Commentary
Best articles published in 2014 in Journal of NeuroInterventional Surgery Italo Linfante,1 Willian Mack,2 Michael Chen,3 Ansaar Rai,4 Felipe Albuquerque,5 Rishi Gupta,6 Joshua A Hirsch,7 J Mocco,8 Dave Fiorella,9 Robert Tarr10 As part of a novel session at the Annual Meeting of the Society of NeuroInterventional Surgery (Colorado Springs, USA), the associate editors of Journal of NeuroInterventional Surgery (JNIS) selected a series of manuscript published in 2014 as best articles. Each associate editor gave his preference, and the final list was approved by editor in chief, Robert Tarr. The aim of this commentary is to acknowledge the authors and briefly highlight the major points of their manuscripts. Turk, et al. ADAPT FAST study: a direct aspiration first pass technique for acute stroke thrombectomy1 This article describes a novel method for mechanical revascularization using a large bore aspiration catheter. The operators utilized the largest caliber aspiration catheter that the target vessel would accommodate. The catheter was then advanced to the face of the thrombus and aspiration applied. The catheter was subsequently withdrawn, attempting to remove the clot en bloc. Adjunct devices were used at the discretion of the operator. The investigators employed the technique in 98 acute ischemic stroke patients harboring large vessel occlusions. The aspiration component achieved Thrombolysis in Cerebral Infarction (TICI) 2b or 3 revascularization in 78% of cases. The adjunct use of stent retrievers increased the TICI 2b/ 3 rate to 95%. The authors demonstrated that this versatile and 1
Baptist Cardiac and Vascular Institute, Miami, Florida, USA; 2Department of Neurosurgery, University of Southern California, Los Angeles, California, USA; 3 Department of Neurological Sciences, Rush University Medical Center, Chicago, Illinois, USA; 4Department of Interventional Neuroradiology, West Virginia University Hospital, Morgantown, West Virginia, USA; 5Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA; 6Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA; 7NeuroEndovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA; 8 Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee, USA; 9Department of Neurosurgery, State University of New York at Stony Brook, Stony Brook, New York, USA; 10Department of Radiology, University Hospitals Case Medical Center, Ohio, USA Correspondence to Dr I Linfante, Baptist Cardiac and Vascular Institute, Miami, FL 33176, USA; linfante. [email protected] 722
technically straightforward revascularization method can be utilized to achieve revascularization. This study is a good example of the ability of neuroendovascular surgeons to join together and channel collective energies and resources. This was a prospective registry, performed without financial support from industry or federal funding. The design and implementation was carried out entirely by the operators involved. Data from this type of prospective study, designed by practicing neurointerventional surgeons, stand the greatest chance of impacting practice patterns for our field. Furthermore, the concept behind this manuscript demonstrates the creativity of the investigators in modifying an existing technique to improve the speed and efficiency of their procedures. This type of ‘thinking outside the box’ drives incremental change in the tools and procedures available to treat neurovascular disease. Horn, et al. Endovascular Reperfusion and Cooling in Cerebral Acute Ischemia (ReCCLAIM I)2 ReCCLAIM is a feasibility and safety, prospective, single arm, open label trial of hypothermia in 20 patients who underwent acute stroke intervention. Inclusion criteria were Alberta Stroke Program Early CT Score 5–7 and National Institutes of Health Stroke Scale score > 13. Intravascular cooling was initiated immediately after intervention. The authors reported an average time to temperature (33°C) of 64 ±50 min. Six patients (30%) achieved a modified Rankin Scale score of 0–2 at 90 days. The protective effect of hypothermia was tested against historical controls (OR 0.09, 95% CI 0.02 to 0.56; p2 Gy radiation developed subacute hair and skin changes.6 The Radiation Dose in Interventional Radiology multicenter study showed that over 75% of neurointerventional procedures have a radiation exposure >2Gy and 25% over 5 Gy dose.7 Software development in the newest generation angiography suites may significantly decrease the radiation needed to perform neuroendovascular procedures. With regards to flow diversion, the Pipeline for Uncoilable or Failed
Linfante I, et al. J NeuroIntervent Surg December 2014 Vol 6 No 10
