Large vessel occlusions (LVOs), variably defined as blockages of the proximal intracranial anterior and posterior circulation, account for approximately 24% to 46% of acute ischemic strokes. Commonly refractory to intravenous tissue plasminogen activator (tPA), LVOs place large cerebral territories at ischemic risk and cause high rates of morbidity and mortality without further treatment. Over the past few years, an abundance of high-quality data has demonstrated the efficacy of endovascular thrombectomy for improving clinical outcomes in patients with LVOs, transforming the treatment algorithm for affected patients. In this review, we discuss the epidemiology, pathophysiology, natural history, and clinical presentation of LVOs as a framework for understanding the recent clinical strides of the endovascular era.
1with these numbers expected to increase as the population ages in the coming decades. 2 The cerebrovascular system is particularly sensitive to injury, with disruptions in cerebral perfusion being the fourth leading cause of death in the United States.1 Timely restoration of normal blood flow and reconstitution of cerebral macrovasculature is critical in patients with cerebrovascular pathology. Endovascular interventions have shown promise for a variety of cerebrovascular diseases, and thrombectomy procedures continue to be a subject of ongoing research and trials for the treatment of ischemic stroke resulting from large-vessel occlusion. [3][4][5][6][7] Early clinical trials studying mechanical embolectomy demonstrated a decoupling of clinical outcomes with the degree of angiographic reperfusion [8][9][10] ; these findings may reflect challenges in patient selection, inadequate reperfusion with first-generation devices, or reperfusion-related injury. 3,7 Clinical trials with second-generation devices are currently ongoing to elucidate the role of adequate, timely mechanical reperfusion in patients with large-vessel strokes. 4,5 Given this clinical need, vascular endothelial cell (EC) damage resulting from altered flow dynamics, reperfusion injury, or iatrogenic trauma represents a potentially important source of secondary neuronal injury that merits further study. 11,12 As modern thrombectomy devices focus on rapid and complete revascularization, considerations of the degree of EC injury have substantial clinical and design implications.The cerebral endothelium is a dynamic biological system that regulates blood brain barrier (BBB) permeability, autoregulates cerebral microcirculation via nitric oxide pathways, and mediates cerebral inflammation via release of tumor necrosis factor-α, interleukin 1β, and interleukin 6. We have previously demonstrated that physiological blood flow and resultant shear stress are crucial for EC maintenance and remodeling after injury [13][14][15][16][17][18][19][20][21][22] and that locally disrupted blood flow contributes to inflammatory cascades. 23 Many of the proposed mechanisms of reperfusion injury after acute ischemic stroke also originate at the EC level.Background and Purpose-Endovascular thrombectomy has shown promise for the treatment of acute strokes resulting from large-vessel occlusion. Reperfusion-related injury may contribute to the observed decoupling of angiographic and clinical outcomes. Iatrogenic disruption of the endothelium during thrombectomy is potentially a key mediator of this process that requires further study. Methods-An in vitro live-cell platform was developed to study the effect of various commercially available endovascular devices on the endothelium. In vivo validation was performed using porcine subjects. Results-This novel in vitro platform permitted high-resolution quantification and characterization of the pattern and timing of endothelial-cell injury among endovascular thrombectomy devices and vessel diameters. Thrombectomy devices displaye...
The novel 3-D 4K-HD exoscope system possesses favorable optics, ergonomics, and maneuverability as compared to the traditional operating microscope, with the exoscope's shared surgical view possessing obvious educational and workflow advantages. Further clinical trials are justified to validate this initial cadaveric experience.
BACKGROUND During its development and preclinical assessment, a novel, 3-dimensional (3D), high-definition (4K-HD) exoscope system was formerly shown to provide an immersive surgical experience, while maintaining a portable, low-profile design. OBJECTIVE To assess the clinical applicability of this 3D 4K-HD exoscope via first-in-man surgical use. METHODS The operative workflow, functionality, and visual haptics of the 3D 4K-HD exoscope were assessed in a variety of microneurosurgical cases at 2 US centers. RESULTS Nineteen microneurosurgical procedures in 18 patients were performed exclusively using the 3D 4K-HD exoscope. Pathologies treated included 4 aneurysms, 3 cavernous malformations (1 with intraoperative electrocorticography), 2 arteriovenous malformations, 1 foramen magnum meningioma, 1 convexity meningioma, 1 glioma, 1 occipital cyst, 1 chiari malformation, 1 carotid endarterectomy, 1 subdural hematoma, 1 anterior cervical discectomy and fusion, and 2 lumbar laminectomies. All patients experienced good surgical and clinical outcomes. Similar to preclinical assessments, the 3D 4K-HD exoscope provided an immersive 3D surgical experience for the primary surgeon, assistants, and trainees. The small exoscope frame, large depth of field, and hand/foot pedal controls improved exoscope mobility, decreased need to re-focus, and provided unobstructed operative corridors. Flexible positioning of the camera allows the surgeon's posture to be kept in a neutral position with uncompromised viewing angles. CONCLUSION The first-in-man clinical experience with the 3D 4K-HD exoscope confirms its excellent optics and ergonomics for the entire operative team, with high workflow adaptability for a variety of microneurosurgical cases. Expanded clinical use of the 3D 4K-HD exoscope is justified.
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