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Purpose To report our two-center initial experience using the Tigertriever 13 in the treatment of acute stroke of distal, medium vessel occlusions (DMVO). Methods We performed a retrospective analysis of all patients treated by mechanical thrombectomy using the Tigertriever 13 device (a manually expandable low profile stent retriever) due to an acute DMVO. Locations included the anterior, middle, and posterior cerebral artery in the A2 and A3, the M3 and M4, and the P2 or P3 segment and the superior cerebellar artery. Results Forty-three patients with 45 DMVOs underwent MTE using the Tigertriever 13 with the intention-to-treat approach between May 2019 and December 2020. After a median of two thrombectomy maneuvers, the successful recanalization rate (mTICI 2b-3) was 84.4% (38/45) with a first pass effect of 26.7% (12/45). The rate of symptomatic intracranial hemorrhages (sICH) and subarachnoid hemorrhages (SAH) was 7.0% (3/43) and 14.0% (6/43), respectively. At discharge, 53.5% (23/43) of the patients had a favorable clinical outcome (mRS 0–2). Conclusion Mechanical thrombectomy in DMVOs using the Tigertriever 13 leads to high recanalization rates. The incidence of mostly asymptomatic hemorrhagic events appears higher compared to MTE procedures in LVOs. Further studies will help to identify anatomic and clinical criteria to define a guideline for MTE in DMVOs.

BackgroundTransvenous embolization of brain arteriovenous malformations (AVMs) can be curative. We aimed to evaluate the cure rate and safety of the transvenous retrograde pressure cooker technique (RPCT) using coils and n-butyl-2-cyanoacrylate as a venous plug.MethodsAll AVM patients treated via transvenous embolization between December 2004 and February 2017 in a single center were extracted from our database. Inclusion criteria were: inability to achieve transarterial cure alone; AVM < 3 cm; and single main draining vein. Outcome measures were immediate and 90 days' angiographic AVM occlusion rate, and morbidity and mortality at 30 days and 12 months, according to the modified Rankin Scale (mRS) score.ResultsFifty-one patients (20 women; median age 47 years) were included. A majority (71%) were high grade (3 to 5 in the Spetzler–Martin classification). AVMs were deeply seated in 30 (59%) and cortical in 21 patients (41%). Thirty-three patients were previously embolized transarterially (65%). All patients but one were cured within a single session with the RPCT (96%). Cure was confirmed on follow-up digital subtraction angiography at 3 months in 82% of patients. Three patients experienced intracranial hemorrhage (6%), one requiring surgical evacuation. There were no deaths. One treatment-related major permanent deficit was observed (2.0%). Mean mRS before treatment, at 30 days, and 12 months after RPCT was 1.5, 1.5, and 1.3, respectively.ConclusionsThe retrograde pressure cooker technique can be curative in carefully selected high-grade AVMs. Long-term follow-up and prospective studies are needed to confirm our results.

Background: After thrombectomy has shown to be effective in acute stroke patients with large vessel occlusion, the potential benefit of secondary referral for such an intervention needs to be validated. Aims: We aimed to compare consecutive stoke patients directly admitted and treated with thrombectomy at a neurointerventional centre with patients secondarily referred for such a procedure from hospitals with a stroke unit. Methods: Periprocedure times and mortality in 300 patients primarily treated in eight neurointerventional centres were compared with 343 patients referred from nine other hospitals in a prospective multicentre study of a German neurovascular network. Data on functional outcome at 3 months was available in 430 (76.4%) patients. Results: In-hospital mortality (14.8% versus 11.7%, p = 0.26) and 3 months mortality (21.9% versus 24.1%, p = 0.53) were not statistically different in both patient groups despite a significant shorter symptom to groin puncture time in directly admitted patients, which was mainly caused by a longer interfacility transfer time. We found a nonsignificant trend for better functional outcome at 3 months in directly admitted patients (modified Rankin Scale 0–2, 44.0% versus 35.7%, p = 0.08). Conclusions: Our results show that a drip-and-ship thrombectomy concept can be effectively organized in a metropolitan stroke network. Every effort should be made to speed up the emergency interfacility transfer to a neurointerventional centre in stroke patients eligible for thrombectomy after initial brain imaging.

IntroductionBalloon-assisted coil embolization of proximal posterior inferior cerebellar artery (PICA) aneurysms may be limited by the inferiorly oriented, acutely angulated origin of the PICA from the vertebral artery. The aim of this study is to evaluate retrograde access to the PICA via the contralateral vertebral artery or the posterior communicating artery.MethodsTwenty-nine proximal PICA aneurysms treated by balloon remodeling with navigation of the balloon in the PICA via the contralateral vertebral artery or posterior communicating artery were found in our database between January 2007 and December 2013 and were reviewed.ResultsAccess to the PICA was made via the contralateral vertebral artery in 26 patients (90%), six of them (23%) with a hypoplastic V4 segment. In three patients (10%) the retrograde approach was made via the posterior communicating artery. After balloon remodeling, additional stenting was performed in 16 patients (55%). The complication rate was 3% (1 acute stent thrombosis). Grade 0 or 1 occlusion was obtained in all patients at completion angiography. No recurrence was found during follow-up.ConclusionsRetrograde access to the PICA to perform balloon-assisted coil embolization of proximal PICA aneurysms with or without additional stenting after coiling is safe and effective. Hypoplastic V4 segment of the contralateral vertebral artery is not a contraindication.

