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Finsel J, Rosenbohm A, Peter RS, Bäzner H, Börtlein A, Dempewolf S, Schabet M, Hecht M, Kohler A, Opherk C, Nägele A, Sommer N, Lindner A, Rothenbacher D, Ludolph AC, Nagel G, Lulé DE. Coping as a resource to allow for psychosocial adjustment in fatal disease: results from patients with amyotrophic lateral sclerosis. Front Psychol 2024; 15:1361767. [PMID: 38638511 PMCID: PMC11024296 DOI: 10.3389/fpsyg.2024.1361767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 03/11/2024] [Indexed: 04/20/2024] Open
Abstract
Background Amyotrophic lateral sclerosis (ALS) is a fatal disorder, which imposes a severe emotional burden on patients. Appropriate coping mechanisms may alleviate this burden and facilitate wellbeing, with social support known to be a successful coping strategy. This observational study aimed to determine the interplay of general coping traits of hope for success and fear of failure, coping behavior of social activity, and patients' wellbeing. Methods In this cross-sectional study, patients with ALS from a clinical-epidemiological registry in Southwestern Germany were interviewed regarding coping traits (achievement-motivated behavior: hope for success and fear of failure), coping behavior of social activity, and psychosocial adjustment, determined using measures of depressiveness, anxiety [both measured by Hospital Anxiety and Depression Scale (HADS)], and quality of life [Anamnestic Comparative Self-Assessment (ACSA)]. Demographics, clinical [ALS Functional Rating Scale revised version (ALSFRS-R)], and survival data were recorded. Results A total of 868 patients [60.70% male patients, mean age: 64.70 (±10.83) years, mean ALSFRS-R: 37.36 ± 7.07] were interviewed. Anxiety in patients was found to be associated with a high fear of failure. In contrast, a generally positive attitude in patients exemplified in high hopes for success was associated with better wellbeing. Finally, coping behavior of social activity explained up to 65% of the variance of depressiveness among the patients with ALS. Conclusion In this study, we present evidence that the wellbeing of patients with ALS is not an immediate fatalistic consequence of physical degradation but rather determined by coping traits and behavior, which may be trained to substantially increase the wellbeing of patients with ALS.
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Affiliation(s)
- Julia Finsel
- Department of Neurology, Ulm University, Ulm, Germany
| | | | - Raphael S. Peter
- Institute for Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
| | - Hansjörg Bäzner
- Department of Neurology, Katharinenhospital Stuttgart, Stuttgart, Germany
| | - Axel Börtlein
- Department of Neurology, Katharinenhospital Stuttgart, Stuttgart, Germany
| | - Silke Dempewolf
- Department of Neurology, RKH Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Martin Schabet
- Department of Neurology, RKH Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Martin Hecht
- Department of Neurology, Klinikum Kaufbeuren, Kliniken Oberallgäu-Kaufbeuren, Kaufbeuren, Germany
| | - Andreas Kohler
- Department of Neurology, Klinikum am Gesundbrunnen Heilbronn, Heilbronn, Germany
| | - Christian Opherk
- Department of Neurology, Klinikum am Gesundbrunnen Heilbronn, Heilbronn, Germany
| | - Andrea Nägele
- Department of Neurology, Christophsbad Göppingen, Göppingen, Germany
| | - Norbert Sommer
- Department of Neurology, Christophsbad Göppingen, Göppingen, Germany
| | - Alfred Lindner
- Department of Neurology, Marienhospital Stuttgart, Stuttgart, Germany
| | | | - Albert C. Ludolph
- Department of Neurology, Ulm University, Ulm, Germany
- German Center for Neurodegenerative Diseases (DZNE), Ulm Site, Ulm, Germany
| | - Gabriele Nagel
- Institute for Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
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Abdulbaki A, Wöhrle JC, Blahak C, Weigel R, Kollewe K, Capelle HH, Bäzner H, Krauss JK. Somatosensory evoked potentials recorded from DBS electrodes: the origin of subcortical N18. J Neural Transm (Vienna) 2024; 131:359-367. [PMID: 38456947 DOI: 10.1007/s00702-024-02752-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 01/30/2024] [Indexed: 03/09/2024]
Abstract
The different peaks of somatosensory-evoked potentials (SEP) originate from a variety of anatomical sites in the central nervous system. The origin of the median nerve subcortical N18 SEP has been studied under various conditions, but the exact site of its generation is still unclear. While it has been claimed to be located in the thalamic region, other studies indicated its possible origin below the pontomedullary junction. Here, we scrutinized and compared SEP recordings from median nerve stimulation through deep brain stimulation (DBS) electrodes implanted in various subcortical targets. We studied 24 patients with dystonia, Parkinson's disease, and chronic pain who underwent quadripolar electrode implantation for chronic DBS and recorded median nerve SEPs from globus pallidus internus (GPi), subthalamic nucleus (STN), thalamic ventral intermediate nucleus (Vim), and ventral posterolateral nucleus (VPL) and the centromedian-parafascicular complex (CM-Pf). The largest amplitude of the triphasic potential of the N18 complex was recorded in Vim. Bipolar recordings confirmed the origin to be close to Vim electrodes (and VPL/CM-Pf) and less close to STN electrodes. GPi recorded only far-field potentials in unipolar derivation. Recordings from DBS electrodes located in different subcortical areas allow determining the origin of certain subcortical SEP waves more precisely. The subcortical N18 of the median nerve SEP-to its largest extent-is generated ventral to the Vim in the region of the prelemniscal radiation/ zona incerta.
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Affiliation(s)
- Arif Abdulbaki
- Department of Neurosurgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Johannes C Wöhrle
- Department of Neurology, Katholisches Klinikum Koblenz Montabaur, Koblenz, Germany
| | - Christian Blahak
- Department of Neurology, Ortenau Klinikum Lahr-Ettenheim, Lahr, Germany
- Department of Neurology, Medical Faculty Mannheim, Universitätsmedizin Mannheim, University of Heidelberg, Mannheim, Germany
| | - Ralf Weigel
- Department of Neurosurgery, Sankt Katharinen Hospital, Frankfurt, Germany
| | - Katja Kollewe
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - H Holger Capelle
- Department of Neurosurgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Hansjörg Bäzner
- Department of Neurology, Katharinenhospital Stuttgart, Stuttgart, Germany
| | - Joachim K Krauss
- Department of Neurosurgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
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Khanafer A, Henkes H, Bücke P, Hennersdorf F, Bäzner H, Forsting M, von Gottberg P. Triple platelet inhibition in intracranial thrombectomy with additional acute cervical stent angioplasty due to tandem lesion: a retrospective single-center analysis. BMC Neurol 2024; 24:99. [PMID: 38500074 PMCID: PMC10946095 DOI: 10.1186/s12883-024-03597-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 03/11/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Acute stroke treatment with intracranial thrombectomy and treatment of ipsilateral carotid artery stenosis/occlusion ("tandem lesion", TL) in one session is considered safe. However, the risk of stent restenosis after TL treatment is high, and antiplatelet therapy (APT) preventing restenosis must be well balanced to avoid intracranial hemorrhage. We investigated the safety and 90-day outcome of patients receiving TL treatment under triple-APT, focused on stent-patency and possible disadvantageous comorbidities. METHODS Patients receiving TL treatment in the setting of acute stroke between 2013 and 2022 were analyzed regarding peri-/postprocedural safety and stent patency after 90 days. All patients received intravenous eptifibatide and acetylsalicylic acid and one of the three drugs prasugrel, clopidogrel, or ticagrelor. Duplex imaging was performed 24 h after treatment, at discharge and 90 days, and digital subtraction angiography was performed if restenosis was suspected. RESULTS 176 patients were included. Periprocedural complications occurred in 2.3% of the patients at no periprocedural death, and in-hospital death in 13.6%. Discharge mRS score was maintained or improved at the 90-day follow-up in 86%, 4.54% had an in-stent restenosis requiring treatment at 90 days. No recorded comorbidity considered disadvantageous for stent patency showed statistical significance, the duration of the endovascular procedure had no significant effect on outcome. CONCLUSION In our data, TL treatment with triple APT resulted in a low restenosis rate, low rates of sICH and a comparably high number of patients with favorable outcome. Aggressive APT in the initial phase may therefore have the potential to prevent recurrent stroke better than restrained platelet inhibition. Comorbidities did not influence stent patency.
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Affiliation(s)
- Ali Khanafer
- Neuroradiological Clinic, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiological Clinic, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Philipp Bücke
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Florian Hennersdorf
- Department of Diagnostic and Interventional Neuroradiology, University of Tübingen, Tübingen, Germany
| | - Hansjörg Bäzner
- Neurological Clinic, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Michael Forsting
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Philipp von Gottberg
- Neuroradiological Clinic, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany.
- Klinik für Neuroradiologie, Klinikum Stuttgart, Kriegsbergstr. 60, 70174, Stuttgart, Germany.
