Background: Acute ischemic stroke occurs more frequently, presents with more severe symptoms, and has worse outcomes in elderly patients. The safety and efficacy of endovascular therapy for acute stroke in this age group has not been fully established. Purpose: We present the results of a systematic review and meta-analysis examining clinical, procedural, and radiologic outcomes of endovascular therapy for acute stroke in patients older than 80 years of age. Data Sources: We searched PubMed, MEDLINE, and EMBASE from 1992 to week 35 of 2017 for studies evaluating endovascular therapy for acute stroke in the elderly. Study Selection: Two independent reviewers selected studies and abstracted data. The primary end point was good functional outcome at 3 months defined as modified Rankin Scale score of ≤2. Data Analysis: Data were analyzed using random-effects meta-analysis. Data Synthesis: Seventeen studies reporting on 860 patients were included. The rate of good functional outcome at 3 months was 27% (95% CI, 21%–32%). Mortality at 3 months was 34% (95% CI, 23%–44%). Successful recanalization was achieved in 78% of patients (95% CI, 72%–85%). Procedure-related complications occurred in 11% (95% CI, 4%–17%). The incidence of intracranial hemorrhage was 24% (95% CI, 15%–32%), and for symptomatic intracranial hemorrhage, it was 8% (95% CI, 5%–10%). The mean time to groin was 251 minutes (95% CI, 224–278 minutes). Procedure time was 99 minutes (95% CI, 67–131 minutes). Limitations: I² values were above 50% for all outcomes, indicating substantial heterogeneity. Conclusions: Good functional recovery in octogenarians treated with endovascular therapy for acute stroke can be achieved in a high proportion of patients despite the higher incidence of comorbidity in this cohort. Outcomes are inferior to those reported for younger patients; however, endovascular therapy can allow at least 1 in 4 patients older than 80 years of age to regain independent function at 3 months. More research is required to improve patient selection in the elderly, but age should not be a discriminator when deciding to offer endovascular therapy for patients with acute stroke.

SUMMARY: Complications of endovascular therapy of aneurysms mainly include aneurysm rupture and thromboembolic events. The widespread use of MR imaging for follow-up of these patients revealed various nonvascular complications such as aseptic meningitis, hydrocephalus, and perianeurysmal brain edema. We present 7 patients from 5 different institutions that developed MR imaging–enhancing brain lesions after endovascular therapy of aneurysms, detected after a median time of 63 days. The number of lesions ranged from 4–46 (median of 10.5), sized 2–20 mm, and were mostly in the same vascular territory used for access. Three patients presented with symptoms attributable to these lesions. After a median follow-up of 21.5 months, the number of lesions increased in 2, was stable in 1, decreased in 3, and disappeared in 1. The imaging and clinical characteristics suggested a foreign body reaction. We could find no correlation to a specific device, but a possible source may be the generic hydrophilic coating.

BACKGROUND AND PURPOSE: Ticagrelor is a novel P2Y12 antagonist, and little is known about its efficacy and safety in the endovascular treatment of aneurysms. This study evaluated the efficacy and safety of ticagrelor versus clopidogrel for stent-assisted coiling or flow-diversion treatment in patients with unruptured cerebral aneurysms. MATERIALS AND METHODS: From November 2003 to February 2019, two hundred one patients (mean age, 57.5 years; 156 women) with 233 unruptured aneurysms underwent stent-assisted coiling or flow-diversion treatment. All patients received antiplatelet therapy of aspirin plus clopidogrel (clopidogrel group, 121 patients with 140 aneurysms) or aspirin plus ticagrelor (ticagrelor group, 80 patients with 93 aneurysms). The clinical and radiologic data in each group were retrospectively reviewed and compared. RESULTS: Two hundred thirty-six procedures were performed, including stent-assisted coiling (n = 101) and flow diversion (n = 135). At 90 days, the primary outcome—a composite of any stroke and death—occurred in 9.9% of the clopidogrel group and 8.6% of the ticagrelor group (P = .822). Ischemic stroke occurred in 10 (7.0%) of the clopidogrel group and 7 (7.5%) of the ticagrelor group (P > .999). Disabling stroke occurred in 4 (2.8%) in the clopidogrel group and in 4 (4.3%) in the ticagrelor group (P = .716). Ninety-day death occurred in 3 (2.1%) in the clopidogrel group and 1 (1.1%) in the ticagrelor group (P > .999). Any bleeding at 90 days occurred in 13 (9.2%) in the clopidogrel group and 6 (6.5%) in the ticagrelor group (P = .479). CONCLUSIONS: Ticagrelor appears to be as effective and safe as clopidogrel in stent-assisted coiling or flow-diversion treatment for unruptured cerebral aneurysms.

