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Zhang Y, Liu P, Li Z, Peng Y, Chen W, Zhang L, Chu J, Kuai D, Chen Z, Wu W, Xu Y, Zhang Y, Zhou B, Geng Y, Yin C, Li J, Wang M, Zhai N, Peng X, Ji Z, Xiao Y, Zhu X, Cai X, Zhang L, Hong B, Xing P, Shen H, Zhang Y, Li M, Shang M, Liu J, Yang P. Endovascular treatment of acute ischemic stroke with a fully radiopaque retriever: A randomized controlled trial. Front Neurol 2022; 13:962987. [PMID: 36588884 PMCID: PMC9796564 DOI: 10.3389/fneur.2022.962987] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 10/26/2022] [Indexed: 12/15/2022] Open
Abstract
Objective The Neurohawk retriever is a new fully radiopaque retriever. A randomized controlled non-inferiority trial was conducted to compare the Neurohawk and the Solitaire FR in terms of safety and efficacy. In order to evaluate the efficacy and safety of endovascular treatment in acute ischemic stroke (AIS) caused by intracranial atherosclerotic disease (ICAD) larger vessel occlusion (LVO), a sub-analysis was performed. Methods Acute ischemic stroke patients aged 18-80 years with LVO in the anterior circulation were randomly assigned to undergo thrombectomy with either the Neurohawk or the Solitaire FR. The primary efficacy endpoint was successful reperfusion (mTICI 2b-3) rate by the allocated retriever. A relevant non-inferiority margin was 12.5%. Safety outcomes were symptomatic intracranial hemorrhage (sICH) and all-cause mortality within 90 days. Secondary endpoints included first-pass effect (FPE), modified FPE, and favorable outcomes at 90 days. In subgroup analysis, the patients were divided into the ICAD group and non-ICAD group according to etiology, and baseline characteristics, angiographic, and clinical outcomes were compared. Results A total of 232 patients were involved in this analysis (115 patients in the Neurohawk group and 117 in the Solitaire group). The rates of successful reperfusion with the allocated retriever were 88.70% in the Neurohawk group and 90.60% in the Solitaire group (95%CI of the difference, -9.74% to 5.94%; p = 0.867). There were similar results in FPE and mFPE in both groups. The rate of sICH seemed higher in the Solitaire group (13.16% vs. 7.02%, p = 0.124). All-cause mortality and favorable outcome rates were comparable as well. In subgroup analysis, 58 patients were assigned to the ICAD group and the remaining 174 to the non-ICAD group. The final successful reperfusion and favorable outcome rates showed no statistically significant differences in two groups. Mortality within 90 days was relatively lower in the ICAD group (6.90% vs. 17.24%; p = 0.054). Conclusion The Neurohawk retriever is non-inferior to the Solitaire FR in the mechanical thrombectomy of large vessel occlusion-acute ischemic stroke (LVO-AIS). The sub-analysis suggested that endovascular treatment including thrombectomy with the retriever and essential rescue angioplasty is effective and safe in AIS patients with intracranial atherosclerotic disease-larger vessel occlusion (ICAD-LVO). Clinical trial registration https://clinicaltrials.gov/ct2/show/NCT04995757, number: NCT04995757.