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Hajiyev K, Henkes H, Khanafer A, Bücke P, Hennersdorf F, Bäzner H, von Gottberg P. Drug-Coated Balloons for Treatment of Internal Carotid Artery Restenosis After Stenting: A Single-Center Mid-Term Outcome Study. Cardiovasc Intervent Radiol 2024; 47:291-298. [PMID: 38326576 PMCID: PMC10920408 DOI: 10.1007/s00270-024-03663-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 01/11/2024] [Indexed: 02/09/2024]
Abstract
PURPOSE Endovascular and surgical treatments of stenosis of the extracranial internal carotid artery (ICA) are common procedures, yet both introduce a risk of restenosis due to endothelial hyperplasia. Drug-coated balloons (DCBs) are designed to decrease neointimal hyperplasia, however rarely used in the neurovascular setting. This study retrospectively analyzes mid-term results of DCB-treated in-stent restenosis (ISR) of the ICA. MATERIALS AND METHODS The medical history, comorbidities, and periprocedural data of patients receiving DCB treatment for > 50% ISR of the ICA after carotid artery stenting were analyzed. Follow-up after DCB treatment was performed with Doppler ultrasound. Suspicious cases were checked with CT- or MR-angiography and-if there was agreement between the modalities-validated with digital subtraction angiography. Potential risk factors for restenosis and differences in outcomes after PTA with three types of DCB balloons were evaluated. RESULTS DCB treatment was performed in 109 cases, 0.9% of which involved in-hospital major stroke; no minor strokes occurred. A total of 17 patients (15.6%) had recurrent ISR after DCB treatment, after a mean time of 30.2 months (7-85 months). Tobacco use was significantly associated with a higher incidence of recurrent ISR. CONCLUSION DCB angioplasty for ISR is an effective treatment that may delay and decrease restenosis. Treating comorbidities and adopting lifestyle changes may additionally help prevent ISR.
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Affiliation(s)
- Kamran Hajiyev
- Neuroradiologische Klinik, Klinikum Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiologische Klinik, Klinikum Stuttgart, Stuttgart, Germany
- Medizinische Fakultät, Universität Duisburg-Essen, Essen, Germany
| | - Ali Khanafer
- Neuroradiologische Klinik, Klinikum Stuttgart, Stuttgart, Germany
| | - Philipp Bücke
- Universitätsklinik für Neurologie, Bern University Hospital, Inselspital, Bern, Switzerland
| | - Florian Hennersdorf
- Abteilung Diagnostische und Interventionelle Neuroradiologie, Radiologische Universitätsklinik Tübingen, Tübingen, Germany
| | - Hansjörg Bäzner
- Neurologische Klinik, Klinikum Stuttgart, Stuttgart, Germany
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Geisler T, Keller T, Martus P, Poli K, Serna-Higuita LM, Schreieck J, Gawaz M, Tünnerhoff J, Bombach P, Nägele T, Klose U, Aidery P, Groga-Bada P, Kraft A, Hoffmann F, Hobohm C, Naupold K, Niehaus L, Wolf M, Bäzner H, Liman J, Wachter R, Kimmig H, Jung W, Huber R, Feurer R, Lindner A, Althaus K, Bode FJ, Petzold GC, Nguyen TN, Mac Grory B, Schrag M, Purrucker JC, Zuern CS, Ziemann U, Poli S. Apixaban versus Aspirin for Embolic Stroke of Undetermined Source. NEJM Evid 2024; 3:EVIDoa2300235. [PMID: 38320511 DOI: 10.1056/evidoa2300235] [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] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Apixaban versus Aspirin for Embolic StrokeIn a trial of 352 patients with embolic stroke of undetermined source, 5 mg of apixaban administered twice daily was compared with 100 mg of aspirin administered once daily for the prevention of recurrent ischemic strokes. At 12 months, 13.6% of patients given apixaban had new ischemic lesions on magnetic resonance imaging compared with 16.0% of patients given aspirin, and the rates of clinically relevant bleeding were also comparable.
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Affiliation(s)
- Tobias Geisler
- Department of Cardiology and Angiology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Timea Keller
- Department of Cardiology and Angiology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Peter Martus
- Institute for Clinical Epidemiology and Applied Biometry, Faculty of Medicine, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Khouloud Poli
- Department of Neurology & Stroke, Eberhard Karls University Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Lina Maria Serna-Higuita
- Institute for Clinical Epidemiology and Applied Biometry, Faculty of Medicine, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Juergen Schreieck
- Department of Cardiology and Angiology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Meinrad Gawaz
- Department of Cardiology and Angiology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Johannes Tünnerhoff
- Department of Neurology & Stroke, Eberhard Karls University Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Paula Bombach
- Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, Tübingen, Germany
- Department of Neurology and Interdisciplinary Neuro-Oncology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Thomas Nägele
- Department of Diagnostic and Interventional Neuroradiology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Uwe Klose
- Department of Diagnostic and Interventional Neuroradiology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Parwez Aidery
- Department of Cardiology and Angiology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Patrick Groga-Bada
- Department of Cardiology and Angiology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Andrea Kraft
- Department of Neurology, Krankenhaus Martha-Maria Halle-Doelau, Halle (Saale), Germany
| | - Frank Hoffmann
- Department of Neurology, Krankenhaus Martha-Maria Halle-Doelau, Halle (Saale), Germany
| | - Carsten Hobohm
- Department of Neurology, Carl-von-Basedow Klinikum Merseburg, Merseburg, Germany
| | - Katrin Naupold
- Department of Neurology, Carl-von-Basedow Klinikum Merseburg, Merseburg, Germany
| | - Ludwig Niehaus
- Department of Neurology, Rems-Murr Kliniken, Winnenden, Germany
| | - Marc Wolf
- Department of Neurology, Klinikum Stuttgart, Stuttgart, Germany
| | - Hansjörg Bäzner
- Department of Neurology, Klinikum Stuttgart, Stuttgart, Germany
| | - Jan Liman
- Department of Neurology, Klinikum Nürnberg, Nürnberg, Germany
- Clinic for Neurology, University Hospital Göttingen, Göttingen, Germany
| | - Rolf Wachter
- Department of Cardiology, University Hospital Leipzig, Leipzig, Germany
- Clinic for Cardiology and Pneumology, University Medicine Göttingen, Göttingen, Germany
- German Center for Cardiovascular Research, Göttingen, Germany
| | - Hubert Kimmig
- Department of Neurology, Schwarzwald-Baar Klinikum, Villingen-Schwenningen, Germany
| | - Werner Jung
- Department of Cardiology, Schwarzwald-Baar Klinikum, Villingen-Schwenningen, Germany
| | - Roman Huber
- Department of Neurology, Klinikum Friedrichshafen, Friedrichshafen, Germany
| | - Regina Feurer
- Department of Neurology, Klinikum Friedrichshafen, Friedrichshafen, Germany
| | - Alfred Lindner
- Department of Neurology, Marienhospital Stuttgart, Stuttgart, Germany
| | | | - Felix J Bode
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Gabor C Petzold
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Thanh N Nguyen
- Department of Radiology, Boston Medical Center, Boston
- Department of Neurology, Boston Medical Center, Boston
| | - Brian Mac Grory
- Duke Clinical Research Institute, Durham, NC
- Department of Neurology, Duke University School of Medicine, Durham, NC
| | - Matthew Schrag
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, TN
| | - Jan C Purrucker
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Christine S Zuern
- Department of Neurology, Klinikum Nürnberg, Nürnberg, Germany
- Department of Cardiology, Universitätsspital Basel, Basel, Switzerland
| | - Ulf Ziemann
- Department of Neurology & Stroke, Eberhard Karls University Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Sven Poli
- Department of Neurology & Stroke, Eberhard Karls University Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard Karls University Tübingen, Tübingen, Germany
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Hajiyev K, Cimpoca A, Ernemann U, Bäzner H, Henkes H, von Gottberg P. Long-term outcomes of carotid stenting in a single neurovascular center: up to 12-year retrospective analysis with a focus on the influence of comorbidities. Neuroradiology 2024; 66:117-127. [PMID: 38010404 DOI: 10.1007/s00234-023-03248-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 11/12/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND The aim of this study was to evaluate long-term outcomes in patients who underwent carotid artery stenting (CAS) for symptomatic or asymptomatic high-grade stenosis. METHODS A total of 1158 patients (asymptomatic, n = 636; symptomatic, n = 522) underwent CAS at our center between 2009 and 2020. A total of 560 patients or contacts (asymptomatic, n = 316; symptomatic, n = 244) were interviewed by telephone to evaluate long-term outcomes with a mean follow-up of 5 years. Mortality from all causes, myocardial infarction, and stroke, as well as comorbidities influencing their occurrence, including overall survival and stroke-free survival, were examined. RESULTS The overall survival rate for all-cause mortality was 91.6% at 1 year, 77.1% at 5 years, and 55.7% at 10 years. A total of 39 (6.9%) patients had an ischemic stroke during long-term follow-up. The stroke-free survival rates at 1 year, 5 years, and 10 years were 97.9%, 92.7%, and 86.6%, respectively. Stroke-free survival and overall survival did not differ significantly between the symptomatic and asymptomatic groups (overall survival, p = 0.304; stroke-free survival, p = 0.336). Regular physical activity reduced the risk of stroke and death and was associated with better long-term clinical outcomes. Age at treatment and diabetes mellitus were statistically significantly associated with death during follow-up. CONCLUSION Long-term follow-up data confirmed the effectiveness and durability of CAS as a therapy option for both symptomatic and asymptomatic patients. In patient selection for CAS, special consideration should be paid to patient age, ability to engage in physical activity, and diabetes mellitus.