Commentary Aneurysms (PUFs) trial reported that treatment with PED may be performed with relatively low complications, in particular in large or giant aneurysms of the carotid cavernous or supraclinoid segment.8 In particular, the PUFs trial reported that major ipsilateral stroke or neurological death was 5.6% (6/107). In support of the use of a PED, particularly in this type of aneurysms, the study of Coby reported less radiation, less fluoroscopy time, and less contrast administration in proximal internal carotid artery aneurysms using PED compared with standard coiling techniques. Park, et al. Critical assessment of complications secondary to the use of pipeline embolic device9 The authors performed a retrospective analysis of their prospectively acquired database of consecutive aneurysms treated with a pipeline embolic device (PED) in a single institution. With a total of 217 PEDs (1.72 PED/patient) the authors treated 137 intracranial aneurysms in 126 patients They reported a total of 40 complications in 33 patients. There were three deaths and one permanent disability (4/126, 3.2%). They also reported 36 complications (28.6%) in 29 patients that resulted in transient focal neurological symptoms or other vascular complications not resulting in permanent disability. Including temporary and permanent disability, the total complication rate associated with the use of the PED in their series was 31.7% (40/126). In the discussion of their data, the authors reviewed the literature reporting complications using PEDs. In particular, they reported data on 414 patients with 448 cerebral aneurysms with an overall procedural complication rate of 10.3% (46/ 447) and procedural mortality of 2.2%. Brinjikji et al performed a meta-analysis of 1451 patients with 1654 aneurysms reported in 29 publications.10 The authors noted a procedure related morbidity of 5% and mortality of 4%. The PUFs trial reported major ipsilateral stroke or neurological death of 5.6% (6/107).8 Park et al acknowledge that their overall complication rate of 31.7% appears to be higher than the current literature on PED in the treatment of intracranial aneurysms. However, the authors in their series included both neurological and non-neurological complications, as well as complications that did not result in permanent disability. Although the PED undoubtedly is a valuable tool, in particular for the
treatment of fusiform complex, and large and giant aneurysms, its use at the present time is not free of possible complications, both neurological and non-neurological. The authors concluded that patient and aneurysm selection is of utmost importance when contemplating treatment with a first generation PED. Burrows, et al. Periprocedural and mid-term technical and clinical events after flow diversion for intracranial aneurysms11 The authors performed a retrospective analysis of their database of consecutive aneurysms treated with the pipeline embolic device (PED) in a single institution. With a total of 100 consecutive procedures, the authors treated 95 intracranial aneurysms in 93 patients. They reported periprocedural technical complications in 35% of the procedures. These consisted of proximal device migration in 12%, incomplete device expansion in 9%, catheter induced vasospasm in 6%, and artery perforation from the wire in 3%. Death occurred in 1% and permanent morbidity in 1% of patients. They also reported perioperative clinical events in 28% of cases (thromboembolism and access site complications). Worsened extraocular motility was seen in 5.4% of patients and resolved in 4/5 patients. Follow-up was 17 months. There were no late clinical or technical issues. Both the papers of Borrows et al and Park et al are self-reported series focused specifically on the complications associated with the use of the PED.9 11 They both demonstrated an overall comparable rate of both transient and permanent neurologic complications. Interestingly, the definition of complications was different from what is reported in the current literature. In particular, both series reported periprocedural technical and clinical events not resulting in permanent deficit in 35% and 31%, and a 1–3% rate of permanent morbidity and mortality. There did not seem to be a single type of transient complication that appeared to be particularly more frequent than others. In fact, many could have occurred during coil embolization. Nevertheless, the report again emphasizes knowledge of both permanent and non-permanent complications to achieve low morbidity and mortality while using a PED for intracranial aneurysms.
CONCLUSION In summary, the editors at JNIS would like to congratulate and thank the authors
Linfante I, et al. J NeuroIntervent Surg December 2014 Vol 6 No 10
of the above manuscripts for their contribution to the knowledge base of those practicing in the field of neurointerventional surgery. Competing interests None. Provenance and peer review Commissioned; not externally peer reviewed.
