall and in both regular and on-call hours. Three-month functional independence was higher with DTA overall (164 of 312 52.6% vs 282 of 763 37.0%; adjusted odds ratio aOR, 1.85 95% CI, 1.33-2.57; P < .001) and during regular (77 of 143 53.8% vs 118 of 292 40.4%; P = .008) and on-call (87 of 169 51.5% vs 164 of 471 34.8%; P < .001) hours. The results did not vary by time window (0-6 vs >6 to 24 hours; P = .88 for interaction). Three-month mortality was lower with DTA (53 of 312 17.0% vs 186 of 763 24.4%; P = .008). A 10-minute increase in EVT-center arrival to groin puncture in the repeated imaging group correlated with 5% reduction in the functional independence odds (aOR, 0.95 95% CI, 0.91-0.99; P = .01). The rates of modified Rankin Scale score of 0 to 2 decreased with interfacility transfer times of greater than 3 hours in the DTA group (96 of 161 59.6% vs 15 of 42 35.7%; P = .006), but not in the repeated imaging group (75 of 208 36.1% vs 71 of 192 37.0%; P = .85).
The DTA approach may be associated with faster treatment and better functional outcomes during all hours and treatment windows, and repeated imaging may be reasonable with prolonged transfer times. Optimal EVT workflow in transfers may be associated with faster, safe reperfusion with improved outcomes.
Few injuries have produced as much debate with respect to management as have blunt cerebrovascular injuries (BCVIs). Recent work (American Association for the Surgery of Trauma 2013) from our ...institution suggested that 64-channel multidetector computed tomographic angiography (CTA) could be the primary screening tool for BCVI. Consequently, our screening algorithm changed from digital subtraction angiography (DSA) to CTA, with DSA reserved for definitive diagnosis of BCVI following CTA-positive study results or unexplained neurologic findings. The current study was performed to evaluate outcomes, including the potential for missed clinically significant BCVI, since this new management algorithm was adopted.
Patients who underwent DSA (positive CTA finding or unexplained neurologic finding) over an 18-month period subsequent to the previous study were identified. Screening and confirmatory test results, complications, and BCVI-related strokes were reviewed and compared.
A total of 228 patients underwent DSA: 64% were male, with mean age and Injury Severity Score (ISS) of 43 years and 22, respectively. A total of 189 patients (83%) had a positive screening CTA result. Of these, DSA confirmed injury in 104 patients (55%); the remaining 85 patients (45%) (false-positive results) were found to have no injury on DSA. Five patients (4.8%) experienced BCVI-related strokes, unchanged from the previous study (3.9%, p = 0.756); two were symptomatic at trauma center presentation, and three occurred while receiving appropriate therapy. No patient with a negative screening CTA result experienced a stroke.
This management scheme using 64-channel CTA for screening coupled with DSA for definitive diagnosis was proven to be safe and effective in identifying clinically significant BCVIs and maintaining a low stroke rate. Definitive diagnosis by DSA led to avoidance of potentially harmful anticoagulation in 45% of CTA-positive patients (false-positive results). No strokes resulted from injuries missed by CTA.
Diagnostic study, level III.
Atherosclerotic steno-occlusive cerebrovascular disease includes extracranial carotid occlusive and intracranial atherosclerotic disease. Despite the negative findings in Carotid Occlusion Surgery ...Study (COSS), many large centers continue to report favorable results for revascularization surgery in select groups of patients. The aim of our study was to perform an updated systematic review to investigate the role of revascularization surgery for atherosclerotic steno-occlusive patients in the modern era.
Five independent reviewers performed Preferred Reporting Items for Systematic Reviews and Meta-Analyses–guided literature searches in October 2022 to identify articles reporting clinical outcomes in adult patients undergoing bypass for atherosclerotic steno-occlusive disease. Primary endpoints used were perioperative and long-term ischemic strokes, intracerebral hemorrhage, bypass patency, and favorable clinical outcomes. Study quality was evaluated with Newcastle-Ottawa, JADAD, and the Oxford Center for Evidence-Based Medicine scales.