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Affiliation(s)
- Yongxin Zhang
- Neurovascular Center, Changhai Hospital, Naval Military Medical University, Shanghai, China
| | - Pei Liu
- Neurovascular Center, Changhai Hospital, Naval Military Medical University, Shanghai, China
| | - Zifu Li
- Neurovascular Center, Changhai Hospital, Naval Military Medical University, Shanghai, China
| | - Ya Peng
- Department of Neurosurgery, Changzhou First People's Hospital, Changzhou, China
| | - Wenhuo Chen
- Department of Neurology, Zhangzhou Hospital Affiliated to Fujian Medical University, Zhangzhou, China
| | - Liyong Zhang
- Department of Neurosurgery, Liaocheng People's Hospital Brain Hospital, Liaocheng, China
| | - Jianfeng Chu
- Department of Neurology, The First People's Hospital of Jining City, Jining, China
| | - Dong Kuai
- Department of Neurosurgery, Shanxi Provincial Cardiovascular Hospital, Taiyuan, China
| | - Zhen Chen
- Department of Neurointervention, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Wei Wu
- Department of Neurology, Qilu Hospital of Shandong University, Jinan, China
| | - Yun Xu
- Department of Neurology, Nanjing Gulou Hospital, Nanjing, China
| | - Yong Zhang
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Bin Zhou
- Department of Neurointervention, Cerebrovascular Disease Center, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China
| | - Yu Geng
- Department of Neurology, Zhejiang Provincial People's Hospital, Hangzhou, China
| | - Congguo Yin
- Department of Neurology, Hangzhou First People's Hospital, Hangzhou, China
| | - Jiang Li
- Department of Neurosurgery, The Second Affiliated Hospital of Air Force Military Medical University, Xi'an, China
| | - Ming Wang
- Department of Neurointervention, Nanyang Second People's Hospital, Nanyang, China
| | - Naichi Zhai
- Department of Neurosurgery, Zibo Central Hospital, Zibo, China
| | - Xiaoxiang Peng
- Department of Neurology, The Third People's Hospital of Hubei Province, Wuhan, China
| | - Zhong Ji
- Department of Neurology, Nanfang Hospital of Southern Medical University, Guangzhou, China
| | - Yaping Xiao
- Department of Neurology, Shanghai Oriental Hospital, Shanghai, China
| | - Xingen Zhu
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xueli Cai
- Department of Neurology, Lishui Municipal Central Hospital, Lishui, China
| | - Lei Zhang
- Neurovascular Center, Changhai Hospital, Naval Military Medical University, Shanghai, China
| | - Bo Hong
- Neurovascular Center, Shanghai General Hospital, Shanghai, China
| | - Pengfei Xing
- Neurovascular Center, Changhai Hospital, Naval Military Medical University, Shanghai, China
| | - Hongjian Shen
- Neurovascular Center, Changhai Hospital, Naval Military Medical University, Shanghai, China
| | - Yongwei Zhang
- Neurovascular Center, Changhai Hospital, Naval Military Medical University, Shanghai, China
| | - Minghua Li
- Institute of Diagnostic and Interventional Neuroradiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Meixia Shang
- Department of Biostatistics, Peking University First Hospital, Beijing, China
| | - Jianmin Liu
- Neurovascular Center, Changhai Hospital, Naval Military Medical University, Shanghai, China,*Correspondence: Jianmin Liu
| | - Pengfei Yang
- Neurovascular Center, Changhai Hospital, Naval Military Medical University, Shanghai, China,Pengfei Yang
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Zhang Y, Hua W, Li Z, Peng Y, Han Z, Li T, Yin C, Wang S, Nan G, Zhao Z, Yang H, Zhou B, Li T, Cai Y, Zhang J, Li G, Peng X, Guan S, Zhou J, Ye M, Wang L, Zhang L, Hong B, Zhang Y, Wan J, Wang Y, Zhu Q, Liu J, Yang P. Efficacy and Safety of a Novel Thrombectomy Device in Patients With Acute Ischemic Stroke: A Randomized Controlled Trial. Front Neurol 2021; 12:686253. [PMID: 34456847 PMCID: PMC8397519 DOI: 10.3389/fneur.2021.686253] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 06/28/2021] [Indexed: 01/01/2023] Open
Abstract
Purpose: The Tonbridge stent is a novel retriever with several design improvements which aim to achieve promising flow reperfusion in the treatment of acute ischemic stroke (AIS). We conducted a randomized controlled, multicenter, non-inferiority trial to compare the safety and efficacy of the Tonbridge stent with the Solitaire FR. Methods: AIS patients aged 18-85 years with large vessel occlusion in anterior circulation who could undergo puncture within 6 h of symptom onset were included. Randomization was performed on a 1:1 ratio to thrombectomy with either the Tonbridge stent or the Solitaire FR. The primary efficacy endpoint was successful reperfusion using a modified thrombolysis in cerebral infarction score (mTICI) of 2b/3. Safety outcomes were symptomatic intracranial hemorrhage (sICH) within 24 ± 6 h and all-cause mortality within 90 days. A clinically relevant non-inferiority margin of 12% was chosen as the acceptable difference between groups. Secondary endpoints included time from groin puncture to reperfusion, National Institutes of Health Stroke Scale (NIHSS) score at 24 h and at 7 days, and a modified Rankin Scale (mRS) score of 0-2 at 90 days. Results: A total of 220 patients were enrolled; 104 patients underwent thrombectomy with the Tonbridge stent and 104 were treated with the Solitaire FR. In all test group patients, the Tonbridge was used as a single retriever without rescuing by other thrombectomy devices. Angioplasty with balloon and/or stent was performed in 26 patients in the Tonbridge group and 16 patients in the Solitaire group (p = 0.084). Before angioplasty, 86.5% of those in the Tonbridge group and 81.7% of those in the Solitaire group reached successful reperfusion (p = 0.343). Finally, more patients in the Tonbridge group achieved successful reperfusion (92.3 vs. 84.6%, 95% CI of difference value 0.9-16.7%, p < 0.0001). There were no significant differences on sICH within 24 ± 6 h between the two groups. All-cause mortality within 90 days was 13.5% in the Tonbridge group and 16.3% in the Solitaire group (p = 0.559). We noted no significant differences between groups on the NIHSS at either 24 h or 7 days and the mRS of 0-2 at 90 days. Conclusion: The trial indicated that the Tonbridge stent was non-inferior to the Solitaire FR within 6 h of symptom onset in cases of large vessel occlusion stroke. Clinical Trial Registration:ClinicalTrials.gov, number: NCT03210623.