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Affiliation(s)
- K Hajiyev
- Neuroradiologische Klinik, Klinikum Stuttgart, Stuttgart, Germany.
| | - A Cimpoca
- Neuroradiologische Klinik, Klinikum Stuttgart, Stuttgart, Germany
| | - U Ernemann
- Diagnostische Und Interventionelle Neuroradiologie, Universitätsklinikum Tübingen, Tübingen, Germany
| | - H Bäzner
- Neurologische Klinik, Klinikum Stuttgart, Stuttgart, Germany
| | - H Henkes
- Neuroradiologische Klinik, Klinikum Stuttgart, Stuttgart, Germany
| | - P von Gottberg
- Neuroradiologische Klinik, Klinikum Stuttgart, Stuttgart, Germany
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7
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Nagel G, Kurz D, Peter RS, Rosenbohm A, Koenig W, Dupuis L, Bäzner H, Börtlein A, Dempewolf S, Schabet M, Hecht M, Kohler A, Opherk C, Naegele A, Sommer N, Lindner A, Tumani H, Ludolph AC, Rothenbacher D. Cystatin C based estimation of chronic kidney disease and amyotrophic lateral sclerosis in the ALS registry Swabia: associated risk and prognostic value. Sci Rep 2023; 13:19594. [PMID: 37949878 PMCID: PMC10638424 DOI: 10.1038/s41598-023-46179-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 10/28/2023] [Indexed: 11/12/2023] Open
Abstract
Kidney function as part of metabolic changes could be associated with amyotrophic lateral-sclerosis (ALS). We investigated the associations between estimated chronic kidney disease (CKD), based on the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) cystatin C equation, and the risk at onset and prognostic value of CKD for ALS. Between October 2010 and June 2014, 362 ALS cases (59.4% men, mean age 65.7 years) and 681 controls (59.5% men, means age 66.3 years) were included in a population-based case-control study based on the ALS registry Swabia in Southern Germany. All ALS cases were followed-up (median 89.7 months), 317 died. Serum samples were measured for cystatin C to estimate the glomerular filtration rate (eGFR) according to the CKD-EPI equation. Information on covariates were assessed by an interview-based standardized questionnaire. Conditional logistic regression models were applied to calculate odds ratios (OR) for risk of ALS associated with eGFR/CKD stages. Time-to-death associated with renal parameters at baseline was assessed in ALS cases only. ALS cases were characterized by lower body mass index, slightly lower smoking prevalence, more intense occupational work and lower education than controls. Median serum cystatin-C based eGFR concentrations were lower in ALS cases than in controls (54.0 vs. 59.5 mL/min pro 1.73 m2). The prevalence of CKD stage ≥ 3 was slightly higher in ALS cases than in controls (14.1 vs. 11.0%). In the adjusted models, CKD stage 2 (OR 1.82, 95% CI 1.32, 2.52) and stage 3 (OR 2.34, 95% CI 1.38, 3.96) were associated with increased ALS risk. In this cohort of ALS cases, eGFR and CKD stage ≥ 3 (HR 0.94; 95% CI 0.64, 1.38) were not associated with prognosis. In this case-control study, higher CKD stages were associated with increased ALS risk, while in the prospective cohort of ALS cases, no indication of an association of CysC-based CKD on mortality was seen. In addition, our work strengthens the importance to evaluate renal function using a marker independent of muscle mass in ALS patients.
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Affiliation(s)
- Gabriele Nagel
- Institute of Epidemiology and Medical Biometry, Ulm University, Helmholtzstr. 22, 89081, Ulm, Germany.
| | - Deborah Kurz
- Institute of Epidemiology and Medical Biometry, Ulm University, Helmholtzstr. 22, 89081, Ulm, Germany
| | - Raphael S Peter
- Institute of Epidemiology and Medical Biometry, Ulm University, Helmholtzstr. 22, 89081, Ulm, Germany
| | | | - Wolfgang Koenig
- Institute of Epidemiology and Medical Biometry, Ulm University, Helmholtzstr. 22, 89081, Ulm, Germany
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Luc Dupuis
- Université de Strasbourg, Inserm, UMR-S1118, Centre de Recherches en Biomédecine de Strasbourg, Strasbourg, France
| | - Hansjörg Bäzner
- Department of Neurology, Klinikum Stuttgart, Stuttgart, Germany
| | - Axel Börtlein
- Department of Neurology, Klinikum Stuttgart, Stuttgart, Germany
| | - Silke Dempewolf
- Department of Neurology, RKH Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Martin Schabet
- Department of Neurology, RKH Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Martin Hecht
- Department of Neurology, Klinikum Kaufbeuren, Kliniken Ostallgäu Kaufbeuren, Kaufbeuren, Germany
| | - Andreas Kohler
- Department of Neurology, Klinikum am Gesundbrunnen Heilbronn, Heilbronn, Germany
| | - Christian Opherk
- Department of Neurology, Klinikum am Gesundbrunnen Heilbronn, Heilbronn, Germany
| | - Andrea Naegele
- Department of Neurology, Christophsbad Goeppingen, Goeppingen, Germany
| | - Norbert Sommer
- Department of Neurology, Christophsbad Goeppingen, Goeppingen, Germany
| | - Alfred Lindner
- Department of Neurology, Marienhospital Stuttgart, Stuttgart, Germany
| | | | - Albert C Ludolph
- Department of Neurology, Ulm University, Ulm, Germany
- Deutsches Zentrum Für Neurodegenerative Erkrankungen (DZNE), Ulm, Germany
| | - Dietrich Rothenbacher
- Institute of Epidemiology and Medical Biometry, Ulm University, Helmholtzstr. 22, 89081, Ulm, Germany
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Bücke P, Cohen JE, Horvath T, Cimpoca A, Bhogal P, Bäzner H, Henkes H. What You Always Wanted to Know about Endovascular Therapy in Acute Ischemic Stroke but Never Dared to Ask: A Comprehensive Review. Rev Cardiovasc Med 2022. [DOI: 10.31083/j.rcm2310340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
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9
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Khanafer A, Cimpoca A, Bhogal P, Bäzner H, Ganslandt O, Henkes H. Intracranial stenting as a bail-out option for posthemorrhagic cerebral vasospasm: a single-center experience with long-term follow-up. BMC Neurol 2022; 22:351. [PMID: 36109690 PMCID: PMC9476569 DOI: 10.1186/s12883-022-02862-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 08/29/2022] [Indexed: 11/21/2022] Open
Abstract
Background Cerebral vasospasm (CVS) is a leading cause of morbidity and mortality in patients after aneurysmal subarachnoid hemorrhage (aSAH). Endovascular treatment, including intraarterial infusion of drugs with vasodilation effects, and balloon- and stentriever angioplasty, are helpful but may achieve only short-term effects. There is a clinical need for long-lasting treatment of refractory recurrent vasospasm. We report our experience in stent implantation as a treatment for recurrent severe post-SAH vasospasm. Methods A retrospective analysis of our institutional database of 883 patients with SAH, managed between January 2010 and December 2021, was performed. Six patients were identified as having received intracranial stenting in the context of post-SAH cerebral vasospasm. All patients were initially treated with intra-arterial infusion of nimodipine and/or milrinone. Self-expanding intracranial stents were implanted during endovascular aneurysm treatment to enable access despite impaired perfusion (Group 1) or as a bail-out strategy after failed intraarterial drug infusion or mechanical treatment (Group 2). All stented patients received dual antiplatelet therapy (DAPT) for 6 months. Results Nine vessels in six patients with severe post-SAH vasospasm were stented. The stents were deployed in 16 vessel segments. All attempted implantations were technically successful. All patients demonstrated radiographic and clinical improvement of the vessel narrowing. No recurrent vasospasm or permanent vessel occlusion of the stented vessels was encountered. A thrombus formation in a Group 1 patient resolved under 4 mg eptifibatide IA infusion. During long-term angiographic follow-up, neither in-stent stenosis nor stent occlusion was found. Conclusions Endovascular implantation of self-expanding stents is a potential ultima ratio strategy for patients with severe refractory post-SAH cerebral vasospasm. Stents with reduced thrombogenicity (avoiding DAPT) and bioabsorbable self-expanding stents might further advance this concept. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-022-02862-4.
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10
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Kuramatsu JB, Gerner ST, Ziai W, Bardutzky J, Sembill JA, Sprügel MI, Mrochen A, Kölbl K, Ram M, Avadhani R, Falcone GJ, Selim MH, Lioutas VA, Endres M, Zweynert S, Vajkoczy P, Ringleb PA, Purrucker JC, Volkmann J, Neugebauer H, Erbguth F, Schellinger PD, Knappe UJ, Fink GR, Dohmen C, Minnerup J, Reichmann H, Schneider H, Röther J, Reimann G, Schwarz M, Bäzner H, Claßen J, Michalski D, Witte OW, Günther A, Hamann GF, Lücking H, Dörfler A, Ishfaq MF, Chang JJ, Testai FD, Woo D, Alexandrov AV, Staykov D, Goyal N, Tsivgoulis G, Sheth KN, Awad IA, Schwab S, Hanley DF, Huttner HB. Association of Intraventricular Fibrinolysis With Clinical Outcomes in Intracerebral Hemorrhage: An Individual Participant Data Meta-Analysis. Stroke 2022; 53:2876-2886. [PMID: 35521958 PMCID: PMC9398945 DOI: 10.1161/strokeaha.121.038455] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In patients with intracerebral hemorrhage (ICH), the presence of intraventricular hemorrhage constitutes a promising therapeutic target. Intraventricular fibrinolysis (IVF) reduces mortality, yet impact on functional disability remains unclear. Thus, we aimed to determine the influence of IVF on functional outcomes. METHODS This individual participant data meta-analysis pooled 1501 patients from 2 randomized trials and 7 observational studies enrolled during 2004 to 2015. We compared IVF versus standard of care (including placebo) in patients treated with external ventricular drainage due to acute hydrocephalus caused by ICH with intraventricular hemorrhage. The primary outcome was functional disability evaluated by the modified Rankin Scale (mRS; range: 0-6, lower scores indicating less disability) at 6 months, dichotomized into mRS score: 0 to 3 versus mRS: 4 to 6. Secondary outcomes included ordinal-shift analysis, all-cause mortality, and intracranial adverse events. Confounding and bias were adjusted by random effects and doubly robust models to calculate odds ratios and absolute treatment effects (ATE). RESULTS Comparing treatment of 596 with IVF to 905 with standard of care resulted in an ATE to achieve the primary outcome of 9.3% (95% CI, 4.4-14.1). IVF treatment showed a significant shift towards improved outcome across the entire range of mRS estimates, common odds ratio, 1.75 (95% CI, 1.39-2.17), reduced mortality, odds ratio, 0.47 (95% CI, 0.35-0.64), without increased adverse events, absolute difference, 1.0% (95% CI, -2.7 to 4.8). Exploratory analyses provided that early IVF treatment (≤48 hours) after symptom onset was associated with an ATE, 15.2% (95% CI, 8.6-21.8) to achieve the primary outcome. CONCLUSIONS As compared to standard of care, the administration of IVF in patients with acute hydrocephalus caused by intracerebral and intraventricular hemorrhage was significantly associated with improved functional outcome at 6 months. The treatment effect was linked to an early time window <48 hours, specifying a target population for future trials.