A total of 6709 articles were identified in the initial search. Of these articles, 50 met the inclusion criteria and were included in the systematic review. A notable increase in the proportion of articles published over the past 10 years was observed. There were 6046 total patients with 4447 bypasses performed over the period from 1978 to 2022. The average length of follow-up was 2.75 ± 2.71 years. The average Newcastle-Ottawa was 6.23 out of 9 stars. There was a significant difference in perioperative stroke (odds ratio OR, 0.65 0.48–0.87; P = 0.004), long-term ischemia (OR, 0.32 0.23–0.44; P < 0.0001), overall ischemia (OR, 0.36 0.28–0.44; P < 0.0001), and favorable outcomes (OR, 3.63 2.84–4.64; P < 0.0001) when comparing pre-COSS to post-COSS time frames in favor of post-COSS.
Based on a systematic review of 50 articles, the existing literature indicates that long-term stroke rates and favorable outcomes for surgical revascularization for steno-occlusive disease have improved over time and are lower than previously reported. Improved patient selection, perioperative care, and surgical techniques may contribute to improved outcomes.
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Stent occlusion is a challenging complication following endovascular interventions that require intracranial stenting.1-4 Although there are small series describing revascularization for ...stenoocclusive disease failing best medical management,5-14 there are few reports in the literature regarding surgical bypass as a treatment for stent occlusion.5 We present the case of a 37-year-old man who presented with right-sided weakness, numbness, and difficulty with speech and ambulation. His history is notable for a left M1 (segment of middle cerebral artery) occlusion 6 months prior that was treated with mechanical thrombectomy requiring repeat thrombectomy and rescue acute middle cerebral artery (MCA) stent placement given vessel reocclusion. Diagnostic cerebral angiography demonstrated stent occlusion. Given his continued ischemic symptoms despite best medical management, the patient underwent a double-barrel superficial temporal artery−MCA direct bypass to revascularize the MCA territory. To our knowledge, there is no literature to date describing a 2-donor-2-recipient direct bypass for the rescue treatment of symptomatic intracranial stent occlusion with recurrent ischemia. We review the case presentation, angiographic findings, surgical nuances, and postoperative course with imaging. The patient provided informed consent for the procedure and verbal support for publishing his image and inclusion in this submission.
The Surpass Evolve flow diverter is a novel 64-wire braided intravascular stent approved to treat unruptured large or giant saccular wide-neck or fusiform intracranial aneurysms of the intracranial ...internal carotid artery.1-3 Flow diverting stents have been used for the treatment of previously stented aneurysms, including residual aneurysms following prior flow diversion.5-8 This patient initially presented with a large symptomatic matricidal cavernous ICA aneurysm4 that was treated with stand-alone Neuroform Atlas stenting at an outside hospital. Here we present a video demonstrating the placement of sequential Surpass Evolve flow diverter stents within a Neuroform Atlas nitinol stent.
Flat panel imaging for emergent large vessel occlusion can be acquired prior to mechanical thrombectomy (MT). In this study, we examined patients undergoing MT with computed tomography angiography ...(CTA) to determine agreement on the site of occlusion and CTA collateral score (CS).
Flat Panel CTA (FP-CTA) was acquired before MT. Time between CTA and FP-CTA acquisition, site of occlusion, and CS were reported. Significant CS change was defined as >2-point change, or any change to/from a malignant profile (CS = 0 to CS > 0, or vice versa).
Eleven patients (mean age, 60.8 years; NIHSS, 17; 55.0% female) were included; IV tPA was administered to 7. Intra-reader occlusion site, dichotomous CS, and continuous CS correlation between CTA and FP-CTA were 96.6%, 90.0%, and 86.6%, respectively. Inter-reader correlation for occlusion site was 93% for CTA and 100% for FP-CTA; dichotomous CS correlation was 87% for both CTA and FP-CTA; correlation of continuous CS was 77% for CTA and 87% for FP-CTA.
Standard CTA and FP-CTA have high intra and inter-reader correlation determining site of occlusion and CS in ELVO setting. This angiographic tool may have potential applications for both triage and patient selection.
•FPD imaging may provide an alternative workflow for acute ischemic stroke patients.•FPD-CTA can evaluate the site of intracranial occlusion and collateral status.•We found strong concordance between FPD-CTA and standard CTA on both.•This technique has important implications for triaging patients evaluated for MT.•Patients with known ELVO transferred from outside hospitals may especially benefit.
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