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Schinz D, Zimmermann T, Göttler J, Sepp D, Zimmer C, Boeckh-Behrens T, Kirschke JS, Kreiser K, Liebl H. Incidence, Clinical Significance, and Longitudinal Signal Characteristics of Ischemic Lesions Related to Diagnostic Cerebral Catheter Angiography. Cardiovasc Intervent Radiol 2023:10.1007/s00270-023-03415-z. [PMID: 36991095 PMCID: PMC10322964 DOI: 10.1007/s00270-023-03415-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 03/06/2023] [Indexed: 03/31/2023]
Abstract
PURPOSE Cerebral DSA is a routine procedure with few complications. However, it is associated with presumably clinically inapparent lesions detectable on diffusion-weighted MRI imaging (DWI lesions). However, there are insufficient data regarding incidence, etiology, clinical relevance, and longitudinal development of these lesions. This study prospectively evaluated subjects undergoing elective diagnostic cerebral DSA for the occurrence of DWI lesions, potentially associated clinical symptoms and risk factors, and longitudinally monitored the lesions using state-of-the-art MRI. MATERIALS AND METHODS Eighty-two subjects were examined by high-resolution MRI within 24 h after elective diagnostic DSA and lesion occurrence was qualitatively and quantitatively evaluated. Subjects' neurological status was assessed before and after DSA by clinical neurological examination and a perceived deficit questionnaire. Patient-related risk factors and procedural DSA data were documented. Subjects with lesions received a follow-up MRI and were questioned for neurological deficits after a median of 5.1 months. RESULTS After DSA, 23(28%) subjects had a total of 54 DWI lesions. Significantly associated risk factors were number of vessels probed, intervention time, age, arterial hypertension, visible calcified plaques, and less examiner experience. Twenty percent of baseline lesions converted to persistent FLAIR lesions at follow-up. After DSA, none of the subjects had a clinically apparent neurological deficit. Self-perceived deficits were nonsignificantly higher at follow-up. CONCLUSION Cerebral DSA is associated with a considerable number of postinterventional lesions, some persisting as scars in brain tissue. Presumably because of the small lesion size and inconsistent location, no clinically apparent neurological deficits have been observed. However, subtle self-perceived changes may occur. Therefore, special attention is needed to minimize avoidable risk factors.
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Affiliation(s)
- David Schinz
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der isar, Technical University of Munich, Ismaninger Street 22, 81675, Munich, Germany.
| | - Thomas Zimmermann
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der isar, Technical University of Munich, Ismaninger Street 22, 81675, Munich, Germany
| | - Jens Göttler
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der isar, Technical University of Munich, Ismaninger Street 22, 81675, Munich, Germany
| | - Dominik Sepp
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der isar, Technical University of Munich, Ismaninger Street 22, 81675, Munich, Germany
| | - Claus Zimmer
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der isar, Technical University of Munich, Ismaninger Street 22, 81675, Munich, Germany
| | - Tobias Boeckh-Behrens
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der isar, Technical University of Munich, Ismaninger Street 22, 81675, Munich, Germany
| | - Jan S Kirschke
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der isar, Technical University of Munich, Ismaninger Street 22, 81675, Munich, Germany
| | - Kornelia Kreiser
- Department of Radiology/Neuroradiology, RKU, Universitäts- und Rehabilitationskliniken Ulm, gGmbH, Oberer Eselsberg 45, 89081, Ulm, Germany
| | - Hans Liebl
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der isar, Technical University of Munich, Ismaninger Street 22, 81675, Munich, Germany
- Department of Radiology/Neuroradiology, BGU, Berufsgenossenschaftliche Unfallklinik, Murnau, Professor-Kuentscher-Straße 8, 82418, Murnau Am Staffelsee, Germany