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Affiliation(s)
| | - Stefan T. Gerner
- Department of Neurology, University of Erlangen-Nuremberg, Germany
| | - Wendy Ziai
- Division of Brain Injury Outcomes, Johns Hopkins University, USA
| | | | | | | | - Anne Mrochen
- Department of Neurology, University of Erlangen-Nuremberg, Germany
| | - Kathrin Kölbl
- Department of Neurology, University of Erlangen-Nuremberg, Germany
| | - Malathi Ram
- Division of Brain Injury Outcomes, Johns Hopkins University, USA
| | - Radhika Avadhani
- Division of Brain Injury Outcomes, Johns Hopkins University, USA
| | - Guido J. Falcone
- Department of Neurology, Yale University School of Medicine, USA
- Department of Neurosurgery, Yale University School of Medicine, USA
| | - Magdy H. Selim
- Beth Israel Deaconess Medical Center, Harvard Medical School, USA
| | | | - Matthias Endres
- Department of Neurology, Charité–Universitätsmedizin Berlin, Germany
- Center for Stroke Research Berlin, Germany
- German Centre for Cardiovascular Research(DZHK), Germany
- German Center for Neurodegenerative Diseases(DZNE), Germany
| | - Sarah Zweynert
- Department of Neurology, Charité–Universitätsmedizin Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité–Universitätsmedizin Berlin, Germany
| | - Peter A. Ringleb
- Department of Neurology, Heidelberg University Hospital, Germany
| | - Jan C. Purrucker
- Department of Neurology, Heidelberg University Hospital, Germany
| | - Jens Volkmann
- Department of Neurology, University of Würzburg, Germany
| | - Hermann Neugebauer
- Department of Neurology, University of Würzburg, Germany
- Department of Neurology, University of Ulm, Germany
| | - Frank Erbguth
- Department of Neurology, Nuremberg General Hospital, Germany
| | - Peter D. Schellinger
- Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center Minden, Germany
| | - Ulrich J. Knappe
- Department of Neurosurgery, Johannes Wesling Medical Center Minden, Germany
| | | | - Christian Dohmen
- Department of Neurology, University of Cologne, Germany
- Department of Neurology, LVR-Hospital Bonn, Germany
| | - Jens Minnerup
- Department of Neurology, University of Münster, Germany
| | | | - Hauke Schneider
- Department of Neurology, University of Dresden, Germany
- Department of Neurology, Klinikum Augsburg, Germany
| | - Joachim Röther
- Department of Neurology, Asklepios Klinikum Hamburg Altona, Germany
| | | | | | | | - Joseph Claßen
- Department of Neurology, University of Leipzig, Germany
| | | | - Otto W. Witte
- Department of Neurology, University of Jena, Germany
| | | | - Gerhard F. Hamann
- Department of Neurology and Neurological Rehabilitation, Bezirkskrankenhaus Günzburg, Germany
| | - Hannes Lücking
- Department of Neuroradiology, University of Erlangen-Nuremberg, Germany
| | - Arnd Dörfler
- Department of Neuroradiology, University of Erlangen-Nuremberg, Germany
| | | | - Jason J Chang
- Department of Critical Care Medicine, MedStar Washington Hospital Center, USA
| | - Fernando D. Testai
- Department of Neurology and Rehabilitation, University of Illinois College of Medicine, USA
| | - Daniel Woo
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, USA
| | | | - Dimitre Staykov
- Department of Neurology, University of Erlangen-Nuremberg, Germany
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center, USA
| | - Georgios Tsivgoulis
- Department of Neurology, University of Tennessee Health Science Center, USA
- Second Department of Neurology, Attikon University Hospital, School of Medicine, Greece
| | - Kevin N Sheth
- Department of Neurosurgery, Yale University School of Medicine, USA
| | - Issam A. Awad
- Department of Neurosurgery, University of Chicago, USA
| | - Stefan Schwab
- Department of Neurology, University of Erlangen-Nuremberg, Germany
| | - Daniel F. Hanley
- Division of Brain Injury Outcomes, Johns Hopkins University, USA
| | - Hagen B. Huttner
- Department of Neurology, University of Erlangen-Nuremberg, Germany
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11
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Hajiyev K, Hellstern V, Cimpoca A, Wendl C, Bäzner H, Henkes H, von Gottberg P. Carotid Artery Stenting in Patients with Symptomatic and Asymptomatic Stenosis: In-Hospital Clinical Outcomes at a Single Neurovascular Center. J Clin Med 2022; 11:jcm11082086. [PMID: 35456179 PMCID: PMC9031352 DOI: 10.3390/jcm11082086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 03/18/2022] [Accepted: 04/05/2022] [Indexed: 02/05/2023] Open
Abstract
Background: Carotid artery stenting (CAS) is a minimally invasive and proven percutaneous procedure that is widely used to treat patients with symptomatic and asymptomatic carotid artery stenosis. The purpose of this study was to characterize the in-hospital outcomes of symptomatic and asymptomatic patients undergoing CAS at a single neurovascular center. Methods: The study was conducted as a retrospective analysis of 1158 patients (asymptomatic, n = 636; symptomatic, n = 522; male, n = 816; median age, 71 years; NASCET method, 70–99% stenosis, n = 830) who underwent CAS between May 2009 and December 2020. In-hospital neurological outcomes, adverse reactions to iodinated contrast media, acute myocardial infarction, intraprocedural complications, and access-site issues were evaluated. The primary endpoints were disabling stroke (including disabling cerebral hyperperfusion syndrome [CHS]) and all in-hospital deaths. Results: A carotid stent could not be deployed in one patient due to calcified plaques (technical failure rate of 0.09%). Four patients (0.3%) experienced in-hospital, stroke-associated death, while five patients (0.4%) died from non-stroke-related causes. All stroke-associated deaths occurred in the symptomatic group and were due to CHS. The disabling stroke rate was 0.9% overall (n = 10; 0.5% versus 1.3% in asymptomatic versus symptomatic patients, respectively). Nineteen patients (1.6%) reached the in-hospital primary endpoint. More patients in the symptomatic group achieved this endpoint than in the asymptomatic group (2.5% versus 0.9%, respectively; p = 0.060). Conclusions: An evaluation was conducted on the in-hospital outcomes of 1158 patients at a single center who underwent CAS and was performed by trained physicians who were supervised by a senior neurovascular interventionist with over 20 years of experience, confirming the excellent safety profile of this procedure with a low rate of complications.
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Affiliation(s)
- Kamran Hajiyev
- Neuroradiologische Klinik, Klinikum Stuttgart, D-70174 Stuttgart, Germany; (V.H.); (A.C.); (H.H.); (P.v.G.)
- Correspondence:
| | - Victoria Hellstern
- Neuroradiologische Klinik, Klinikum Stuttgart, D-70174 Stuttgart, Germany; (V.H.); (A.C.); (H.H.); (P.v.G.)
| | - Alexandru Cimpoca
- Neuroradiologische Klinik, Klinikum Stuttgart, D-70174 Stuttgart, Germany; (V.H.); (A.C.); (H.H.); (P.v.G.)
| | - Christina Wendl
- Institut für Röntgendiagnostik, Zentrum für Neuroradiologie, Fakultät für Medizin, Universität Regensburg, D-93053 Regensburg, Germany;
| | - Hansjörg Bäzner
- Neurologische Klinik, Klinikum Stuttgart, D-70174 Stuttgart, Germany;
| | - Hans Henkes
- Neuroradiologische Klinik, Klinikum Stuttgart, D-70174 Stuttgart, Germany; (V.H.); (A.C.); (H.H.); (P.v.G.)
- Medizinische Fakultät, University Duisburg-Essen, D-47057 Duisburg, Germany
| | - Philipp von Gottberg
- Neuroradiologische Klinik, Klinikum Stuttgart, D-70174 Stuttgart, Germany; (V.H.); (A.C.); (H.H.); (P.v.G.)
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12
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Wagner S, Güthe T, Bhogal P, Cimpoca A, Ganslandt O, Bäzner H, Henkes H. Aneurysmal subarachnoid hemorrhage as a trigger for Takotsubo syndrome: a comprehensive review. Rev Cardiovasc Med 2021; 22:1241-1251. [PMID: 34957767 DOI: 10.31083/j.rcm2204132] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 09/29/2021] [Accepted: 09/30/2021] [Indexed: 11/06/2022] Open
Abstract
Takotsubo syndrome (TTS) can result in acute heart failure and lead to a potentially life-threatening complication of aneurysmal subarachnoid hemorrhage (aSAH). The incidence of TTS in aSAH is less than 10% of all patients with aSAH, with a preponderance of postmenopausal women. Early indicators of TTS include elevated serum troponin levels and electrocardiographic abnormalities. The key finding is left ventricular wall motion abnormality. Echocardiography and coronary angiography help to establish the diagnosis. Vasopressors, milrinone, levosimendan, insulin, and anticoagulation may be required. The value of beta-blockers is a matter of controversy. TTS must not delay the treatment of a ruptured aneurysm. The clinical outcome in patients with aSAH and TTS is mostly determined by the aSAH and not the TTS.