IntroductionThe Derivo 2 Flow diverter has been previously described for the treatment of intracranial aneurysms. To overcome the risk of in-stent thrombosis and thrombo-embolism the device was modified by adding an anti-thrombogenic fibrin-heparin coating. The fibrin network aims at surface passivation, reduction of inflammatory reactions and endothelial healing. The covalently bound heparin reduces the thrombogenicity by inhibiting the platelet activation and the coagulation cascade.Aim of StudyTo assess the safety and effectiveness of the Derivo 2 heal (D2H) Flow diverter.MethodsWe performed a retrospective multicenter trial at seven neurovascular centers. Patients treated with the D2H for unruptured or ruptured intracranial aneurysms were included in the study. The primary endpoint was angiographic aneurysm occlusion at six months assessed by the O’Kelly-Marotta scale. Clinical outcome was evaluated after intervention and at six months, with major morbidity defined as modified Rankin Scale scores of 3–5.Results17 Patients with available follow-up were subjected to a preliminary analysis. All patients received standard of care antiplatelet therapy according to the respective institutions, with no deviations being reported. Mean aneurysm size was 12 mm. Sufficient aneurysm occlusion (OKM C-D) at six months angiographic follow-up was observed in 88.2%. Device displacement and proximal fish-mouthing occurred in 1 patient with no clinical sequelae. Neither in-stent thrombosis nor in-stent stenosis were detected.ConclusionThe Derivo 2 heal Flow Diverter is a promising antithrombogenic coated device for the treatment of intracranial aneurysms. Early post-interventional and long-term results will provide insight into the effect of antithrombogenicity and endothelial healing.Disclosure of InterestHannes Nordmeyer and Daniel Behme received speaker honoraria from Acandis. All other authors have nothing to declare.

PurposeThis study aims to evaluate the safety and efficacy of the CGuard dual-layer stent with its mesh embolic protection system (EPS) in elective cases for treatment of internal carotid artery stenosis and compares it to the Carotid Wallstent as benchmark.MethodsIn this retrospective, multicenter study, we analyzed data from consecutive patients who underwent carotid artery stenting with CGuard at two high-volume neurointerventional centers and compared them with prior consecutive patients treated with Carotid Wallstent (CWS), with and without a balloon guiding catheter (BGC) as protection, at the same institutions. Patient demographics, procedural details, clinical complications, early in-stent thrombosis and occlusion rates, and late follow-up restenosis rates were assessed.ResultsA total of 428 patients were treated, 144 with the CGuard stent, 203 with CWS + BGC and 83 with CWS-BGC, the majority of patients for symptomatic stenoses. Technical success was achieved in 98.6% of CGuard patients. No clinical complications were observed in CGuard patients, however the clinical complication rate was 2.96% (6/203) for CWS + BGC and 4.94% (4/83) for CWS-BGC patients (p = 0.052). The in-hospital stent occlusion rate was 0.69% (1/144) for CGuard and 2.1% (6/286) in CWS ± BGC patients (p = 0.49). On long-term follow-up (mean 9.9 months) the CGuard demonstrated a comparatively low rate of restenosis (6.25%) and retreatment (2.1%).ConclusionThe CGuard dual-layer stent was safe and effective for carotid artery stenting in our series. Its design appears to contribute to a low risk of periprocedural complications, high technical success rate, while maintaining restenosis rates comparable to the Carotid Wallstent.

BackgroundNo randomized trial has investigated the effect of mechanical thrombectomy (MT) alone in patients with acute stroke. There are conflicting results as to whether prior intravenous thrombolysis (IVT) facilitates subsequent MT, and data in patients treated with MT alone owing to contraindications to IVT are limited.ObjectiveTo compare consecutive patients treated with MT alone or with preceding IVT in a large tertiary neurointerventional center, with special emphasis on contraindications to IVT.MethodsRetrospective analysis of 283 consecutive patients with acute ischemic stroke treated with MT in a tertiary neurovascular center over 14 months. Data on characteristics of periprocedural times, recanalization rate, complications, and long-term functional outcome were collected prospectively.ResultsInformation on prior IVT and functional outcome was available in 250 patients. Mean (SD) follow-up period was 5.7 (5.1) months and 105 (42%) patients received both IVT and MT. No significant differences were found in successful recanalization rates (Thrombolysis in Cerebral Infarction (TICI) 2b/3, 73.8% vs 73.1, p=0.952), complication rates, and long-term favorable outcome (modified Rankin Scale 0–2, 35.2% vs 40%, p=0.444) between patients receiving MT plus IVT and those receiving MT alone. A favorable outcome in patients directly treated with MT alone who were eligible for IVT was achieved in 48.2%. Thrombectomy was safe and resulted in a favorable outcome in 32% of patients with absolute contraindications to IVT.ConclusionsPreceding use of IVT was not an independent predictor of favorable outcome in patients with acute stroke treated with MT and complication rates did not differ whether or not IVT was used. MT is safe and achieved a favorable outcome in one-third of patients with stroke ineligible for IVT.