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Ganesh A, Goyal M, Wilson AT, Ospel JM, Demchuk AM, Mikulis D, Poublanc J, Krings T, Anderson R, Tymianski M, Hill MD. Association of Iatrogenic Infarcts With Clinical and Cognitive Outcomes in the Evaluating Neuroprotection in Aneurysm Coiling Therapy Trial. Neurology 2022; 98:e1446-e1458. [PMID: 35169007 DOI: 10.1212/wnl.0000000000200111] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 01/11/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Small iatrogenic brain infarcts are often seen on diffusion-weighted MRI (DWI) following surgical or endovascular procedures, but there are few data on their clinical effects. We examined the association of iatrogenic infarcts with outcomes in the ENACT (Evaluating Neuroprotection in Aneurysm Coiling Therapy) randomized controlled trial of nerinetide in patients undergoing endovascular repair of intracranial aneurysms. METHODS In this post hoc analysis, we used multivariable models to evaluate the association of the presence and number of iatrogenic infarcts on DWI with neurologic impairment (NIH Stroke Scale [NIHSS]), functional status (modified Rankin Scale [mRS]), and cognitive and neuropsychiatric outcomes (30-minute test battery) at 1-4 days and 30 days postprocedure. We also related infarct number to a z score-derived composite outcome score using quantile regression. RESULTS Among 184 patients (median age 56 years [interquartile range (IQR) 50-64]), 124 (67.4%) had postprocedural DWI lesions (median 4, IQR 2-10.5). Nerinetide treatment was associated with fewer iatrogenic infarcts but no overall significant clinical treatment effects. Patients with infarcts had lower Mini-Mental State Examination (MMSE) scores at 2-4 days (median 28 vs 29, adjusted coefficient [acoef] -1.11, 95% CI -1.88 to -0.34, p = 0.005). Higher lesion counts were associated with worse day 1 NIHSS (adjusted odds ratio for NIHSS ≥1: 1.07, 1.02-1.12, p = 0.009), day 2-4 mRS (adjusted common odds ratio [acOR] 1.05, 1.01-1.09, p = 0.005), and day 2-4 MMSE (acoef -0.07, -0.13 to -0.003, p = 0.040) scores. At 30 days, infarct number remained associated with worse mRS (acOR 1.04, 1.01-1.07, p = 0.016) and Hopkins Verbal Learning Test (HVLT) delayed recall scores (acoef -0.21, -0.39 to -0.03, p = 0.020). Patients with infarcts trended towards lower 30-day Digit Symbol Substitution Test (DSST) scores (acoef -3.73, -7.36 to -0.10, p = 0.044). Higher lesion count was associated with worse composite outcome scores at both 1-4 days and 30 days (30-day acoef -0.12, 95% CI -0.21 to -0.03, p = 0.008). Among those with infarcts, day 1 NIHSS and day 2-4 mRS correlated with 30-day NIHSS, DSST, HVLT, and mRS scores, whereas day 2-4 MMSE correlated with 30-day NIHSS and DSST scores (Spearman ρ 0.47, p = 0.001). DISCUSSION Iatrogenic brain infarcts were associated with subtle differences in postprocedural (1-4 days) and 30-day outcomes on different measures in this middle-aged cohort, with earlier dysfunction correlating with later differences. TRIAL REGISTRATION INFORMATION Clinical trials registration NCT00728182.
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Affiliation(s)
- Aravind Ganesh
- From the Calgary Stroke Program, Department of Clinical Neurosciences (A.G., M.G., A.T.W., J.M.O., A.M.D., M.D.H.), Department of Community Health Sciences (A.G., M.D.H.), Hotchkiss Brain Institute (A.G., M.G., A.M.D., M.D.H.), and Department of Radiology (M.G., A.M.D., M.D.H.), University of Calgary, Canada; Department of Radiology (J.M.O.), University Hospital Basel, University of Basel, Switzerland; Department of Medical Imaging (D.M., J.P.) and Division of Neuroradiology (T.K.), Toronto Western Hospital, University Health Network and University of Toronto; NoNO Inc. (R.A., M.T.), Toronto; Division of Neurosurgery and Neurovascular Therapeutics Program (M.T.), University Health Network, Toronto; Departments of Surgery and Physiology (M.T.), University of Toronto; Toronto Western Hospital Research Institute (M.T.); and Department of Medicine (M.D.H.), University of Calgary Cumming School of Medicine, Canada
| | - Mayank Goyal
- From the Calgary Stroke Program, Department of Clinical Neurosciences (A.G., M.G., A.T.W., J.M.O., A.M.D., M.D.H.), Department of Community Health Sciences (A.G., M.D.H.), Hotchkiss Brain Institute (A.G., M.G., A.M.D., M.D.H.), and Department of Radiology (M.G., A.M.D., M.D.H.), University of Calgary, Canada; Department of Radiology (J.M.O.), University Hospital Basel, University of Basel, Switzerland; Department of Medical Imaging (D.M., J.P.) and Division of Neuroradiology (T.K.), Toronto Western Hospital, University Health Network and University of Toronto; NoNO Inc. (R.A., M.T.), Toronto; Division of Neurosurgery and Neurovascular Therapeutics Program (M.T.), University Health Network, Toronto; Departments of Surgery and Physiology (M.T.), University of Toronto; Toronto Western Hospital Research Institute (M.T.); and Department of Medicine (M.D.H.), University of Calgary Cumming School of Medicine, Canada