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Affiliation(s)
- Sören Wagner
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Thomas Güthe
- Klinik für Innere Medizin 1, Schwerpunkt Kardiologie, Marienhospital Stuttgart, D-70199 Stuttgart, Germany
| | - Pervinder Bhogal
- Department of Interventional Neuroradiology, The Royal London Hospital, E1 1BB London, UK
| | - Alexandru Cimpoca
- Neuroradiologische Klinik, Klinikum Stuttgart, D-70174 Stuttgart, Germany
| | - Oliver Ganslandt
- Neurochirurgische Klinik, Klinikum Stuttgart, D-70174 Stuttgart, Germany
| | - Hansjörg Bäzner
- Neurologische Klinik, Klinikum Stuttgart, D-70174 Stuttgart, Germany
| | - Hans Henkes
- Neuroradiologische Klinik, Klinikum Stuttgart, D-70174 Stuttgart, Germany.,Institut für Diagnostische und Interventionelle Radiologie und Neuroradiologie, Universitätsklinikum Essen, Universität Duisburg-Essen, D-45147 Essen, Germany
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13
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von Gottberg P, Hellstern V, Wendl C, Wolf ME, Niehaus L, Bäzner H, Henkes H. Combined Anticoagulation and Antiaggregation in Acute Cervical Artery Dissection. J Clin Med 2021; 10:jcm10194580. [PMID: 34640598 PMCID: PMC8509613 DOI: 10.3390/jcm10194580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 09/21/2021] [Accepted: 09/27/2021] [Indexed: 11/21/2022] Open
Abstract
Cervical artery dissection (CAD) is a frequent cause of stroke in young adults. Previous studies investigating the efficiency of anticoagulation (AC) versus antiplatelet therapy (AT) found an insignificant difference. We therefore retrospectively evaluated a combination of AC plus AT in patients with acute CAD regarding safety and efficacy. Twenty-eight patients with CAD and minor neurological symptoms/no major infarction received either single (n = 14) or dual AT (n = 14) combined with AC. Angiographic follow-up during hospitalization, 4-8 weeks and 3–6 months after CAD focused on occlusion, residual stenosis, and functional recanalization. Possible adverse events were surveyed. We compared the AC plus AT group to 22 patients with acute CAD treated with AC or AT. Compared to preceding AC-/AT-only studies, AC plus single or dual AT resulted in more frequent, faster recanalization. Frequency and severity of adverse events was comparable. No major adverse events or death occurred. Preceding works on conservative treatment of CAD are discussed and compared to this study. Considerations are given to pathophysiology and the dynamic of CAD. Combining AC plus AT in CAD may result in more reliable recanalization in a shorter time. The risk for adverse events appears similar to treatment with only AC or AT.
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Affiliation(s)
- Philipp von Gottberg
- Neuroradiologische Klinik, Klinikum Stuttgart, 70174 Stuttgart, Germany; (V.H.); (H.H.)
- Correspondence: ; Tel.: +49-711-2783-4501
| | - Victoria Hellstern
- Neuroradiologische Klinik, Klinikum Stuttgart, 70174 Stuttgart, Germany; (V.H.); (H.H.)
| | - Christina Wendl
- Institut für Röntgendiagnostik, Zentrum für Neuroradiologie, Fakultät für Medizin der Universität Regensburg, 93053 Regensburg, Germany;
| | - Marc E. Wolf
- Neurologische Klinik, Klinikum Stuttgart, 70174 Stuttgart, Germany; (M.E.W.); (H.B.)
| | - Ludwig Niehaus
- Neurologische Fachklinik, Rems-Murr-Kliniken, 71364 Winnenden, Germany;
| | - Hansjörg Bäzner
- Neurologische Klinik, Klinikum Stuttgart, 70174 Stuttgart, Germany; (M.E.W.); (H.B.)
| | - Hans Henkes
- Neuroradiologische Klinik, Klinikum Stuttgart, 70174 Stuttgart, Germany; (V.H.); (H.H.)
- Medizinische Fakultät, Universität Duisburg-Essen, 45147 Essen, Germany
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14
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Althaus K, Möller P, Uzun G, Singh A, Beck A, Bettag M, Bösmüller H, Guthoff M, Dorn F, Petzold GC, Henkes H, Heyne N, Jumaa H, Kreiser K, Limpach C, Luz B, Maschke M, Müller JA, Münch J, Nagel S, Pötzsch B, Müller J, Schlegel C, Viardot A, Bäzner H, Wolf M, Pelzl L, Warm V, Willinek WA, Steiner J, Schneiderhan-Marra N, Vollherbst D, Sachs UJ, Fend F, Bakchoul T. Antibody-mediated procoagulant platelets in SARS-CoV-2-vaccination associated immune thrombotic thrombocytopenia. Haematologica 2021; 106:2170-2179. [PMID: 34011137 PMCID: PMC8327736 DOI: 10.3324/haematol.2021.279000] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Indexed: 12/13/2022] Open
Abstract
The COVID-19 pandemic has resulted in significant morbidity and mortality worldwide. To prevent severe infection, mass COVID-19 vaccination campaigns with several vaccine types are currently underway. We report pathological and immunological findings in 8 patients who developed vaccine-induced immune thrombotic thrombocytopenia (VITT) after administration of SARS-CoV-2 vaccine ChAdOx1 nCoV-19. We analyzed patient material using enzyme immune assays, flow cytometry and heparin-induced platelet aggregation assay and performed autopsies on two fatal cases. Eight patients (5 female, 3 male) with a median age of 41.5 years (range, 24 to 53) were referred to us with suspected thrombotic complications 6 to 20 days after ChAdOx1 nCoV-19 vaccination. All patients had thrombocytopenia at admission. Patients had a median platelet count of 46.5 x109/L (range, 8 to 92). Three had a fatal outcome and 5 were successfully treated. Autopsies showed arterial and venous thromboses in various organs and the occlusion of glomerular capillaries by hyaline thrombi. Sera from VITT patients contain high titer antibodies against platelet factor 4 (PF4) (OD 2.59±0.64). PF4 antibodies in VITT patients induced significant increase in procoagulant markers (P-selectin and phosphatidylserine externalization) compared to healthy volunteers and healthy vaccinated volunteers. The generation of procoagulant platelets was PF4 and heparin dependent. We demonstrate the contribution of antibody-mediated platelet activation in the pathogenesis of VITT.
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Affiliation(s)
- Karina Althaus
- Institute for Clinical and Experimental Transfusion Medicine, Medical Faculty of Tuebingen, University Hospital of Tuebingen; Institute for Clinical Transfusion Medicine, University Hospital of Tuebingen
| | - Peter Möller
- Institute for Pathology, University Hospital of Ulm
| | - Günalp Uzun
- Institute for Clinical Transfusion Medicine, University Hospital of Tuebingen
| | - Anurag Singh
- Institute for Clinical and Experimental Transfusion Medicine, Medical Faculty of Tuebingen, University Hospital of Tuebingen
| | - Annika Beck
- Institute for Pathology, University Hospital of Ulm
| | - Martin Bettag
- Department of Neurosurgery, Krankenhaus der Barmherzigen Brüder Trier, Trier
| | - Hans Bösmüller
- Institute for Pathology and Neuropathology, University Hospital of Tuebingen
| | - Martina Guthoff
- Department of Internal Medicine IV, Section of Nephrology and Hypertension, University Hospital of Tuebingen
| | | | | | - Hans Henkes
- Department of Neuroradiology, Klinikum Stuttgart, Stuttgart
| | - Nils Heyne
- Department of Internal Medicine IV, Section of Nephrology and Hypertension, University Hospital of Tuebingen
| | - Hassan Jumaa
- Institute for Immunology, University Hospital of Ulm
| | | | - Caroline Limpach
- Department of Neurology, Krankenhaus der Barmherzigen Brüder Trier, Trier
| | - Beate Luz
- Institute of Transfusion Medicine, Klinikum Stuttgart, Stuttgart
| | - Matthias Maschke
- Department of Neurology, Krankenhaus der Barmherzigen Brüder Trier, Trier
| | - Janis A Müller
- Institute of Molecular Virology, Ulm University Medical Center, Ulm
| | - Jan Münch
- Institute of Molecular Virology, Ulm University Medical Center, Ulm
| | - Simon Nagel
- Department of Neurology, University Hospital Heidelberg
| | - Bernd Pötzsch
- Institute for Experimental Hematology and Transfusion Medicine, Bonn
| | - Jens Müller
- Institute for Experimental Hematology and Transfusion Medicine, Bonn
| | | | | | | | - Marc Wolf
- Department of Neurology, Klinikum Stuttgart, Stuttgart
| | - Lisann Pelzl
- Institute for Clinical and Experimental Transfusion Medicine, Medical Faculty of Tuebingen, University Hospital of Tuebingen
| | - Verena Warm
- Institute for Pathology and Neuropathology, University Hospital of Tuebingen
| | | | - Jochen Steiner
- Anaesthesiology and Intensive Care Medicine, University Hospital Tuebingen
| | | | | | - Ulrich J Sachs
- Department of Thrombosis and Hemostasis and Institute of Immunology and Transfusion Medicine, Giessen
| | - Falko Fend
- Institute for Pathology and Neuropathology, University Hospital of Tuebingen
| | - Tamam Bakchoul
- Institute for Clinical and Experimental Transfusion Medicine, Medical Faculty of Tuebingen, University Hospital of Tuebingen; Institute for Clinical Transfusion Medicine, University Hospital of Tuebingen
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15
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Hellstern V, Aguilar-Pérez M, Henkes E, Serna-Candel C, Wendl C, Bäzner H, Ganslandt O, Henkes H. Endovascular Treatment of Posterior Circulation Saccular Aneurysms With the p64 Flow Modulation Device: Mid-and Long-Term Results in 54 Aneurysms From a Single Center. Front Neurol 2021; 12:711863. [PMID: 34335461 PMCID: PMC8322946 DOI: 10.3389/fneur.2021.711863] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 06/21/2021] [Indexed: 01/21/2023] Open
Abstract
Objective: Flow diverter (FD) stents have become one of the most common tools for treating intracranial aneurysms; however, their role in treating posterior circulation aneurysms is still discussed with controversy. In this study, we evaluated the safety and effectiveness of p64 FD for the treatment of saccular, unruptured aneurysms in the posterior circulation over a long-term follow-up period in a single center. Methods: From our prospectively maintained database, we retrospectively identified patients who underwent treatment of an intracranial saccular aneurysm arising from the posterior circulation with ≥1 p64 FD implanted or attempted between October 2012 and December 2019. Aneurysms could have been treated with prior or concomitant saccular treatment (e.g., coiling, intra-aneurysmal flow diversion). Aneurysms with parent vessel implants other than p64, fusiform aneurysms, and dissections were excluded. Peri- and postprocedural complications, clinical outcome, and clinical and angiographic follow-up results were evaluated. Results: In total, 54 patients (45 female, 9 male; mean age 55.1 years) with 54 intracranial aneurysms met the inclusion criteria. In 51 cases (94.4%), one p64 was implanted; in 2 cases (3.7 %), two p64s were implanted; in one case, deployment of the p64 was not feasible. Procedural complications occurred in 3.7% and postprocedural complications in 9.3 %, respectively. Hemorrhagic complications occurred in 2/54 patients (3.7%), thereof one fatal parenchymal hemorrhage. Ischemic complications were observed in 5/54 patients (9.3%). Early, mid-term, and long-term angiographic follow-up examinations showed complete or near-complete aneurysm occlusion, defined according to the O'Kelly -Marotta (OKM) scale as OKM C + D in 56, 75.6, and 82.9 %, respectively. Asymptomatic side vessel occlusions occurred in 3.8%, each during the first follow-up. Conclusions: The implantation of a p64 FD is a safe and effective device for endovascular treatment of posterior circulation saccular aneurysms with a high success rate and low morbi-mortality.