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Affiliation(s)
- Yongxin Zhang
- Department of Stroke Center, Changhai Hospital, Naval Military Medical University, Shanghai, China
| | - Weilong Hua
- Department of Stroke Center, Changhai Hospital, Naval Military Medical University, Shanghai, China
| | - Zifu Li
- Department of Stroke Center, Changhai Hospital, Naval Military Medical University, Shanghai, China
| | - Ya Peng
- Department of Neurosurgery, The First People's Hospital of Changzhou, Changzhou, China
| | - Zhian Han
- Zhongshan City People's Hospital, Zhongshan, China
| | - Tong Li
- Department of Neurology, The Second Nanning People's Hospital, Nanning, China
| | - Congguo Yin
- Department of Neurology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Shoucun Wang
- Department of Neurology, The First Hospital of Jilin University, Jilin, China
| | - Guangxian Nan
- Department of Neurology, China-Japan Union Hospital of Jilin University, Jilin, China
| | - Zhenwei Zhao
- Department of Neurosurgery, Tangdu Hospital the Fourth Military Medical University, Xi'an, China
| | - Hua Yang
- Department of Neurosurgery, The Affiliated Hospital of Guizhou Medical University, Guizhou, China
| | - Bin Zhou
- The Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, China
| | - Tianxiao Li
- Henan Provincial People's Hospital, Zhengzhou, China
| | - Yiling Cai
- PLA Strategic Support Force Characteristic Medical Center, Beijing, China
| | - Jianmin Zhang
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Guifu Li
- Guangdong Provincial Hospital of Traditional Chinese Medicine, Guangzhou, China
| | - Xiaoxiang Peng
- Department of Neurology, The Third People's Hospital of Hubei Province, Wuhan, China
| | - Sheng Guan
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Junshan Zhou
- Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Ming Ye
- The Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, China
| | - Liqin Wang
- The Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, China
| | - Lei Zhang
- Department of Stroke Center, Changhai Hospital, Naval Military Medical University, Shanghai, China
| | - Bo Hong
- Department of Stroke Center, Changhai Hospital, Naval Military Medical University, Shanghai, China
| | - Yongwei Zhang
- Department of Stroke Center, Changhai Hospital, Naval Military Medical University, Shanghai, China
| | - Jieqing Wan
- Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yang Wang
- Medical Research & Biometrics Center, National Center for Cardiovascular Disease, China
| | - Qing Zhu
- Zhuhai Ton-Bridge Medical Tech. Co., Ltd., Zhuhai, China
| | - Jianmin Liu
- Department of Stroke Center, Changhai Hospital, Naval Military Medical University, Shanghai, China
| | - Pengfei Yang
- Department of Stroke Center, Changhai Hospital, Naval Military Medical University, Shanghai, China
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Yedavalli VS, Tong E, Martin D, Yeom KW, Forkert ND. Artificial intelligence in stroke imaging: Current and future perspectives. Clin Imaging 2020; 69:246-254. [PMID: 32980785 DOI: 10.1016/j.clinimag.2020.09.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/08/2020] [Accepted: 09/11/2020] [Indexed: 12/12/2022]
Abstract
Artificial intelligence (AI) is a fast-growing research area in computer science that aims to mimic cognitive processes through a number of techniques. Supervised machine learning, a subfield of AI, includes methods that can identify patterns in high-dimensional data using labeled 'ground truth' data and apply these learnt patterns to analyze, interpret, or make predictions on new datasets. Supervised machine learning has become a significant area of interest within the medical community. Radiology and neuroradiology in particular are especially well suited for application of machine learning due to the vast amount of data that is generated. One devastating disease for which neuroimaging plays a significant role in the clinical management is stroke. Within this context, AI techniques can play pivotal roles for image-based diagnosis and management of stroke. This overview focuses on the recent advances of artificial intelligence methods - particularly supervised machine learning and deep learning - with respect to workflow, image acquisition and reconstruction, and image interpretation in patients with acute stroke, while also discussing potential pitfalls and future applications.
