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Mujanovic A, Kurmann CC, Serrallach BL, Dobrocky T, Meinel TR, Windecker D, Grunder L, Beyeler M, Seiffge DJ, Pilgram-Pastor S, Arnold M, Piechowiak EI, Gralla J, Fischer U, Kaesmacher J. Intra-Arterial Thrombolysis is Associated with Delayed Reperfusion of Remaining Vessel Occlusions following Incomplete Thrombectomy. AJNR Am J Neuroradiol 2023; 44:1050-1056. [PMID: 37500281 PMCID: PMC10494949 DOI: 10.3174/ajnr.a7943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 06/22/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND AND PURPOSE Intra-arterial thrombolytics may be used to treat distal vessel occlusions, which cause incomplete reperfusion following mechanical thrombectomy. Because immediate reperfusion after intra-arterial thrombolytics occurs rarely, the aim of this study was to assess the delayed effect of intra-arterial thrombolytics using follow-up perfusion imaging. MATERIALS AND METHODS We included patients from a prospective stroke registry (February 2015 to September 2022) who had undergone mechanical thrombectomy and had incomplete reperfusion (expanded TICI 2a-2c) and available 24 hour perfusion imaging. Perfusion imaging was rated as delayed reperfusion if time-sensitive perfusion maps did not show wedge-shaped delays suggestive of persisting occlusions corresponding to the post-mechanical thrombectomy angiographic deficit. Patients treated with intra-arterial thrombolytics were compared with controls using multivariable logistic regression and inverse probability of treatment weighting matching for baseline differences and factors associated with delayed reperfusion. RESULTS The median age of the final study population (n = 459) was 74 years (interquartile range, 63-81 years), and delayed reperfusion occurred in 61% of cases. Patients treated with additional intra-arterial thrombolytics (n = 40) were younger and had worse expanded TICI scores. After matching was performed, intra-arterial thrombolytics was associated with higher rates of delayed reperfusion (adjusted OR = 2.7; 95% CI, 1.1-6.4) and lower rates of new infarction in the residually hypoperfused territory after mechanical thrombectomy (adjusted OR = 0.3; 95% CI, 0.1-0.7). No difference was found in the rates of functional independence (90-day mRS, 0-2; adjusted OR = 1.4; 95% CI, 0.4-4.1). CONCLUSIONS Rescue intra-arterial thrombolytics is associated with delayed reperfusion of remaining vessel occlusions following incomplete mechanical thrombectomy. The value of intra-arterial thrombolytics as a potential therapy for incomplete reperfusions after mechanical thrombectomy should be assessed in the setting of randomized controlled trials.
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Affiliation(s)
- A Mujanovic
- From the Department of Diagnostic and Interventional Neuroradiology (A.M., C.C.K., B.L.S., T.D., D.W., L.G., S.P.-P., E.I.P., J.G., J.K.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - C C Kurmann
- From the Department of Diagnostic and Interventional Neuroradiology (A.M., C.C.K., B.L.S., T.D., D.W., L.G., S.P.-P., E.I.P., J.G., J.K.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
- Department of Diagnostic, Interventional and Pediatric Radiology (C.C.K.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - B L Serrallach
- From the Department of Diagnostic and Interventional Neuroradiology (A.M., C.C.K., B.L.S., T.D., D.W., L.G., S.P.-P., E.I.P., J.G., J.K.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - T Dobrocky
- From the Department of Diagnostic and Interventional Neuroradiology (A.M., C.C.K., B.L.S., T.D., D.W., L.G., S.P.-P., E.I.P., J.G., J.K.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - T R Meinel
- Department of Neurology (T.R.M., M.B., D.J.S., M.A., U.F.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - D Windecker
- From the Department of Diagnostic and Interventional Neuroradiology (A.M., C.C.K., B.L.S., T.D., D.W., L.G., S.P.-P., E.I.P., J.G., J.K.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - L Grunder