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Affiliation(s)
- Victoria Hellstern
- Neuroradiologische Klinik, Kopf- und Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Marta Aguilar-Pérez
- Neuroradiologische Klinik, Kopf- und Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Elina Henkes
- Neuroradiologische Klinik, Kopf- und Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Carmen Serna-Candel
- Neuroradiologische Klinik, Kopf- und Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Christina Wendl
- Institut für Röntgendiagnostik, Zentrum für Neuroradiologie, Universitätsklinikum Regensburg, Regensburg, Germany
| | - Hansjörg Bäzner
- Neurologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Oliver Ganslandt
- Neurochirurgische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiologische Klinik, Kopf- und Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany.,Medizinische Fakultät der Universität Duisburg-Essen, Essen, Germany
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16
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Serna Candel C, Aguilar Pérez M, Bäzner H, Henkes H, Hellstern V. First-Pass Reperfusion by Mechanical Thrombectomy in Acute M1 Occlusion: The Size of Retriever Matters. Front Neurol 2021; 12:679402. [PMID: 34267722 PMCID: PMC8276778 DOI: 10.3389/fneur.2021.679402] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 05/03/2021] [Indexed: 12/18/2022] Open
Abstract
Introduction: Single-pass complete reperfusion using stent retrievers has been shown to improve functional outcome in patients with large vessel occlusion strokes. The aim of this study was to investigate the optimal size of stent retrievers to achieve one-pass complete reperfusion by mechanical thrombectomy. Methods: The study evaluated the results of aspiration-assisted mechanical thrombectomy of acute isolated occlusion of the middle cerebral artery in the M1 segment with a novel 5 × 40-mm stent retriever compared to the usual 4 × 20-mm device. Reperfusion status was quantified using the Thrombolysis In Cerebral Infarction (TICI) scale. We hypothesized that thrombectomy of M1 occlusions with 5 × 40-mm stent retriever yields higher rates of complete first-pass reperfusion (FP) (TICI ≥2c after one pass) and successful or modified FP (mFP) (TICI ≥2b after one pass) than thrombectomy with 4 × 20. We included isolated M1 occlusions treated with pRESET 5 × 40 (phenox) as first-choice device for thrombectomy and compared with M1 occlusions treated with pRESET 4 × 20. We excluded patients with additional occlusions or tandem stenosis or who received an intracranial stent or angioplasty as a part of the endovascular treatment. Results: One hundred thirteen patients were included in the 4 × 20 group and 57 patients in the 5 × 40 group. The 5 × 40 group achieved higher FP compared to 4 × 20 group [61.4% (35 of 57 patients) vs. 40.7% (46 of 113), respectively; adjusted odds ratio (OR) and 95% confidence interval (95% CI) = 2.20 (1.08-4.48), p = 0.030] and a higher mFP [68.4%, 39 of 57 patients vs. 48.7%, 55 of 113; adjusted OR (95% CI) = 2.11 (1.04-4.28), p = 0.037]. Frequency of successful reperfusion (TICI ≥2b) was similar in both groups (100 vs. 97.3%), but frequency of complete reperfusion (TICI ≥2c) was higher in the 5 × 40 group [82.5 vs. 61.9%, adjusted OR (95% CI) = 2.47 (1.01-6.04), p = 0.047]. Number of passes to achieve reperfusion was lower in the 5 × 40 group than in the 4 × 20 group [1.6 ± 1.1 vs. 2 ± 1.4, p = 0.033; adjusted incidence rate ratio (95% CI) = 0.84 (0.69-1.03), p = 0.096]. Modified Rankin scale at 90 days was similar in 5 × 40 and 4 × 20 groups. Conclusions: The size of stent retriever matters in acute M1 occlusions treated with aspiration-assisted mechanical thrombectomy. A longer stent retriever with a larger nominal diameter achieves a higher complete and successful FP and higher successful reperfusion compared to a shorter stent retriever.
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Affiliation(s)
| | | | - Hansjörg Bäzner
- Neurologische Klinik, Klinikum Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiologische Klinik, Klinikum Stuttgart, Stuttgart, Germany
- Medical Faculty, University Duisburg-Essen, Essen, Germany
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17
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Bhogal P, Makalanda L, Hassan AE, Fiorella D, Andersson T, Ahmad M, Bäzner H, Jaffer O, Henkes H. COVID-19 and Delayed Cerebral Ischemia-More in Common Than First Meets the Eye. J Clin Med 2021; 10:2646. [PMID: 34208470 PMCID: PMC8233948 DOI: 10.3390/jcm10122646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 06/06/2021] [Accepted: 06/09/2021] [Indexed: 01/22/2023] Open
Abstract
Since the arrival of the global COVID-19 pandemic scientists around the world have been working to understand the pathological mechanisms resulting from infection. There has gradually been an understanding that COVID-19 triggers a widespread endotheliopathy and that this can result in a widespread thrombosis and in particular a microthrombosis. The mechanisms involved in the microthrombosis are not confined to infection and there is evidence that patients with aneurysmal sub-arachnoid haemorrhage (SAH) also suffer from an endotheliopathy and microthrombosis. In this article we attempt to shed light on similarities in the underlying processes involved in both diseases and suggest potential treatment options.
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Affiliation(s)
- Pervinder Bhogal
- Department of Interventional Neuroradiology, The Royal London Hospital, Barts NHS Trust, Whitechapel Road, Whitechapel, London E1 1BB, UK;
| | - Levansri Makalanda
- Department of Interventional Neuroradiology, The Royal London Hospital, Barts NHS Trust, Whitechapel Road, Whitechapel, London E1 1BB, UK;
| | - Ameer E. Hassan
- Departments of Neurology and Radiology, University of Texas Rio Grande Valley, Harlingen, TX 78550, USA;
| | - Dave Fiorella
- Department of Neurosurgery, Stony Brook University Hospital, Stony Brook, NY 11794, USA;
| | - Tommy Andersson
- Department of Interventional Neuroradiology, The Karolinska University Hospital, 171 76 Stockholm, Sweden;
| | | | - Hansjörg Bäzner
- Department of Neurology, Klinikum Stuttgart, 70174 Stuttgart, Germany;
| | - Ounali Jaffer
- Department of Interventional Radiology, The Royal London Hospital, Barts NHS Trust, Whitechapel Road, Whitechapel, London E1 1BB, UK;
| | - Hans Henkes
- Department of Neuroradiology, Klinikum Stuttgart, 70174 Stuttgart, Germany;
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18
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Bücke P, Henkes H, Arnold G, Herting B, Jüttler E, Klötzsch C, Lindner A, Mauz U, Niehaus L, Reinhard M, Waibel S, Horvath T, Bäzner H, Aguilar Pérez M. Seasonal patterns and associations in the incidence of acute ischemic stroke requiring mechanical thrombectomy. Eur J Neurol 2021; 28:2229-2237. [PMID: 33738909 PMCID: PMC9290541 DOI: 10.1111/ene.14832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 03/14/2021] [Indexed: 11/28/2022]
Abstract
Background In order to identify risk periods with an increased demand in technical and human resources, we tried to determine patterns and associations in the incidence of acute ischemic stroke due to embolic large vessel occlusions (eLVO) requiring mechanical thrombectomy (MT). Methods We conducted a time series analysis over a 9‐year period (2010–2018) based on observational data in order to detect seasonal patterns in the incidence of MT due to eLVO (n = 2628 patients). In a series of sequential negative binominal regression models, we aimed to detect further associations (e.g., temperature, atmospheric pressure, air pollution). Results There was a 6‐month seasonal pattern in the incidence of MT due to eLVO (p = 0.024) peaking in March and September. Colder overall temperature was associated with an increase in MT due to eLVO (average marginal effect [AME], [95% CI]: −0.15 [−0.30–0.0001]; p = 0.05; per °C). A current increase in the average monthly temperature was associated with a higher incidence of MT due to eLVO (0.34 [0.11–0.56]; p = 0.003). Atmospheric pressure was positively correlated with MT due to eLVO (0.38 [0.13–0.64]; p = 0.003; per hectopascal [hPa]). We could detect no causal correlation between air pollutants and MT due to eLVO. Conclusions Our data suggest a 6‐month seasonal pattern in the incidence of MT due to eLVO peaking in spring and early autumn. This might be attributed to two different factors: (1) a current temperature rise (comparing the average monthly temperature in consecutive months) and (2) colder overall temperature. These results could help to identify risk periods requiring an adaptation in local infrastructure.