| | - Alexis T Wilson
- From the Calgary Stroke Program, Department of Clinical Neurosciences (A.G., M.G., A.T.W., J.M.O., A.M.D., M.D.H.), Department of Community Health Sciences (A.G., M.D.H.), Hotchkiss Brain Institute (A.G., M.G., A.M.D., M.D.H.), and Department of Radiology (M.G., A.M.D., M.D.H.), University of Calgary, Canada; Department of Radiology (J.M.O.), University Hospital Basel, University of Basel, Switzerland; Department of Medical Imaging (D.M., J.P.) and Division of Neuroradiology (T.K.), Toronto Western Hospital, University Health Network and University of Toronto; NoNO Inc. (R.A., M.T.), Toronto; Division of Neurosurgery and Neurovascular Therapeutics Program (M.T.), University Health Network, Toronto; Departments of Surgery and Physiology (M.T.), University of Toronto; Toronto Western Hospital Research Institute (M.T.); and Department of Medicine (M.D.H.), University of Calgary Cumming School of Medicine, Canada
| | - Johanna Maria Ospel
- From the Calgary Stroke Program, Department of Clinical Neurosciences (A.G., M.G., A.T.W., J.M.O., A.M.D., M.D.H.), Department of Community Health Sciences (A.G., M.D.H.), Hotchkiss Brain Institute (A.G., M.G., A.M.D., M.D.H.), and Department of Radiology (M.G., A.M.D., M.D.H.), University of Calgary, Canada; Department of Radiology (J.M.O.), University Hospital Basel, University of Basel, Switzerland; Department of Medical Imaging (D.M., J.P.) and Division of Neuroradiology (T.K.), Toronto Western Hospital, University Health Network and University of Toronto; NoNO Inc. (R.A., M.T.), Toronto; Division of Neurosurgery and Neurovascular Therapeutics Program (M.T.), University Health Network, Toronto; Departments of Surgery and Physiology (M.T.), University of Toronto; Toronto Western Hospital Research Institute (M.T.); and Department of Medicine (M.D.H.), University of Calgary Cumming School of Medicine, Canada
| | - Andrew M Demchuk
- From the Calgary Stroke Program, Department of Clinical Neurosciences (A.G., M.G., A.T.W., J.M.O., A.M.D., M.D.H.), Department of Community Health Sciences (A.G., M.D.H.), Hotchkiss Brain Institute (A.G., M.G., A.M.D., M.D.H.), and Department of Radiology (M.G., A.M.D., M.D.H.), University of Calgary, Canada; Department of Radiology (J.M.O.), University Hospital Basel, University of Basel, Switzerland; Department of Medical Imaging (D.M., J.P.) and Division of Neuroradiology (T.K.), Toronto Western Hospital, University Health Network and University of Toronto; NoNO Inc. (R.A., M.T.), Toronto; Division of Neurosurgery and Neurovascular Therapeutics Program (M.T.), University Health Network, Toronto; Departments of Surgery and Physiology (M.T.), University of Toronto; Toronto Western Hospital Research Institute (M.T.); and Department of Medicine (M.D.H.), University of Calgary Cumming School of Medicine, Canada
| | - David Mikulis
- From the Calgary Stroke Program, Department of Clinical Neurosciences (A.G., M.G., A.T.W., J.M.O., A.M.D., M.D.H.), Department of Community Health Sciences (A.G., M.D.H.), Hotchkiss Brain Institute (A.G., M.G., A.M.D., M.D.H.), and Department of Radiology (M.G., A.M.D., M.D.H.), University of Calgary, Canada; Department of Radiology (J.M.O.), University Hospital Basel, University of Basel, Switzerland; Department of Medical Imaging (D.M., J.P.) and Division of Neuroradiology (T.K.), Toronto Western Hospital, University Health Network and University of Toronto; NoNO Inc. (R.A., M.T.), Toronto; Division of Neurosurgery and Neurovascular Therapeutics Program (M.T.), University Health Network, Toronto; Departments of Surgery and Physiology (M.T.), University of Toronto; Toronto Western Hospital Research Institute (M.T.); and Department of Medicine (M.D.H.), University of Calgary Cumming School of Medicine, Canada
| | - Julien Poublanc
