BackgroundEvidence is mounting that first-pass complete recanalization during mechanical thrombectomy is associated with better clinical outcomes in patients presenting with an emergent large vessel occlusion. We hypothesize that aspiration achieving complete clot ingestion results in higher first-pass successful recanalization with quantitative reduction in distal emboli.MethodsA patient-specific cerebrovascular replica was connected to a flow loop. Occlusion of the middle cerebral artery was achieved with clot analogs. Independent variables were the diameter of the aspiration catheter (0.054–0.088in) and aspiration pattern (static versus cyclical). Outcome measures were the first-pass rates of complete clot ingestion, the extent of recanalization, and the particle-size distribution of distal emboli.ResultsAll aspiration catheters were successfully navigated to the occlusion. Complete clot ingestion during aspiration thrombectomy resulted in first-pass complete recanalization in every experiment, only achieved in 21% of experiments with partial ingestion (P<0.0001). Aspiration through the large bore 0.088in device resulted in the highest rates of complete clot ingestion (90%). Cyclical aspiration (18–29 inHg, 0.5 Hz) significantly increased the rate of complete clot ingestion (OR21 [1.6, 266]; P=0.04). In all experiments, complete clot ingestion resulted in fewer and smaller distal emboli.ConclusionsComplete clot ingestion results in fewer distal emboli and the highest rates of first-pass complete recanalization. The rate of complete ingestion during aspiration thrombectomy is a function of both the inner diameter of the aspiration catheter and use of cyclical aspiration.

BackgroundNeo-intimal hyperplasia (NIH) is frequently observed after flow-diverter stent (FDS) implantation. Although mostly asymptomatic, this vascular response can sometimes lead to delayed ischemic strokes. This study intended to evaluate the factors potentially influencing the rates of NIH following FDS treatment.Material and MethodsAll aneurysm treatments performed with a Pipeline embolization device (PED) or a SILK stent from May 2011 to May 2015 were collected in a prospectively maintained database. Patient demographics, clinical, and angiographic outcomes including both digital subtraction angiography and C-arm cone-beam CT were registered. Two blind reviewers rated the presence of NIH on a binary scale (present/absent).ResultsFrom 148 patients, 63 datasets were available for analysis. Inter-reader agreement was excellent (Kappa=0.88). NIH was positively correlated with smoking, dyslipidemia, and high blood pressure, but not with aneurysm characteristics. At early follow-up (<12 months), NIH was more frequently associated with the use of the SILK stent (68%) rather than the PED (38%): P<0.02. At long-term follow-up, the NIH rate in the total population dropped from 55% to 26% with no more significant difference between the two stents. The complete occlusion rate as seen in early follow-up was higher in the SILK group with 76% vs 65% but without statistical significance (P=0.4).ConclusionNIH is a dual-vessel reaction after FDS implant. When planning a treatment in locations at risk of ischemic complications if severe NIH would occur, then the stent design should be considered. However, minimal NIH might also be needed as it is involved in aneurysm healing. Before treatment patients should be recommended best medical management of their cardiovascular risks factors to prevent an excessive NIH reaction.

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The clot crossing maneuver has a significant effect on the total number of small particles induced during mechanical thrombectomy. Smaller microcatheter sizes should be favored when possible.

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10 cases out of a pool of 22 case scenarios and asked how they would treat the patient A) assumed there were no economical or infrastructural constraints, and B) given their current working conditions. Subgroup analyses were performed for female and male physicians respectively. Results 607 physicians (97 women, 508 men, 2 who did not disclose their sex), of different specialties (326 neurologists, 173 interventional neuroradiologists, 81 interventional neurosurgeons, 2 geriatricians, 5 internists, 20 other) from 38 countries participated in this survey. 6070 responses were obtained. Neurologists constituted the largest group of both female (76.3%) and male (49.2%) physicians, with a more even distribution of specialties in male physicians. Assuming ideal conditions, no significant differences in EVT decision making was observed (EVT was favored by 77% of female and 79.3% of male physicians). Under their current working conditions, female physicians decided less frequently in favor of EVT (69.1%) as compared to their male colleagues (76.9%, p<0.001). Conclusion Under the ideal conditions, EVT decision between male and female physicians did not differ. Current working conditions restricted female physicians' endovascular treatment decision to a greater degree as compared to their male colleagues, resulting in a significantly lower decision rate in favor of EVT.

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