Carlos Pérez-García

Background Acute intracranial internal carotid artery (ICA) occlusion lowers first-pass reperfusion rates and clinical outcomes. Aspiration catheter and stent-retriever thrombectomy (CA+SR) is becoming a first-line approach, but data on its performance versus contact aspiration alone (CA) in real-world practice using newer large-bore catheters are scarce. We compared angiographic and clinical outcomes between CA and CA+SR strategies for ICA occlusion. Methods Patients with isolated intracranial ICA occlusion treated between January and December 2024 were included in this multicenter SARA-3 registry study. Patients were grouped by first-line technique (CA or CA+SR). We compared procedural times, angiographic outcomes (modified Thrombolysis in Cerebral Infarction (mTICI) score), and clinical outcomes (24-hour National Institutes of Health Stroke Scale (NIHSS) and 3 month modified Rankin Scale (mRS) scores). Results Of 181 patients (median age, 74 years; 51% women), 53 received CA and 128 CA+SR. In CA, 75% achieved final recanalization (mTICI 2c–3) compared with 86% (CA+SR) (P=0.066), with similar procedural times and complications. No differences were found between 48% and 39% of patients who achieved first-pass mTICI 2b-3. The overall cohort had a 64% favorable outcome (mRS ≤2 at 3 months), with CA showing higher rates (70% vs 62%; P=0.4). Complete first-pass recanalization reduced symptomatic intracranial hemorrhages (ICH) and embolization but did not improve functional outcomes. Conclusion With newer large-bore aspiration catheters, CA was comparable to CA+SR as a first-line technique for intracranial ICA occlusion, with similar recanalization rates and favorable clinical outcomes.

Background: Chronic subdural hematoma (CSDH) is a common condition in older adults with rising rates of incidence. While burr hole drainage remains the standard treatment, it is associated with significant recurrence and complications. This study assesses MMA embolization with Squid, both as a standalone procedure and as an adjunct to surgery. Methods: Our prospective registry included 101 patients with 134 CSDH cases treated at two tertiary care centers from December 2020 to January 2024. Patients were divided into two groups: embolization alone and embolization combined with surgery. Demographic, clinical, radiological, and procedural data were collected. Follow-up imaging was conducted at 1, 3, and 6 months. Treatment failure was defined as rescue surgery, hematoma thickness ≥ 10 mm, midline shift > 3 mm at 6 months, or procedure-related death. Results: Fifty-two patients (51.5%) underwent combined treatment, and forty-nine (48.5%) received embolization alone. Most were men (68.3%) and the median age was 82 years. Combined-treatment patients had larger hematomas and more symptoms. Procedures were performed under general anesthesia in 72.3% of patients, with radial and femoral access used equally frequently, and 32.7% underwent bilateral embolization. Patients’ hematoma thickness in follow-up imaging showed a significant decrease (p = 0.000), reaching a median of 0 mm at six months, with no significant difference between groups. Complications occurred in 5.9%, and treatment failure in 4%. Mortality was higher in the embolization-only group, likely reflecting greater rates of comorbidities. Conclusions: This study supports the use of MMA embolization with Squid as a safe and effective treatment for CSDH. Comparable procedural and radiological outcomes in both groups suggest embolization alone may suffice in select patients, offering a less invasive alternative.