- From the Calgary Stroke Program, Department of Clinical Neurosciences (A.G., M.G., A.T.W., J.M.O., A.M.D., M.D.H.), Department of Community Health Sciences (A.G., M.D.H.), Hotchkiss Brain Institute (A.G., M.G., A.M.D., M.D.H.), and Department of Radiology (M.G., A.M.D., M.D.H.), University of Calgary, Canada; Department of Radiology (J.M.O.), University Hospital Basel, University of Basel, Switzerland; Department of Medical Imaging (D.M., J.P.) and Division of Neuroradiology (T.K.), Toronto Western Hospital, University Health Network and University of Toronto; NoNO Inc. (R.A., M.T.), Toronto; Division of Neurosurgery and Neurovascular Therapeutics Program (M.T.), University Health Network, Toronto; Departments of Surgery and Physiology (M.T.), University of Toronto; Toronto Western Hospital Research Institute (M.T.); and Department of Medicine (M.D.H.), University of Calgary Cumming School of Medicine, Canada
| | - Timo Krings
- From the Calgary Stroke Program, Department of Clinical Neurosciences (A.G., M.G., A.T.W., J.M.O., A.M.D., M.D.H.), Department of Community Health Sciences (A.G., M.D.H.), Hotchkiss Brain Institute (A.G., M.G., A.M.D., M.D.H.), and Department of Radiology (M.G., A.M.D., M.D.H.), University of Calgary, Canada; Department of Radiology (J.M.O.), University Hospital Basel, University of Basel, Switzerland; Department of Medical Imaging (D.M., J.P.) and Division of Neuroradiology (T.K.), Toronto Western Hospital, University Health Network and University of Toronto; NoNO Inc. (R.A., M.T.), Toronto; Division of Neurosurgery and Neurovascular Therapeutics Program (M.T.), University Health Network, Toronto; Departments of Surgery and Physiology (M.T.), University of Toronto; Toronto Western Hospital Research Institute (M.T.); and Department of Medicine (M.D.H.), University of Calgary Cumming School of Medicine, Canada
| | - Roberta Anderson
- From the Calgary Stroke Program, Department of Clinical Neurosciences (A.G., M.G., A.T.W., J.M.O., A.M.D., M.D.H.), Department of Community Health Sciences (A.G., M.D.H.), Hotchkiss Brain Institute (A.G., M.G., A.M.D., M.D.H.), and Department of Radiology (M.G., A.M.D., M.D.H.), University of Calgary, Canada; Department of Radiology (J.M.O.), University Hospital Basel, University of Basel, Switzerland; Department of Medical Imaging (D.M., J.P.) and Division of Neuroradiology (T.K.), Toronto Western Hospital, University Health Network and University of Toronto; NoNO Inc. (R.A., M.T.), Toronto; Division of Neurosurgery and Neurovascular Therapeutics Program (M.T.), University Health Network, Toronto; Departments of Surgery and Physiology (M.T.), University of Toronto; Toronto Western Hospital Research Institute (M.T.); and Department of Medicine (M.D.H.), University of Calgary Cumming School of Medicine, Canada
| | - Michael Tymianski
- From the Calgary Stroke Program, Department of Clinical Neurosciences (A.G., M.G., A.T.W., J.M.O., A.M.D., M.D.H.), Department of Community Health Sciences (A.G., M.D.H.), Hotchkiss Brain Institute (A.G., M.G., A.M.D., M.D.H.), and Department of Radiology (M.G., A.M.D., M.D.H.), University of Calgary, Canada; Department of Radiology (J.M.O.), University Hospital Basel, University of Basel, Switzerland; Department of Medical Imaging (D.M., J.P.) and Division of Neuroradiology (T.K.), Toronto Western Hospital, University Health Network and University of Toronto; NoNO Inc. (R.A., M.T.), Toronto; Division of Neurosurgery and Neurovascular Therapeutics Program (M.T.), University Health Network, Toronto; Departments of Surgery and Physiology (M.T.), University of Toronto; Toronto Western Hospital Research Institute (M.T.); and Department of Medicine (M.D.H.), University of Calgary Cumming School of Medicine, Canada
| | - Michael D Hill
- From the Calgary Stroke Program, Department of Clinical Neurosciences (A.G., M.G., A.T.W., J.M.O., A.M.D., M.D.H.), Department of Community Health Sciences (A.G., M.D.H.), Hotchkiss Brain Institute (A.G., M.G., A.M.D., M.D.H.), and Department of Radiology (M.G., A.M.D., M.D.H.), University of Calgary, Canada; Department of Radiology (J.M.O.), University Hospital Basel, University of Basel, Switzerland; Department of Medical Imaging (D.M., J.P.) and Division of Neuroradiology (T.K.), Toronto Western Hospital, University Health Network and University of Toronto; NoNO Inc. (R.A., M.T.), Toronto; Division of Neurosurgery and Neurovascular Therapeutics Program (M.T.), University Health Network, Toronto; Departments of Surgery and Physiology (M.T.), University of Toronto; Toronto Western Hospital Research Institute (M.T.); and Department of Medicine (M.D.H.), University of Calgary Cumming School of Medicine, Canada
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