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Affiliation(s)
- Philipp Bücke
- Department of Neurology, Inselspital, University Hospital Bern, Bern, Switzerland.,Neurological Clinic, Klinikum Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiological Clinic, Klinikum Stuttgart, Stuttgart, Germany.,Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - Guy Arnold
- Neurological Clinic, Klinikum Sindelfingen-Böblingen, Sindelfingen, Germany
| | - Birgit Herting
- Neurological Clinic, Diakonie-Klinikum Schwäbisch Hall, Schwäbisch Hall, Germany
| | - Eric Jüttler
- Neurological Clinic, Ostalb-Klinikum Aalen, Aalen, Germany
| | - Christof Klötzsch
- Neurological Clinic, Hegau-Bodensee-Klinikum Singen, Singen, Germany
| | - Alfred Lindner
- Neurological Clinic, Marienhospital Stuttgart, Stuttgart, Germany
| | - Uwe Mauz
- Neurological Clinic, MEDIUS Klinik Kirchheim, Kirchheim, Germany
| | - Ludwig Niehaus
- Neurological Clinic, Rems-Murr-Klinikum Winnenden, Winnenden, Germany
| | - Matthias Reinhard
- Clinic for Neurology and Clinical Neurophysiology, Klinikum Esslingen, Esslingen, Germany
| | - Stefan Waibel
- Center for Internal Medicine, Stauferklinikum Schwäbisch Gmünd, Schwäbisch Gmünd, Germany
| | - Thomas Horvath
- Department of Neurology, Inselspital, University Hospital Bern, Bern, Switzerland
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19
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Aguilar Pérez M, Henkes E, Hellstern V, Serna Candel C, Wendl C, Bäzner H, Ganslandt O, Henkes H. Endovascular Treatment of Anterior Circulation Aneurysms With the p64 Flow Modulation Device: Mid- and Long-Term Results in 617 Aneurysms From a Single Center. Oper Neurosurg (Hagerstown) 2021; 20:355-363. [PMID: 33469666 PMCID: PMC8133326 DOI: 10.1093/ons/opaa425] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 10/09/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Flow diverters have become an important tool in the treatment of intracranial aneurysms, especially when dealing with difficult-to-treat or complex aneurysms. The p64 is the only fully resheathable and mechanically detachable flow diverter available for clinical use. OBJECTIVE To evaluate the safety and effectiveness of p64 for the treatment of intracranial saccular unruptured aneurysms arising from the anterior circulation over a long-term follow-up period. METHODS We retrospectively reviewed our prospectively maintained database to identify all patients who underwent treatment for an intracranial saccular (unruptured or beyond the acute hemorrhage phase) aneurysm arising from the anterior circulation with ≥1 p64 between December 2011 and December 2019. Fusiform aneurysms and dissections were excluded. Aneurysms with prior or concomitant saccular treatment (eg, coiling and clipping) were included. Aneurysms with parent vessel implants other than p64 were excluded. Anatomic features, intraprocedural complications, clinical outcome, as well as clinical and angiographic follow-ups were all recorded. RESULTS In total, 530 patients (388 females; median age 55.9 yr) with 617 intracranial aneurysms met the inclusion criteria. The average number of devices used per aneurysm was 1.1 (range 1-3). Mean aneurysm dome size was 4.8 mm (range 1-27 mm). Treatment-related morbimortality was 2.4%. Early, mid-term, and long-term angiographic follow-up showed complete or near-complete aneurysm occlusion in 76.8%, 89.7%, and 94.5%, respectively. CONCLUSION Treatment of intracranial saccular unruptured aneurysms of the anterior circulation using p64 is a safe and effective treatment option with high rate of occlusion at long-term follow-up and low morbimortality.
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Affiliation(s)
- Marta Aguilar Pérez
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Elina Henkes
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Victoria Hellstern
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Carmen Serna Candel
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Christina Wendl
- Institut für Röntgendiagnostik, Zentrum für Neuroradiologie, Universitätsklinikum Regensburg, Regensburg, Germany
| | - Hansjörg Bäzner
- Neurologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Oliver Ganslandt
- Neurochirurgische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
- Medizinische Fakultät der Universität Duisburg-Essen, Essen, Germany
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20
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Henkes H, Bhogal P, Hellstern V, Bäzner H. Endovascular Management of Intracranial Atherosclerotic Stenosis: Lessons from Mistakes in the Past and how to Achieve Improved Outcomes. Clin Neuroradiol 2021; 31:31-34. [PMID: 33751167 PMCID: PMC7943425 DOI: 10.1007/s00062-021-01005-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Hans Henkes
- Neuroradiologische Klinik, Katharinenhospital, Klinikum Stuttgart, Kriegsbergstraße 60, 70194, Stuttgart, Germany. .,Medical Faculty, University Duisburg-Essen, Essen, Germany.
| | - Pervinder Bhogal
- Department of Interventional Neuroradiology, The Royal London Hospital, London, UK
| | - Victoria Hellstern
- Neuroradiologische Klinik, Katharinenhospital, Klinikum Stuttgart, Kriegsbergstraße 60, 70194, Stuttgart, Germany
| | - Hansjörg Bäzner
- Neurologische Klinik, Katharinenhospital, Klinikum Stuttgart, Kriegsbergstraße 60, Stuttgart, 70194, Germany
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21
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AlMatter M, Aguilar Pérez M, Hellstern V, Mitrovic G, Ganslandt O, Bäzner H, Henkes H. Flow Diversion for Treatment of Acutely Ruptured Intracranial Aneurysms : A Single Center Experience from 45 Consecutive Cases. Clin Neuroradiol 2020; 30:835-842. [PMID: 31686121 PMCID: PMC7728654 DOI: 10.1007/s00062-019-00846-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 10/03/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Reports about the use of flow diverter stents (FDS) in the acute setting of subarachnoid hemorrhage (SAH) are limited. This article presents a single center experiences based on 45 consecutive cases with emphasis on complication rates and clinical and radiologic outcomes. METHODS A prospectively maintained database of all cases treated with FDS as a stand-alone or adjunct device was retrospectively reviewed. All patients treated within 30 days of SAH were included. Records were made of clinical presentation, details of endovascular treatment, procedural complications, clinical outcome, and degree of occlusion on follow-up. RESULTS In this study 45 patients (48.9% females; mean age 58.8 ± 12.4 years) were included. Flow diversion was performed after a median of 4 days. The procedural complication rate was 13.3% resulting in 2.2% permanent morbidities and 4.4% mortalities. No major hemorrhagic complications related to antiplatelet therapy were recorded. Immediate complete occlusion was achieved in 13.3%. Among survivors, complete occlusion was achieved in 94.6%. Excellent clinical outcome was recorded in 68.9% and 81.6% of the total population and survivors, respectively. There were no records of rebleeding from the target lesions. CONCLUSION Flow diversion is an attractive alternative strategy for management of acutely ruptured aneurysms with high rates of delayed complete occlusion and acceptable complication rates.
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Affiliation(s)
- Muhammad AlMatter
- Neuroradiologische Klinik, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany.
| | - Marta Aguilar Pérez
- Neuroradiologische Klinik, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Victoria Hellstern
- Neuroradiologische Klinik, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Goran Mitrovic
- Neuroradiologische Klinik, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Oliver Ganslandt
- Neurochirurgische Klinik, Klinikum Stuttgart, Stuttgart, Germany
| | - Hansjörg Bäzner
- Neurologische Klinik, Klinikum Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiologische Klinik, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
- Medizinische Fakultät, der Universität Duisburg-Essen, Essen, Germany
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22
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Aguilar Perez M, Hellstern V, Serna Candel C, Wendl C, Bäzner H, Gansladt O, Henkes H. Use of pCONUS HPC for the treatment of unruptured wide-necked bifurcation aneurysms: early clinical experience using single antiplatelet therapy. Stroke Vasc Neurol 2020; 6:57-64. [PMID: 32920538 PMCID: PMC8005901 DOI: 10.1136/svn-2020-000399] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 07/13/2020] [Accepted: 07/30/2020] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND In recent years, a growing number of stents and stent-like devices have become available to facilitate the treatment of challenging aneurysms. However, the need for dual antiplatelet therapy can limit their use, especially in ruptured aneurysms. The hydrophilic polymer coating (pHPC, phenox) is a novel glycan-based multilayer polymer that reduces platelet adhesion. This study aims to report our initial experience using the pCONUS HPC device for the treatment of unruptured wide-necked bifurcation aneurysms (WNBA) using acetylsalicylic acid (ASA) as single antiplatelet therapy (SAPT). METHODS We retrospectively identified all patients who were treated with the pCONUS HPC for unruptured WNBA in a multi-staged procedure using ASA as SAPT. Records were made of periprocedural complications, clinical outcome and angiographic and clinical follow-up. RESULTS We identified 15 patients with 15 WNBA. The average age was 69 years old (range, 41-76). Seven aneurysms were located in the middle cerebral artery, five in the anterior communicating artery, two at the basilar tip and one in the posterior communicating artery. Immediate post-treatment angiography showed five aneurysms with modified Raymond-Roy classification (mRRC) grade I and four aneurysms with mRRC grade II. There were no haemorrhagic complications. Four patients developed thrombus formation during the second treatment session, all of them completely resolving after administration of glycoprotein IIb/IIIa antagonists. Angiographic follow-up data were available for 10 patients and showed adequate occlusion (mRRC I or II) in eight aneurysms (80%). In-stent stenosis was observed in one patient whereas two patients showed de novo stenosis in one of the efferent branches. CONCLUSIONS This early experience on the use of the pCONUS HPC device suggests that it can be useful for treating unruptured WNBA under ASA as SAPT. Further investigation with a randomised treatment registry and larger cohort is needed.