Background Although mechanical thrombectomy (MT) is an effective treatment for large vessel occlusion (LVO) with a high successful recanalization rate, MT failure (MTF) occurs in 10–15% of cases and is associated with unfavorable outcomes. However, little is known about the clinical, technical, and radiological reasons for MTF. We investigated the technical factors associated with MTF. Methods We conducted a retrospective analysis of consecutive patients with anterior LVO prospectively included in the ongoing observational multicenter ROSSETTI registry. Patients were categorized according to the success (≥mTICI 2b) or failure (Results We analyzed 4135 patients, including 325 patients (7.9%) with MTF. Patients in the MTF group had a significantly lower Alberta Stroke Program Early CT Score (ASPECTS) at baseline (8 (7–10) vs 9 (8–10)), longer time since last time seen well (279 min vs 262 min), increased MT procedure time (76 min vs 31 min), higher rate of complications (23% vs 4%), higher symptomatic intracerebral hemorrhage (21% vs 7.9%), higher 24 hour National Institutes of Health Stroke Scale score (19 vs 6), worse functional outcome at 3 months (modified Rankin Scale score 0–2, 15.6% vs 53%), and higher mortality (45% vs 20%). Four or more passes were an independent predictor of MTF (OR 3.46, 95% CI 2.58 to 4.63; PConclusion In this study, MTF in anterior circulation LVO was associated with a high complication rate and worse outcomes.

BACKGROUND: The double-stent retriever (SR) technique has been described as an effective rescue technique when single-SR fails to induce recanalization. We aimed to assess the safety and efficacy of first-line double-SR in patients with stroke undergoing thrombectomy. METHODS: This was a multicenter, randomized, controlled, blinded adjudicated primary outcome study. Patients with a large vessel occlusion stroke within 24 hours after onset and undergoing thrombectomy were included. Upon confirmation of large vessel occlusion on initial angiogram, patients were randomly allocated to receive a first-line strategy: single-SR versus double-SR technique. Investigators could use their technique of choice if further passes were needed. The primary objective was to evaluate the efficacy of double-SR defined as first-pass complete recanalization (expanded Treatment in Cerebral Infarction grade 2c-3) compared with single-SR. First-pass recanalization and final successful recanalization (expanded Treatment in Cerebral Infarction grade 2b50-3) were centrally assessed by a blinded investigator. The safety outcome was the occurrence of a symptomatic intracerebral hemorrhage. The data safety monitoring board stopped the recruitment after a preplanned interim analysis because a predefined efficacy boundary was reached. RESULTS: From April 2022 to October 2023, 108 patients were included: 50 (46%) in the single-SR group and 58 (54%) in the double-SR group. First-pass recanalization was achieved in 12 of 50 patients (24%) allocated to single-SR and 27 of 58 patients (46%) allocated to double-SR (adjusted odds ratio, 2.72 [95% CI, 1.19–6.46]). Substantial reperfusion within 3 attempts was obtained in 42 patients (84%) allocated to single-SR and in 52 patients (89%) allocated to double-SR (adjusted odds ratio, 1.74 [95% CI, 0.5–5.76]). The mean number of passes was 2±1.3 with single-SR and 1.7±1 with double-SR (mean difference, −0.37 [95% CI, −0.9 to 0.06]). A symptomatic intracerebral hemorrhage occurred in 3 patients (6%) allocated to single-SR and in 6 patients (10%) allocated to double-SR (adjusted odds ratio, 1.66 [95% CI, 0.40–8.35]). CONCLUSIONS: In patients with stroke undergoing thrombectomy, first-line double-SR is safe and superior to single-SR in achieving first-pass recanalization but not final recanalization. Implications on clinical outcomes should be studied in specifically designed trials. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT05632458.

For patients with symptomatic acute occlusions of the internal carotid artery below the circle of Willis, endovascular and best medical treatment were both effective and safe therapeutic options.

Objective: This study aims to describe our experience and safety considerations associated with the use of the transulnar approach in neurointerventional procedures when radial access is not feasible. Methods: A prospective exploratory analysis was conducted on 35 patients who underwent diagnostic or therapeutic neuroangiography via transulnar approach due to radial access limitations. Technical aspects of the transulnar approach, patient demographics, procedural details, and complications were documented. Statistical analysis was performed using SPSS Statistics software. Results: Among the 35 procedures, the transulnar approach demonstrated a high success rate (97.14%), with only one procedural failure. Indications for transulnar access included larger ulnar artery caliber (46%), radial artery spasm (37%), severe tortuosity of the radial artery (17%), and other anatomical considerations. Complications were rare, with only two access-related complications observed: a type I hematoma and ulnar artery vasospasm. No major bleeding episodes occurred, highlighting the safety profile of transulnar access. Conclusion: The transulnar approach represents a feasible alternative for neurointerventional procedures when radial access is not achievable. It offers high success rates and minimal complications, comparable to the radial approach. Anatomical considerations, safety profile, and patient preference support its consideration as a secondary option in neurointerventional practice. Further research and larger studies are warranted to validate its efficacy and safety in a broader patient population.