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Affiliation(s)
- Vivek S Yedavalli
- Stanford University, Department of Radiology, Division of Neuroradiology and Neurointervention, 300 Pasteur Drive, Room S047, Stanford, CA 94305, United States of America; Johns Hopkins Hospital, Department of Radiological Sciences, 600 N. Wolfe St. B 112-D, Baltimore, MD 21287, United States of America.
| | - Elizabeth Tong
- Stanford University, Department of Radiology, Division of Neuroradiology and Neurointervention, 300 Pasteur Drive, Room S031, Stanford, CA 94305, United States of America.
| | - Dann Martin
- Stanford University, Department of Radiology, Division of Neuroradiology and Neurointervention, 300 Pasteur Drive, Room S047, Stanford, CA 94305, United States of America.
| | - Kristen W Yeom
- Stanford University, Department of Radiology, Divisions of Neuroradiology and Pediatric Neuroradiology, 725 Welch Rd. MC 5654, Stanford, CA 94304, United States of America.
| | - Nils D Forkert
- Department of Radiology, Alberta Children's Hospital Research Institute, Hotchkiss Brain Institute Cumming School of Medicine, University of Calgary, HSC Building, Room 2913, 3330 Hospital Drive NW, Calgary, AB T2N 4N1, Canada; Department Clinical Neurosciences, Alberta Children's Hospital Research Institute, Hotchkiss Brain Institute Cumming School of Medicine, University of Calgary, HSC Building, Room 2913, 3330 Hospital Drive NW, Calgary, AB T2N 4N1, Canada.
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Broocks G, Hanning U, Faizy TD, Scheibel A, Nawabi J, Schön G, Forkert ND, Langner S, Fiehler J, Gellißen S, Kemmling A. Ischemic lesion growth in acute stroke: Water uptake quantification distinguishes between edema and tissue infarct. J Cereb Blood Flow Metab 2020; 40:823-832. [PMID: 31072174 PMCID: PMC7168794 DOI: 10.1177/0271678x19848505] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 03/11/2019] [Accepted: 04/02/2019] [Indexed: 01/31/2023]
Abstract
Infarct growth from the early ischemic core to the total infarct lesion volume (LV) is often used as an outcome variable of treatment effects, but can be overestimated due to vasogenic edema. The purpose of this study was (1) to assess two components of early lesion growth by distinguishing between water uptake and true net infarct growth and (2) to investigate potential treatment effects on edema-corrected net lesion growth. Sixty-two M1-MCA-stroke patients with acute multimodal and follow-up CT (FCT) were included. Ischemic lesion growth was calculated by subtracting the initial CTP-derived ischemic core volume from the LV in the FCT. To determine edema-corrected net lesion growth, net water uptake of the ischemic lesion on FCT was quantified and subtracted from the volume of uncorrected lesion growth. The mean lesion growth without edema correction was 20.4 mL (95% CI: 8.2-32.5 mL). The mean net lesion growth after edema correction was 7.3 mL (95% CI: -2.1-16.7 mL; p < 0.0001). Lesion growth was significantly overestimated due to ischemic edema when determined in early-FCT imaging. In 18 patients, LV was lower than the initial ischemic core volume by CTP. These apparently "reversible" core lesions were more likely in patients with shorter times from symptom onset to imaging and higher recanalization rates.