- From the Department of Diagnostic and Interventional Neuroradiology (A.M., C.C.K., B.L.S., T.D., D.W., L.G., S.P.-P., E.I.P., J.G., J.K.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - M Beyeler
- Department of Neurology (T.R.M., M.B., D.J.S., M.A., U.F.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - D J Seiffge
- Department of Neurology (T.R.M., M.B., D.J.S., M.A., U.F.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - S Pilgram-Pastor
- From the Department of Diagnostic and Interventional Neuroradiology (A.M., C.C.K., B.L.S., T.D., D.W., L.G., S.P.-P., E.I.P., J.G., J.K.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - M Arnold
- Department of Neurology (T.R.M., M.B., D.J.S., M.A., U.F.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - E I Piechowiak
- From the Department of Diagnostic and Interventional Neuroradiology (A.M., C.C.K., B.L.S., T.D., D.W., L.G., S.P.-P., E.I.P., J.G., J.K.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - J Gralla
- From the Department of Diagnostic and Interventional Neuroradiology (A.M., C.C.K., B.L.S., T.D., D.W., L.G., S.P.-P., E.I.P., J.G., J.K.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - U Fischer
- Department of Neurology (T.R.M., M.B., D.J.S., M.A., U.F.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
- Department of Neurology (U.F.), University Hospital Basel, University of Basel, Basel, Switzerland
| | - J Kaesmacher
- From the Department of Diagnostic and Interventional Neuroradiology (A.M., C.C.K., B.L.S., T.D., D.W., L.G., S.P.-P., E.I.P., J.G., J.K.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
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Serrallach BL, Schafer ES, Kralik SK, Tran BH, Huisman TAGM, Wright JN, Morgan LA, Desai NK. Imaging Findings in Children Presenting with CNS Nelarabine Toxicity. AJNR Am J Neuroradiol 2022; 43:1802-1809. [PMID: 36328408 DOI: 10.3174/ajnr.a7692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 09/29/2022] [Indexed: 11/06/2022]
Abstract
Nelarabine is a nucleoside analog critical for the treatment of patients with T-cell acute lymphoblastic leukemia/lymphoma. However, clinical peripheral and central neurologic adverse events associated with nelarabine administration have been reported. Neuroimaging of brain neurotoxicity has only been described in very few reports in pediatric patients so far. Six children with diagnosed T-cell acute lymphoblastic leukemia who clinically experienced possible, probable, or definite nelarabine-induced toxicity and underwent spine and/or brain MR imaging were reviewed. Neuroimaging findings showed a mixture of patterns including features of acute toxic leukoencephalopathy (seen in 6 cases), posterior reversible encephalopathy syndrome (2 cases), involvement of deep gray structures (1 case) and brainstem (2 cases), cranial and spinal neuropathy (2 cases each), and myelopathy (2 cases). Even though neuroimaging findings are nonspecific, the goal of this article was to alert the pediatric neuroradiologists, radiologists, and clinicians about the possibility of nelarabine-induced neurotoxicity and its broad neuroimaging spectrum.
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Affiliation(s)
- B L Serrallach
- From the Edward B. Singleton Department of Radiology (B.L.S., S.K.K., B.H.T., T.A.G.M.H., N.K.D.)
| | - E S Schafer
- Department of Pediatrics (E.S.S.), Section of Hematology-Oncology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - S K Kralik
- From the Edward B. Singleton Department of Radiology (B.L.S., S.K.K., B.H.T., T.A.G.M.H., N.K.D.)
| | - B H Tran
- From the Edward B. Singleton Department of Radiology (B.L.S., S.K.K., B.H.T., T.A.G.M.H., N.K.D.)
| | - T A G M Huisman
- From the Edward B. Singleton Department of Radiology (B.L.S., S.K.K., B.H.T., T.A.G.M.H., N.K.D.)
| | | | - L A Morgan
- Neurology (L.A.M.), Division of Child Neurology, Seattle Children's Hospital, Seattle, Washington
| | - N K Desai
- From the Edward B. Singleton Department of Radiology (B.L.S., S.K.K., B.H.T., T.A.G.M.H., N.K.D.)