To cite Linfante I, Mack W, Chen M, et al. J NeuroIntervent Surg 2014;6:722–723. Accepted 29 September 2014 J NeuroIntervent Surg 2014;6:722–723. doi:10.1136/neurintsurg-2014-011489
REFERENCES 1
2
3
4
5
6
7
8
9
10
11
Turk AS, Frei D, Fiorella D, et al. ADAPT FAST study: a direct aspiration first pass technique for acute stroke thrombectomy. J Neurointerv Surg 2014;6:260–4. Horn CM, Sun CH, Nogueira RG, et al. Endovascular Reperfusion and Cooling in Cerebral Acute Ischemia (ReCCLAIM I). J Neurointerv Surg 2014;69:1–5. Yenari MA, Han HS. Neuroprotective mechanisms of hypothermia in brain ischaemia. Nat Rev Neurosci 2012;13:267–78. De Georgia MA, Krieger DW, Abou-Chebl A, et al. Cooling for acute ischemic brain damage (COOL AID): a feasibility trial of endovascular cooling. Neurology 2004;63:312–17. Colby GP, Lin L-M, Nundkumar N, et al. Radiation dose analysis of large and giant internal carotid artery aneurysm treatment with the pipeline embolization device versus traditional coiling techniques. J Neurointervent Surgi 2014. Published Online First: 8th Apr 2014. doi:10.1136/ neurintsurg-2014-00193 Peterson EC, Kanal KM, Dickinson RL, et al. Radiation-induced complications in endovascular neurosurgery:incidence of skin effects and feasibility of estimating the future tumor formation. Neurosurgery 2013;72:566–72. Miller DL, Balter S, Cole PE, et al. Radiotion doses in interventional radiology procedures: the RAD-IR study: Part I: Overall measures of dose. J Vasc Interv Rad 2003;14:711–27. Becske T, Kallmes DF, Saatci I, et al. Pipeline for uncoilable or failed aneurysms: results from a multicenter clinical trial. Radiology 2013;267:858–68. Park MS, Albuquerque FC, Nanaszko M, et al. Critical assessment of complications secondary to the use of pipeline embolic. J Neurointerv Surg 2014. Published Online First: 26th Jun 2014. doi:10.1136/ neurintsurg-2014–011265 Brinjikji W, Murad MH, Lanzino G, et al. Endovascular treatment of intracranial aneurysms with flow diverters: a meta-analysis. Stroke 2013;44:442–7. Burrows AM, Cloft H, Kallmes DF, et al. Periprocedural and mid-term technical and clinical events after flow diversion for intracranial aneurysms. J Neurointervent Surg 2014. Published Online First: 31st Jul 2014. doi:10.1136/neurintsurg-2014– 011184
723
Copyright of Journal of NeuroInterventional Surgery is the property of BMJ Publishing Group and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Best articles published in 2014 in Journal of NeuroInterventional Surgery Italo Linfante,1 Willian Mack,2 Michael Chen,3 Ansaar Rai,4 Felipe Albuquerque,5 Rishi Gupta,6 Joshua A Hirsch,7 J Mocco,8 Dave Fiorella,9 Robert Tarr10 As part of a novel session at the Annual Meeting of the Society of NeuroInterventional Surgery (Colorado Springs, USA), the associate editors of Journal of NeuroInterventional Surgery (JNIS) selected a series of manuscript published in 2014 as best articles. Each associate editor gave his preference, and the final list was approved by editor in chief, Robert Tarr. The aim of this commentary is to acknowledge the authors and briefly highlight the major points of their manuscripts. Turk, et al. ADAPT FAST study: a direct aspiration first pass technique for acute stroke thrombectomy1 This article describes a novel method for mechanical revascularization using a large bore aspiration catheter. The operators utilized the largest caliber aspiration catheter that the target vessel would accommodate. The catheter was then advanced to the face of the thrombus and aspiration applied. The catheter was subsequently withdrawn, attempting to remove the clot en bloc. Adjunct devices were used at the discretion of the operator. The investigators employed the technique in 98 acute ischemic stroke patients harboring large vessel occlusions. The aspiration component achieved Thrombolysis in Cerebral Infarction (TICI) 2b or 3 revascularization in 78% of cases. The adjunct use of stent retrievers increased the TICI 2b/ 3 rate to 95%. The authors demonstrated that this versatile and 1
Baptist Cardiac and Vascular Institute, Miami, Florida, USA; 2Department of Neurosurgery, University of Southern California, Los Angeles, California, USA; 3 Department of Neurological Sciences, Rush University Medical Center, Chicago, Illinois, USA; 4Department of Interventional Neuroradiology, West Virginia University Hospital, Morgantown, West Virginia, USA; 5Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA; 6Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA; 7NeuroEndovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA; 8 Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee, USA; 9Department of Neurosurgery, State University of New York at Stony Brook, Stony Brook, New York, USA; 10Department of Radiology, University Hospitals Case Medical Center, Ohio, USA Correspondence to Dr I Linfante, Baptist Cardiac and Vascular Institute, Miami, FL 33176, USA; linfante. [email protected] 722
technically straightforward revascularization method can be utilized to achieve revascularization. This study is a good example of the ability of neuroendovascular surgeons to join together and channel collective energies and resources. This was a prospective registry, performed without financial support from industry or federal funding. The design and implementation was carried out entirely by the operators involved. Data from this type of prospective study, designed by practicing neurointerventional surgeons, stand the greatest chance of impacting practice patterns for our field. Furthermore, the concept behind this manuscript demonstrates the creativity of the investigators in modifying an existing technique to improve the speed and efficiency of their procedures. This type of ‘thinking outside the box’ drives incremental change in the tools and procedures available to treat