Neurosurgery
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Large vessel occlusions (LVOs), variably defined as blockages of the proximal intracranial anterior and posterior circulation, account for approximately 24% to 46% of acute ischemic strokes. Commonly refractory to intravenous tissue plasminogen activator (tPA), LVOs place large cerebral territories at ischemic risk and cause high rates of morbidity and mortality without further treatment. Over the past few years, an abundance of high-quality data has demonstrated the efficacy of endovascular thrombectomy for improving clinical outcomes in patients with LVOs, transforming the treatment algorithm for affected patients. In this review, we discuss the epidemiology, pathophysiology, natural history, and clinical presentation of LVOs as a framework for understanding the recent clinical strides of the endovascular era.
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Geometric factors of intracranial aneurysms and surrounding vasculature could affect the risk of aneurysm rupture. However, large-scale assessments of morphological parameters correlated with intracranial aneurysm rupture in a location-specific manner are scarce. ⋯ These practical morphological parameters specific to MCA aneurysms are easy to assess when examining 3D reconstructions of unruptured aneurysms and could aid in risk evaluation in these patients.
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Mechanical thrombectomy has become the accepted standard of care in patients with large-vessel occlusions; however, the management of more distal occlusions is more variable. Although often less clinically severe than proximal occlusions, M2 occlusions can cause significant disability, particularly when they occur in the dominant cerebral hemisphere. Recanalization of M2 occlusions with intravenous recombinant tissue plasminogen activator has been reported to be unreliable (only successful in 30.8% of cases).1 Reliable recanalization of M2 occlusions (thrombolysis in cerebral infarction [TICI] grade 2b or 3 in 76.9% of cases) using contemporary endovascular techniques has been reported.2 A multi-institutional experience demonstrated similar radiographic and clinical success rates when comparing direct aspiration and primary stent retrieval to treat M2 occlusions.3 In this video, we present the case of a 62-yr-old woman with a left M2 occlusion treated using the "Solumbra" technique.4 This technique utilizes a stent retriever in conjunction with aspiration, which is achieved by advancing the aspiration catheter adjacent to the clot. ⋯ However, as demonstrated in this video, placement of the aspiration catheter at the M2 ostia with deployment of the stent retriever in the M2 clot can provide effective recanalization. It should be noted that care should be taken when advancing a guide catheter into the petrous carotid artery for support as this is an advanced maneuver and may increase the risk of iatrogenic injury in inexperienced hands. Consent was obtained from the patient prior to performing the procedure. Institutional Review Board approval is not required for the report of a single case.
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Antiplatelet premedication is widely accepted for interventional treatment of cerebral aneurysms to prevent thromboembolism. However, antiplatelet resistance sometimes limits the effectiveness of premedication. ⋯ Prasugrel was found to be more effective in reducing periprocedural thromboembolism compared to clopidogrel.
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Brief electrical stimulation (ES) therapy to the nerve may improve outcome in lacerated, repaired nerves. However, most human nerve injuries leave the nerve in continuity with variable and often poor functional recovery from incomplete axon regeneration and reinnervation. ⋯ The application of brief ES for in-continuity nerve injury promotes faster recovery, although in a rat model where regeneration distances are short the control group ultimately recovers to a similar degree. Brief EF requires further evaluation as a promising therapy for in-continuity nerve injuries in humans.