Background Efficient recanalization of occluded cerebral arteries is crucial in the treatment of acute ischemic stroke. Double stent retrievers have shown the potential to enhance the rates of recanalization on the first pass. This study aims to evaluate the efficacy and safety of the double stent retriever technique and the predictors of achieving first-pass effect in patients with acute ischemic stroke. Methods This prospective multicenter study involved 209 patients from 16 comprehensive stroke centers in Spain. Patients with occlusions in the anterior circulation were treated using the Aperio Hybrid double stent retriever. The study examined various deployment techniques, including simultaneous and sequential deployment and stent configurations, comparing the Y-shaped and parallel configurations. Results The double stent retriever technique achieved a first-pass effect in 72.7% of cases and a final successful recanalization rate of 99.5%. The Y-shaped configuration was significantly associated with higher recanalization rates on the first pass (OR 2.59, 95% CI 1.18 to 5.68, P=0.02). Procedural complications were mild to moderate in 6.7% and severe in 1.5% of cases, with symptomatic intracranial hemorrhage occurring in 3.3% of patients. At 3 months follow-up, 57.2% of patients achieved a good clinical outcome, with a mortality rate of 15.1%. Conclusion The findings support the efficacy of the double stent retriever technique, particularly the Y-shaped configuration, in achieving high recanalization rates on the first pass with an acceptable safety profile. This technique may offer clinical benefits for future acute ischemic stroke treatment protocols.

Importance Double stentretriever (double-SR) is used as a rescue technique when recanalization is not achieved in stroke patients undergoing thrombectomy. Double-SR, if applied as first-line technique could increase first-pass recanalization rates, known to be associated with better outcomes. Objective To assess the safety and efficacy of first-line double-SR in stroke patients undergoing thrombectomy. Design Randomized, controlled, blinded adjudicated primary outcome study between 2022 and 2023. Setting Multicenter (5 sites), national (Spain). Participants Patients with ischemic stroke due to large vessel occlusion within 24 hours after onset, undergoing thrombectomy. Interventions Upon confirmation of large vessel occlusion on initial angiogram, patients were randomly allocated to receive a first-line strategy: single-SR Vs double-SR technique. Investigators could use their technique of choice if further passes were needed. Main Outcomes and Measures The primary objective was to evaluate the efficacy of double-SR defined as first-pass complete recanalization (eTICI 2c-3) compared to single-SR. First/pass and final successful recanalization (eTICI2b50-3) were centrally assessed by a blinded investigator. The safety outcome was the occurrence of a symptomatic intracerebral hemorrhage (sICH). The data safety monitoring board stopped the recruitment after a pre-planned interim analysis because a predefined efficacy boundary was reached. Results From April 2022 to October 2023, 108 patients were included, 50 patients (46%) in the single-SR group and 58 (54%) in the double-SR group. FPR was achieved in 12/50 patients (24%) allocated to single-SR and 27/58 (46%) allocated to double-SR (aOR 2.72; 95% CI, 1.19-6.46). Substantial reperfusion within 3 attempts was obtained in 42 patients (84%) allocated to single-SR and in 52 (89%) allocated to double-SR (aOR 1.74; 95% CI, 0.55 - 5.76). The mean number of passes was 2±1.3 with single-SR and 1.7±1 with double-SR (mean difference, −0.37; 95% CI, −0.79 - 0.06). A sICH occurred in 3 patients (6%) allocated to single-SR and in 6 (10%) allocated to double-SR (aOR 1.66; 95% CI, 0.40-8.35). Conclusions and Relevance In stroke patients undergoing thrombectomy, first-line double-SR is safe and superior to single-SR in achieving first pass but not final recanalization. Implications on clinical outcomes should be studied in specifically designed trials. Trial Identification NCT05632458 Question What is the safety and efficacy of the double stentretriever (SR) technique as a first-line treatment in acute ischemic stroke patients undergoing endovascular treatment? Findings In this multicenter randomized, blinded primary endpoint adjudicated clinical trial that included 108 acute stroke patients, the rate of first-pass recanalization (TICI2c-3) was superior with double-SR as compared to single-SR technique. Meaning In acute stroke patients with a large vessel occlusion, the first-line use of the double SR technique increases the chances of first-pass recanalization, which has been associated with improved clinical outcomes.