This study compared the accuracy of contrast-enhanced MR angiography (CE-MRA) to intraarterial cerebral angiography (IA-DSA) for assessment of intracranial aneurysms after stent-assisted coiling and to check if the presence of a stent in the parent artery diminishes the accuracy of CE-MRA. Consecutive patients with cerebral aneurysms treated by stent-assisted coiling were evaluated retrospectively. Matching follow-up CE-MRA and IA-DSA were evaluated separately. Evaluation included the presence of aneurysmal remnant, patency and stenosis of parent artery. Twenty-seven patients with 28 aneurysms and 33 matched CE-MRA and IA-DSA studies were evaluated. Nineteen aneurysmal remnants were seen on CE-MRA and 16 on IA-DSA. CE-MRA diagnosed three aneurysmal remnants not appreciated on IA-DSA. Five other remnants were larger on CE-MRA than IA-DSA. None of the remnants were missed on CE-MRA. Parent arteries were patent on both modalities. CE-MRA showed false stenosis of the stented artery in six cases and exaggerated stenosis in two. In 18 cases, CE-MRA showed a short focal “pseudo-stenosis” where the stent's marker bands were located. This was noted whenever the stent's marker bands were located in an artery with luminal diameter ≤2 mm and was called “marker band effect”. CE-MRA is an accurate technique for follow-up of aneurysms post stent-assisted coiling with excellent depiction of remnants in spite of the presence of a stent. Apparent stenosis of the stented parent artery on CE-MRA is often false or exaggerated. “Marker band effect” should be recognized as an artifact that appears when stent's marker bands are in a small artery.

Cone beam CT (CBCT) imaging assessment of acute ischemic stroke (AIS) patients with large-vessel occlusion (LVO) in the angiosuite may improve stroke workflow and decrease time to recanalization. In order for this workflow to gain widespread acceptance, current CBCT imaging needs further development to improve image quality. Our study aimed to compare the image quality of a new CBCT protocol performed directly in the angiosuite with imaging from multidetector CT as a gold standard. AIS patients with an LVO who were candidates for endovascular treatment were prospectively included in this study. Following conventional multidetector CT (MDCT), patients underwent unenhanced cone beam CT (XperCT, Philips) imaging in the angiosuite, using two different protocols: a standard 20.8 s XperCT and/or an improved 10.4 s XperCT protocol. Images were evaluated using both qualitative and quantitative methods. We included 65 patients in the study. Patients received CBCT imaging prior to endovascular treatment; 18 patients were assessed with a standard 20.8 s protocol scans and 47 with a newer 10.4 s scan. The quantitative analysis showed that the mean contrast-to-noise ratio (CNR) was significantly higher for the newer 10.4 s protocol compared with the 20.8 s protocol (2.08 +/- 0.64 vs. 1.15 +/- 0.27, p < 0.004) and the mean image noise was significantly lower for the 10.4 s XperCTs when compared with the 20.8 s XperCTs (6.30 +/- 1.34 vs. 7.82 +/- 2.03, p=<0.003). Qualitative analysis, including 6 measures of image quality, demonstrated that 74.1 % of the 10.4 s XperCT scans were ranked as 'Acceptable' for assessing parenchymal imaging in AIS patients(scoring 3-5 points on a 5-point Likert-scale), compared with 32.4 % of the standard 20.8 s XperCT and 100 % of the MDCT scans. Compared to the MDCT studies, 83 % of the 10.4 s XperCT scans were deemed sufficient image quality for a direct-to-angiosuite selection, compared to only 11 % for the standard 20.8 s scans. The largest image quality improvements included grey/white matter differentiation (59 % improvement), and reduction of image noise and artefacts (63 % & 50 % improvement, respectively). Continued advances in cone-beam CT allow marked improvements in image quality for the assessment of brain parenchyma, which supports a direct-to-angiosuite approach for AIS patients eligible for thrombectomy treatment.