IntroductionMechanical thrombectomy (MT) has become the standard treatment for acute ischemic stroke due to large vessel occlusions (LVO). However, MT may not result in successful recanalization due to underlying stenosis and bail-out stenting may achieve permanent recanalization.Aim of StudyTo present the heal technology and the Credo heal Stent as an approach to intracranial atherosclerotic disease (ICAD) treatment and report the final results of a multicenter analysis.MethodsWe retrospectively analysed data from 16 stroke centres. Patients treated with the Credo heal Stent were divided into two groups: symptomatic intracranial stenosis (sICAD) and persisting LVO due to underlying stenosis after futile mechanical thrombectomy (Rescue Stenting group). Primary endpoints were improvement of stenosis grade and rate of successful recanalization. Favourable neurological outcome was defined by modified Rankin Score at 90 days.Results121 patients were treated from 2021–2023 with the CREDO heal Stent. Rescue stenting and sICAD treatment was performed in 82 and 39 cases respectively. Overall, a final TICI ≥2b score was achieved in 94.5%. In 14% periprocedural complications occurred where in-stent thrombosis accounted for 6.3% (rescue stenting group). The mean stenosis grade in the sICAD group was 90% before and 15% after PTA and stenting. On follow-up (n=27) restenosis was observed in 2.8%.ConclusionThe Credo heal stent offers a treatment option for patients with sICAD or with persistent occlusion. The rate of restenosis is low compared to previous trials. Its effectiveness with regard to long-term ischemic complications will be evaluated in the prospective ReCHRUT trial.Disclosure of InterestHannes Nordmeyer and Franziska Dorn received speaker honoraria from Acandis. All other author have nothing to disclose.

BackgroundAlthough recently presented randomized trials have failed to prove an overall benefit of mechanical thrombectomy (MT) for patients with medium vessel occlusions (MeVOs), questions remain unanswered, particularly regarding the technology and the role of dedicated small devices. This prospective multicenter, core lab reviewed registry study investigates the efficacy and safety of the APERIO Hybrid used as a first-line device for the treatment of MeVO patients.MethodsData from all MeVO patients who underwent MT with the APERIO or APERIO Hybrid17 as a first-line technique were prospectively included. The primary endpoint was the successful recanalization (Thrombolysis In Cerebral Infarction (TICI) 2b/3) after up to three passes with the APERIO without the use of a rescue technique and without any symptomatic intracranial hemorrhage (ICH).Results134 patients were enrolled from 10 stroke centers. The primary endpoint was reached in 97 patients (81.5%, 95% CI 74.5% to 88.5%). In patients who failed the primary endpoint, TICI 2b/3 was reached with 4 to 6 APERIO passes in 4 patients (3.3%) and with other techniques in 18 patients (15%). Overall recanalization success was 95.8%. TICI 2b/3 with APERIO Hybrid was achieved after the first pass in 76 patients (63.9%), in 23 (19.3%) after 2 passes, and in 1 patient (0.8%) after 3 passes. Modified Rankin Scale (mRS) 0–2 at 90 days was reached by 79.0% of the patients. Symptomatic ICH occurred in no patients, asymptomatic ICH in 16 (13.5%), and subarachnoid hemorrhage in 15 patients (12.6%).ConclusionAPERIO and APERIO Hybrid17 have been proven to be both safe and effective first-line devices for MT in MeVO stroke at different centers and with high rates of successful recanalization.

IntroductionSubarachnoid haemorrhage (SAH) can result in cerebral vasospasms and delayed cerebral ischemia, which contribute significantly to morbidity and mortality. The effectiveness of endovascular treatment for this condition is still a subject of debate. However, the adjustable neck-bridging device Comaneci (Rapid Medical, Yokneam, Israel) may offer a safe and effective alternative to balloon angioplasty.Aim of StudyThe Comaneci Registry Trial is the first multicentre registry designed to evaluate the clinical and radiologic safety and efficacy of Comaneci in angioplasty of cerebral vasospasm in a standardized manner in patients with severe cerebral vasospasm after SAH.MethodsAll patients with severe vasospasm (>50%) in digital subtraction angiography (DSA) after aneurysmatic SAH treated with the Comaneci device as first-line therapy are included and evaluated through an angiographic vessel-by-vessel analysis using a 4-level scale as primary endpoint. All vessel-segments in anterior and posterior circulation up to M3-,A3- and P2-level are eligible for angioplasty with Comaneci. Clinical outcome is assessed with National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale mRS.ResultsAlthough the study is still ongoing, the preliminary findings have demonstrated the safety and effectiveness of the treatment for vasospasm with Comaneci as a first-line angioplasty device.ConclusionThe Comaneci device has the potential to serve as a first-line device for providing therapeutic benefit to patients with SAH and vasospasm. However, future prospective trials are required.Disclosure of InterestNothing to disclose