Chronic subdural hematoma (CSDH) is a prevalent medical condition with potentially severe consequences if left untreated. While surgical removal has traditionally been the standard approach for treatment, middle meningeal artery (MMA) embolization has emerged as a promising minimally invasive alternative to reduce recurrences. This comprehensive review provides the general radiology community with an overview of MMA embolization as a therapeutic option for managing CSDH. The authors base their insights on existing evidence and their institutional experience. This overview encompasses the pathophysiology of CSDH as well as the potential advantages and limitations, safety profile, and potential complications of MMA embolization as compared with surgical treatment. The imaging findings seen before and after MMA, as well as insights into the procedural techniques used at the authors' institution, are described. On the basis of reports in the current literature, MMA embolization appears to be a safe and effective therapeutic option for managing CSDH, especially in patients who are unsuitable for surgery or at risk for recurrence. Nonetheless, further research is needed to validate these findings. Results from ongoing clinical trials hold promise for future validation and the establishment of scientific evidence. ^©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material. See the invited commentary by Chatterjee in this issue.

Objectives Magnetic resonance–guided focused ultrasound (MRgFUS) thalamotomy is a novel, minimally invasive ablative treatment for essential tremor (ET). The use of a four-tract probabilistic tractography technique, targeting the intersection between the dentato-rubro-thalamic tracts (both decussating and non-decussating), while evaluating the corticospinal tract and the medial lemniscus, may obtain immediate clinical results with reduced adverse events. Our aim is to present our experience with the four-tract technique for patients undergoing ET treatment with MRgFUS. Methods Retrospective analysis of a prospective database of consecutive patients undergoing ET treatment in a single center from February 2022 to February 2023. Procedural parameters were collected, and tremor improvement was assessed with the Clinical Rating Scale for Tremor (CRST) at baseline and at 3 and 6 months. Adverse events were also reported. Results Forty-three patients (median age, 72 years [interquartile range, 66–76]; 22 females) were evaluated. Tremor improved significatively in all CRST subsections at 3 months, including the CRST part A + B treated hand tremor (22 [19–27] vs 4 [2–7], p < 0.001) and CRST part C (16 [13–19] vs 3 [1–4], p < 0.001). Differences persisted significant at 6 months. Adverse events were few (4.1% of paresthesias and 12.5% of objective gait disturbance at follow-up) and recorded as mild. The median number of sonications was 7 [6–8] and mean operative time 68.7 ± 24.2 min. Conclusion Our data show support for the feasibility and benefits of systematic targeting approach with four-tract probabilistic tractography for treating ET using MRgFUS. Clinical relevance statement An approach with four-tract probabilistic tractography for treating essential tremor (ET) patients with magnetic resonance–guided focused ultrasound decreases interindividual variability with good clinical outcomes, low number of sonications, few adverse effects, and short procedure times. Key Points • The optimal target for the treatment of essential tremor with MR-guided focused ultrasound remains unknown. • Four-tract probabilistic tractography is a feasible technique that reduces interindividual variability, with good clinical results, few side effects, and short operative time. • The four-tract tractography approach can be performed using different MRI scanners and post-processing software in comparison with the initial description of the technique.