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Serrallach BL, Kralik SF, Tran BH, Huisman TAGM, Patel RP, Allen CE, McClain KL, Gulati N, Dillard-Ilboudo CQ, Hicks MJ, Mohila CA, Desai NK. Neuroimaging in Pediatric Patients with Juvenile Xanthogranuloma of the CNS. AJNR Am J Neuroradiol 2022; 43:1667-1673. [PMID: 36265894 PMCID: PMC9731252 DOI: 10.3174/ajnr.a7683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 08/08/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND PURPOSE Juvenile xanthogranuloma is a rare clonal, myeloid, neoplastic disorder. Typically, juvenile xanthogranuloma is a self-limited disorder of infancy, often presenting as a solitary red-brown or yellow skin papule/nodule. A small subset of patients present with extracutaneous, systemic juvenile xanthogranuloma, which may include the CNS. The goal of this retrospective study was to evaluate and categorize the neuroimaging findings in a representative cohort of pediatric patients with CNS juvenile xanthogranuloma. MATERIALS AND METHODS The brain and/or spine MR imaging data of 14 pediatric patients with pathology-proven juvenile xanthogranuloma were categorized and evaluated for the location; the signal intensity of xanthogranulomas on T1WI, T2WI, DWI, and a matching ADC map for the pattern and degree of contrast enhancement; and the presence of perilesional edema, cysts, or necrosis. RESULTS Fourteen pediatric patients (8 girls, 6 boys; mean age, 84 months) were included in the study. Patients presented with a wide variety of different symptoms, including headache, seizure, ataxia, strabismus, hearing loss, facial paresis, and diabetes insipidus. Juvenile xanthogranuloma lesions were identified in a number of different sites, including supra- and infratentorial as well as intracranial and spinal leptomeningeal. Five patients were categorized into the neuroradiologic pattern unifocal CNS juvenile xanthogranuloma; 8, into multifocal CNS juvenile xanthogranuloma; and 1, into multifocal CNS juvenile xanthogranuloma with intracranial and spinal leptomeningeal disease. In most cases, xanthogranulomas were small-to-medium intra-axial masses with isointense signal on T1WI (compared with cortical GM), iso- or hyperintense signal on T2WI, had restricted diffusion and perilesional edema. Almost all xanthogranulomas showed avid contrast enhancement. However, we also identified less common patterns with large lesions, nonenhancing lesions, or leptomeningeal disease. Four cases had an additional CT available. On CT, all xanthogranulomas were homogeneously hyperdense (solid component) without evident calcifications. CONCLUSIONS CNS juvenile xanthogranuloma may demonstrate heterogeneous neuroimaging appearances potentially mimicking other diseases, such as primary brain neoplasms, metastatic disease, lymphoma and leukemia, other histiocytic disorders, infections, or granulomatous diseases.
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Affiliation(s)
- B L Serrallach
- From the Edward B. Singleton Department of Radiology (B.L.S., S.F.K., B.H.T., T.A.G.M.H., R.P.P., N.K.D.)
| | - S F Kralik
- From the Edward B. Singleton Department of Radiology (B.L.S., S.F.K., B.H.T., T.A.G.M.H., R.P.P., N.K.D.)
| | - B H Tran
- From the Edward B. Singleton Department of Radiology (B.L.S., S.F.K., B.H.T., T.A.G.M.H., R.P.P., N.K.D.)
| | - T A G M Huisman
- From the Edward B. Singleton Department of Radiology (B.L.S., S.F.K., B.H.T., T.A.G.M.H., R.P.P., N.K.D.)
| | - R P Patel
- From the Edward B. Singleton Department of Radiology (B.L.S., S.F.K., B.H.T., T.A.G.M.H., R.P.P., N.K.D.)
| | - C E Allen
- Department of Pediatrics (C.E.A., K.L.M., N.G., C.Q.D.-I.), Section of Hematology-Oncology
| | - K L McClain
- Department of Pediatrics (C.E.A., K.L.M., N.G., C.Q.D.-I.), Section of Hematology-Oncology
| | - N Gulati
- Department of Pediatrics (C.E.A., K.L.M., N.G., C.Q.D.-I.), Section of Hematology-Oncology
| | - C Q Dillard-Ilboudo
- Department of Pediatrics (C.E.A., K.L.M., N.G., C.Q.D.-I.), Section of Hematology-Oncology
| | - M J Hicks
- Department of Pathology and Immunology (M.J.H., C.A.M.), Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - C A Mohila
- Department of Pathology and Immunology (M.J.H., C.A.M.), Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - N K Desai
- From the Edward B. Singleton Department of Radiology (B.L.S., S.F.K., B.H.T., T.A.G.M.H., R.P.P., N.K.D.)
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