neurovascular disease. Horn, et al. Endovascular Reperfusion and Cooling in Cerebral Acute Ischemia (ReCCLAIM I)2 ReCCLAIM is a feasibility and safety, prospective, single arm, open label trial of hypothermia in 20 patients who underwent acute stroke intervention. Inclusion criteria were Alberta Stroke Program Early CT Score 5–7 and National Institutes of Health Stroke Scale score > 13. Intravascular cooling was initiated immediately after intervention. The authors reported an average time to temperature (33°C) of 64 ±50 min. Six patients (30%) achieved a modified Rankin Scale score of 0–2 at 90 days. The protective effect of hypothermia was tested against historical controls (OR 0.09, 95% CI 0.02 to 0.56; p2 Gy radiation developed subacute hair and skin changes.6 The Radiation Dose in Interventional Radiology multicenter study showed that over 75% of neurointerventional procedures have a radiation exposure >2Gy and 25% over 5 Gy dose.7 Software development in the newest generation angiography suites may significantly decrease the radiation needed to perform neuroendovascular procedures. With regards to flow diversion, the Pipeline for Uncoilable or Failed
Linfante I, et al. J NeuroIntervent Surg December 2014 Vol 6 No 10
Commentary Aneurysms (PUFs) trial reported that treatment with PED may be performed with relatively low complications, in particular in large or giant aneurysms of the carotid cavernous or supraclinoid segment.8 In particular, the PUFs trial reported that major ipsilateral stroke or neurological death was 5.6% (6/107). In support of the use of a PED, particularly in this type of aneurysms, the study of Coby reported less radiation, less fluoroscopy time, and less contrast administration in proximal internal carotid artery aneurysms using PED compared with standard coiling techniques. Park, et al. Critical assessment of complications secondary to the use of pipeline embolic device9 The authors performed a retrospective analysis of their prospectively acquired database of consecutive aneurysms treated with a pipeline embolic device (PED) in a single institution. With a total of 217 PEDs (1.72 PED/patient) the authors treated 137 intracranial aneurysms in 126 patients They reported a total of 40 complications in 33 patients. There were three deaths and one permanent disability (4/126, 3.2%). They also reported 36 complications (28.6%) in 29 patients that resulted in transient focal neurological symptoms or other vascular complications not resulting in permanent disability. Including temporary and permanent disability, the total complication rate associated with the use of the PED in their series was 31.7% (40/126). In the discussion of their data, the authors reviewed the literature reporting complications using PEDs. In particular, they reported data on 414 patients with 448 cerebral aneurysms with an overall procedural complication rate of 10.3% (46/ 447) and procedural mortality of 2.2%. Brinjikji et al performed a meta-analysis of 1451 patients with 1654 aneurysms reported in 29 publications.10 The authors noted a procedure related morbidity of 5% and mortality of 4%. The PUFs trial reported major ipsilateral stroke or neurological death of 5.6% (6/107).8 Park et al acknowledge that their overall complication rate of 31.7% appears to be higher than the current literature on PED in the treatment of intracranial aneurysms. However, the authors in their series included both neurological and non-neurological complications, as well as complications that did not result in permanent disability. Although the PED undoubtedly is a valuable tool, in particular for the
treatment of fusiform complex, and large and giant aneurysms, its use at the present time is not free of possible complications, both neurological and non-neurological. The authors concluded that patient and aneurysm selection is of utmost importance when contemplating treatment with a first generation PED. Burrows, et al. Periprocedural and mid-term technical and clinical events after flow diversion for intracranial aneurysms11 The authors performed a retrospective analysis of their database of consecutive aneurysms treated with the pipeline embolic device (PED) in a single institution. With a total of 100 consecutive procedures, the authors treated 95 intracranial aneurysms in 93 patients. They reported periprocedural technical complications in 35% of the procedures. These consisted of proximal device migration in 12%, incomplete device expansion in 9%, catheter induced vasospasm in 6%, and artery perforation from the wire in 3%. Death occurred in 1% and permanent morbidity in 1% of patients. They also reported perioperative clinical events in 28% of cases (thromboembolism and access site complications). Worsened extraocular motility was seen in 5.4% of patients and resolved in 4/5 patients. Follow-up was 17 months. There were no late clinical or technical issues. Both the papers of Borrows et al and Park et al are self-reported series focused specifically on the complications associated with the use of the PED.9 11 They both demonstrated an overall comparable rate of both transient and permanent neurologic complications. Interestingly, the definition of complications was different from what is reported in the current literature. In particular, both series reported periprocedural technical and clinical events not resulting in permanent deficit in 35% and 31%, and a 1–3% rate of permanent morbidity and mortality. There did not seem to be a single type of transient complication that appeared to be particularly more frequent than others. In fact, many could have occurred during coil embolization. Nevertheless, the report again emphasizes knowledge of both permanent and non-permanent complications to achieve low morbidity and mortality while using a PED for intracranial aneurysms.