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Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional
Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional
Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias D Faizy
- Department of Diagnostic and Interventional
Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alexandra Scheibel
- Department of Diagnostic and Interventional
Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jawed Nawabi
- Department of Diagnostic and Interventional
Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and
Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nils D Forkert
- Department of Radiology, Hotchkiss Brain
Institute, University of Calgary, Calgary, Canada
| | - Soenke Langner
- Department of Neuroradiology, University of
Rostock, Rostock, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional
Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Gellißen
- Department of Diagnostic and Interventional
Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andre Kemmling
- Department of Neuroradiology, University
Hospital Schleswig-Holstein, Luebeck, Germany
- Department of Neurology, University Hospital
Münster, Münster, Germany
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Fiehler J, Thomalla G, Bernhardt M, Kniep H, Berlis A, Dorn F, Eckert B, Kemmling A, Langner S, Remonda L, Reith W, Rohde S, Möhlenbruch M, Bendszus M, Forkert ND, Gellissen S. ERASER. Stroke 2020; 50:1275-1278. [PMID: 31009356 DOI: 10.1161/strokeaha.119.024858] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Using a novel study design with virtual comparators based on predictive modeling, we investigated whether next-generation mechanical thrombectomy devices improve outcomes in patients with ischemic stroke. We hypothesized that this new study design shows that a next-generation mechanical thrombectomy system is superior to intravenous tPA (tissue-type plasminogen activator) therapy (IVT) alone. Methods- ERASER (Eric Acute Stroke Recanalization) was an investigator-initiated, prospective, multicenter, single-arm (virtual 2-arm) study that evaluated the effectiveness of a new recanalization device together with a specific intermediate catheter (Embolus Retriever with Interlinked Cages/SOFIA, Microvention) in stroke patients with internal carotid artery or middle cerebral artery occlusions. The primary end point was the volume of saved tissue. Volume of saved tissue was defined as the difference of actual infarct volume and brain volume predicted to develop infarction using a machine learning model based on data from intravenous tPA therapy patients. Results- Eighty-one patients were enrolled. The median patient age was 71 years (interquartile range, 61-77). National Institutes of Health Stroke Scale score was 14 (interquartile range, 12-18). The actual infarct volume was smaller than predicted by the intravenous tPA therapy model, with a median volume of saved tissue of 50 mL (interquartile range, 19-103; P<0.0001). Good clinical outcome (modified Rankin Scale, 0-2 at 90 days) was observed in 48 out of 69 (70%). The recanalization rate (Thrombolysis in Cerebral Infarction 2b/3) was 95%. Conclusions- ERASER is the first mechanical thrombectomy study with a primary end point based on predictive analytics enabling intraindividual virtual comparisons. The next-generation mechanical thrombectomy method resulted in smaller infarcts than predicted after intravenous tPA therapy alone and showed a high rate of good clinical outcome. The novel study design with virtual comparisons is promising for further application and testing in the neurovascular arena. Clinical Trial Registration- URL: https://www.clinicaltrials.gov . Unique identifier: NCT02534701.
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Affiliation(s)
- Jens Fiehler
- From the Department of Neuroradiology (J.F., M.B., H.K., S.G.), University Hospital Hamburg-Eppendorf, Germany
| | - Goetz Thomalla
- Department of Neurology (G.T.), University Hospital Hamburg-Eppendorf, Germany
| | - Martina Bernhardt
- From the Department of Neuroradiology (J.F., M.B., H.K., S.G.), University Hospital Hamburg-Eppendorf, Germany
| | - Helge Kniep
- From the Department of Neuroradiology (J.F., M.B., H.K., S.G.), University Hospital Hamburg-Eppendorf, Germany
| | - Ansgar Berlis
- Department of Neuroradiology, Augsburg Hospital, Germany (A.B.)
| | - Franziska Dorn
- Department of Neuroradiology, University Hospital, LMU Munich, Germany (F.D.)
| | - Bernd Eckert
- Department of Neuroradiology, Asklepios Klinik Altona, Germany (B.E.)
| | - Andre Kemmling
- Department of Radiology, University Hospital Muenster, Germany (A.K.)
| | - Soenke Langner
- Department of Neuroradiology, University Hospital Rostock, Germany (S.L.)
| | - Luca Remonda
- Department of Neuroradiology, Cantonal Hospital Aarau, Switzerland (L.R.)
| | - Wolfgang Reith
- Department of Neuroradiology, Saarland University Medical Center, Homburg-Saar, Germany (W.R.)
| | - Stefan Rohde
- Department of Radiology and Neuroradiology, Klinikum Dortmund, Germany (S.R.)
| | - Markus Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany (M.M., M.B.)
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany (M.M., M.B.)
| | - Nils D Forkert
- Radiology and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada (N.D.F.)
| | - Susanne Gellissen
- From the Department of Neuroradiology (J.F., M.B., H.K., S.G.), University Hospital Hamburg-Eppendorf, Germany
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