November Journal Round-Up
Welcome to the November journal round-up! This month we are lucky to have Jonathon Buwanabala, an interventional neuroradiology trainee in Cambridge, writing for us on his most important articles in intervention.
New frontier: A distal thrombectomy option
The current evidence for thrombectomy devices is limited to LVO in proximal anterior circulation stroke. Pushing standard thrombectomy devices deeper into the cerebral tree has a potential for complications. Crockett et al. in JNIS have published an interesting interventional option around this challenge with the use of microcatheters and a ‘micro-ADAPT’ technique to treat distal vessel occlusions. In this early review the recanalisation rate was 79% and most of these cases were upgraded to a higher TICI grade. This pathology is often seen in tandem with a large vessel occlusion or as a secondary embolism after treatment of a proximal occlusion.
Novel treatment – Embolisation in chronic subdural haemorrhage
Link et al. in Neurosurgery discuss a novel technique of managing chronic subdural hematoma with middle meningeal artery embolisation. Benefit was seen in a mixture of patient groups and with these promising initial results a larger trial has been suggested. A further benefit of this treatment method is that the interventionalist can look for an anomalous ophthalmic artery from the MMA prior to treatment. Would your centre engage in recruitment for a larger trial?
Why do low TICIs happen?
TICI (Thrombolysis in Cerebral Infarction score) 3 is always the goal in endovascular treatment of stroke, however, we often find ourselves with faced with less satisfactory angiographic results. Leischner et al. in JNIShave published an article analysing cases with lower TICI grades. They establish the main causes as broadly fitting into 1) failing to reach the thrombus, 2) reached but impassable thrombus and 3) incomplete recanalisation despite device deployment. Additionally, there is discussion around what strategies might facilitate a higher recanalisation rate such as, direct carotid artery puncture in cases of tortuous carotid anatomy and stenting and/or Intra-arterial infusions enface with the clot in irretrievable cases.
Case of the month
The global #Neurorad Twittersphere has a thriving online presence, which serves as a portal for collaboration with a strong focus on education and training. Stemming from this are a subset of neurointerventionalists who are sharing their cases on Twitter with some very interesting discussions being had about differences in local practices/patient selection, equipment choice and procedural planning amongst other things. Naturally being evidence-based practitioners a paper was published by Dmytriw et al. in JNIS. clarifying that cases published on Twitter don’t reflect the day to day complication rates seen in interventional neuroradiology; however, they can be very useful educational resources. A good example is the case below.
Case courtesy of Dr Stanimir Sirakov, St Ivan Rilski University Hospital, Bulgaria:
Why not tweet your cases using the hashtag #INRCOTM so that they are all searchable to other INR trainees? We will select the most interesting one as our interventional case of the month in the next blog.