Advances in stroke: Advances in interventional radiology 2013.

The simultaneous publication of 3 randomized control trials comparing intravenous thrombolysis therapy to the endovas-cular treatment (EVT) of acute ischemic stroke might have lead to the erroneous conclusion that EVT has no place in the management of acute ischemic stroke. However, careful analysis of these studies shows that these reports have shortcomings because of changes in imaging and device technology and to study designs. These randomized control trials have demonstrated that the EVT is not deleterious for the patients and subgroup analyses in Interventional Management of Stroke III have shown that the EVT can provide some benefits for some patients. Dedicated research in the area of EVT of stroke continues to expand having the goal to optimize devices, techniques, and c-arm–based imaging. The new generation of stent-retrievers has shown great improvement during the earlier technology 6,7 ; however, further refinements are desired to select patients properly that will benefit from EVT, efficiently transfer those patients selected for EVT to the angiosuite, and to facilitate all aspects of the thrombectomy procedure to provide rapid and complete revascularization. A potential factor that may contribute to poor clinical outcomes in mechanical thrombectomy is fragmentation of the clot leading to downstream emboli. This has been characterized in vitro, and reduction of distal emboli was achieved using a proxi-mal balloon guide catheter with aspiration during stent-retriever EVT. 8 This experimental approach has been validated by clinical data that show the use of the balloon guide catheter is an independent predictor of good functional outcome at 90 days. 9 Although the role of perfusion computed tomography in triage of acute ischemic stroke is still debated, 10 tremendous advances to perform perfusion imaging with c-arms in the angiosuite have been realized in the past 2 years. C-arm–based cerebral blood volume and cerebral perfusion assessments have evolved to clinical evaluation. Tremendous efforts have been made in the past years to develop new endovascular approaches that will overcome the limitations of the procedure, including aneurysm recanalization and difficulty to treat some complex aneurysms (large and giant, fusiform, or wide-neck aneurysms). 13 Flow diversion has now entered in a more mature phase with the appearance of trials and large series evaluating precisely the safety and efficacy of this technique. Pipeline for Uncoilable or Failed aneurysms (PUFs) trial included 108 patients with aneurysms arising from the internal carotid artery measuring ≥10 mm diameter and a neck ≥4 mm. 14 Complete occlusion …