CONCLUSION In summary, the editors at JNIS would like to congratulate and thank the authors
Linfante I, et al. J NeuroIntervent Surg December 2014 Vol 6 No 10
of the above manuscripts for their contribution to the knowledge base of those practicing in the field of neurointerventional surgery. Competing interests None. Provenance and peer review Commissioned; not externally peer reviewed.
To cite Linfante I, Mack W, Chen M, et al. J NeuroIntervent Surg 2014;6:722–723. Accepted 29 September 2014 J NeuroIntervent Surg 2014;6:722–723. doi:10.1136/neurintsurg-2014-011489
REFERENCES 1
2
3
4
5
6
7
8
9
10
11
Turk AS, Frei D, Fiorella D, et al. ADAPT FAST study: a direct aspiration first pass technique for acute stroke thrombectomy. J Neurointerv Surg 2014;6:260–4. Horn CM, Sun CH, Nogueira RG, et al. Endovascular Reperfusion and Cooling in Cerebral Acute Ischemia (ReCCLAIM I). J Neurointerv Surg 2014;69:1–5. Yenari MA, Han HS. Neuroprotective mechanisms of hypothermia in brain ischaemia. Nat Rev Neurosci 2012;13:267–78. De Georgia MA, Krieger DW, Abou-Chebl A, et al. Cooling for acute ischemic brain damage (COOL AID): a feasibility trial of endovascular cooling. Neurology 2004;63:312–17. Colby GP, Lin L-M, Nundkumar N, et al. Radiation dose analysis of large and giant internal carotid artery aneurysm treatment with the pipeline embolization device versus traditional coiling techniques. J Neurointervent Surgi 2014. Published Online First: 8th Apr 2014. doi:10.1136/ neurintsurg-2014-00193 Peterson EC, Kanal KM, Dickinson RL, et al. Radiation-induced complications in endovascular neurosurgery:incidence of skin effects and feasibility of estimating the future tumor formation. Neurosurgery 2013;72:566–72. Miller DL, Balter S, Cole PE, et al. Radiotion doses in interventional radiology procedures: the RAD-IR study: Part I: Overall measures of dose. J Vasc Interv Rad 2003;14:711–27. Becske T, Kallmes DF, Saatci I, et al. Pipeline for uncoilable or failed aneurysms: results from a multicenter clinical trial. Radiology 2013;267:858–68. Park MS, Albuquerque FC, Nanaszko M, et al. Critical assessment of complications secondary to the use of pipeline embolic. J Neurointerv Surg 2014. Published Online First: 26th Jun 2014. doi:10.1136/ neurintsurg-2014–011265 Brinjikji W, Murad MH, Lanzino G, et al. Endovascular treatment of intracranial aneurysms with flow diverters: a meta-analysis. Stroke 2013;44:442–7. Burrows AM, Cloft H, Kallmes DF, et al. Periprocedural and mid-term technical and clinical events after flow diversion for intracranial aneurysms. J Neurointervent Surg 2014. Published Online First: 31st Jul 2014. doi:10.1136/neurintsurg-2014– 011184
723
Copyright of Journal of NeuroInterventional Surgery is the property of BMJ Publishing Group and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