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Affiliation(s)
- Marta Aguilar Perez
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Victoria Hellstern
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Carmen Serna Candel
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Christina Wendl
- Institut für Röntgendiagnostik, Zentrum für Neuroradiologie, Fakultät für Medizin der Universität Regensburg, Regensburg, Germany
| | - Hansjörg Bäzner
- Neurologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Oliver Gansladt
- Neurochirurgische, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany.,Medizinische Fakultät, Universität Duisburg-Essen, Essen, Germany
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23
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Aguilar Perez M, AlMatter M, Hellstern V, Wendl C, Ganslandt O, Bäzner H, Henkes H. Use of the pCONus HPC as an adjunct to coil occlusion of acutely ruptured aneurysms: early clinical experience using single antiplatelet therapy. J Neurointerv Surg 2020; 12:862-868. [PMID: 32102920 PMCID: PMC7476363 DOI: 10.1136/neurintsurg-2019-015746] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 01/30/2020] [Accepted: 02/05/2020] [Indexed: 12/27/2022]
Abstract
Background Coil occlusion has become the standard treatment for many ruptured aneurysms. However, specific aneurysm structures pose technical difficulties and may require the use of adjunctive neck-bridging devices, which necessitate the use of dual antiplatelet therapy. The hydrophilic polymer coating (pHPC, phenox) is a surface modification that inhibits platelet adhesion. Objective To present initial experience with the pCONUS HPC device as an adjunct to coil embolization for ruptured aneurysms using single antiplatelet therapy (SAPT). Methods All patients who were treated with the pCONUS HPC for ruptured aneurysms using SAPT were retrospectively identified. The occurrence of thromboembolic and hemorrhagic complications was recorded together with the angiographic and clinical follow-up details. Results Fifteen patients were identified (nine female) with a median age of 54 years (range 27–81). Six aneurysms were located at the anterior communicating artery, five at the middle cerebral artery bifurcation, two at the basilar artery bifurcation, one at the posterior communicating artery, and one involving the intradural internal carotid artery. Ten patients (66.6%) achieved modified Raymond–Roy classification I or II at post-treatment angiography, with 45.5% of patients having adequate occlusion (defined as complete occlusion or neck remnant) at follow-up. All patients received acetylsalicylic acid (ASA) as SAPT before and after the procedure. Intraprocedural thrombus formation was seen in three patients (20%), resolving in two patients after a bolus dose of eptifibatide, and one treated with mechanical aspiration. No clinical or radiological consequences were seen. There were no recurrent aneurysm ruptures. One patient died owing to cerebral vasospasm. Conclusion This initial clinical experience highlights the possibility and limitations of using the pCONUS HPC device in the treatment of complex ruptured aneurysm with ASA as SAPT. Randomized trials with longer follow-up in larger cohorts are underway.
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Affiliation(s)
- Marta Aguilar Perez
- Neuroradiologische Klinik, Klinikum Stuttgart, Stuttgart, Baden-Württemberg, Germany
| | - Muhammad AlMatter
- Neuroradiologische Klinik, Klinikum Stuttgart, Stuttgart, Baden-Württemberg, Germany
| | - Victoria Hellstern
- Neuroradiologische Klinik, Klinikum Stuttgart, Stuttgart, Baden-Württemberg, Germany
| | - Christina Wendl
- Institut für Röntgendiagnostik, Zentrum für Neuroradiologie, Universitatsklinikum Regensburg, Regensburg, Bayern, Germany
| | - Oliver Ganslandt
- Neurochirurgische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Baden-Württemberg, Germany
| | - Hansjörg Bäzner
- Neurologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Baden-Württemberg, Germany
| | - Hans Henkes
- Neuroradiologische Klinik, Klinikum Stuttgart, Stuttgart, Baden-Württemberg, Germany.,Medizinische Fakultät der Universität Duisburg-Essen, Essen, Germany
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24
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Serna Candel C, Hellstern V, Beitlich T, Aguilar Pérez M, Bäzner H, Henkes H. Management of a decompensated acute-on-chronic intracranial venous sinus thrombosis. Ther Adv Neurol Disord 2019; 12:1756286419895157. [PMID: 31903097 PMCID: PMC6931136 DOI: 10.1177/1756286419895157] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 11/22/2019] [Indexed: 12/22/2022] Open
Abstract
A 34-year-old female patient presented during the 10th week of her second gravidity with headache, nausea and vomiting 2 weeks before admission. Her medical history was remarkable for a heterozygous factor V Leiden mutation, elevated lipoprotein A, and a cerebral venous thrombosis (CVT) after oral contraceptive intake 15 years before. Magnetic resonance imaging (MRI) suggested acute and massive intracranial sinus thrombosis. Despite full-dose anticoagulation, the patient deteriorated clinically and eventually became comatose. Now, MRI/magnetic resonance angiography revealed vasogenic edema of both thalami, of the left frontal lobe, and of the head of the caudate nucleus, with venous stasis and frontal petechial hemorrhage. She was referred for endovascular treatment. Diagnostic angiography confirmed a complete superficial and deep venous sinus occlusion. Endovascular access to the straight and superior sagittal sinus was possible, but neither rheolysis nor balloon angioplasty resulted in recanalization of the venous sinuses. Monitored heparinization was continued and antiaggregation was initiated. The patient remained comatose for another 5 days and MRI showed progress of the cytotoxic edema. On day 6, infusion of eptifibatide at body-weight-adapted dosage was started. The following day, the patient improved and slowly regained consciousness. MRI confirmed regression of the edema. The eptifibatide infusion was continued for a total of 14 days. Thereafter two doses of 180 mg ticagrelor per os (PO) daily were started. The patient remained on acetylsalicylic acid (ASA), ticagrelor, and enoxaparin on an unchanged dosage regimen. She was discharged home 26 days after the endovascular treatment without serious neurological deficit, with the pregnancy intact. At the 30th week of pregnancy the dosage of ASA was reduced to 300 mg once PO daily. Cesarian delivery was carried out at the 38th week of pregnancy. The newborn was completely healthy. Ultima ratio therapeutic options for severe intracranial venous sinus thrombosis refractory to anticoagulation are discussed, with an emphasis on platelet-function inhibition.
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Affiliation(s)
| | | | - Tania Beitlich
- Neurologsche Klinik, Klinikum Karlsruhe,
Karlsruhe, Germany
| | | | | | - Hans Henkes
- Neuroradiologische Klinik, Klinikum Stuttgart,
Kriegsbergstrasse 60, Stuttgart 70174, Germany
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Serna Candel C, Aguilar Pérez M, Hellstern V, AlMatter M, Bäzner H, Henkes H. Recanalization of Emergent Large Intracranial Vessel Occlusion through Intravenous Thrombolysis: Frequency, Clinical Outcome, and Reperfusion Pattern. Cerebrovasc Dis 2019; 48:115-123. [PMID: 31747667 DOI: 10.1159/000503850] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 10/02/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND According to a recent meta-analysis, 1 out of 10 patients with emergent large intracranial vessel occlusion (ELVO) causing stroke have recanalization after intravenous thrombolysis (IVT) alone. However, rate, clinical outcome, and recanalization pattern of this phenomenon are poorly understood. OBJECTIVES AND METHODS Patients with ELVO recanalized only by IVT were analyzed, and frequency of recanalization, clinical outcome, safety variables, and reperfusion pattern were assessed. These patients were compared to a group of patients with ELVO who underwent endovascular thrombectomy with or without prior IVT. RESULTS Successful or sufficient recanalization after IVT alone occurred in 81 of 760 patients (10.6%) with ELVO who had been referred for endovascular thrombectomy. These 81 patients (group 1) were compared to a group of patients receiving endovascular thrombectomy with prior IVT (group 2) or without (group 3). A good clinical outcome at 90 days was seen in 61.7% of patients in group 1, 32.2% in group 2, and 34.5% in group 3 (p < 0.001). The 3 groups had no significant differences in intracranial hemorrhage. IVT was not independently associated with symptomatic intracranial hemorrhage, parenchymal hematoma, or subarachnoid hemorrhage. Mortality at 90 days was 9.9% in group 1, 20.7% in group 2, and 29.6% in group 3 (p < 0.001). After adjusting for all relevant variables, outcome and mortality differences were nonsignificant. No difference in the rate of successful reperfusion (modified treatment in cerebral ischemia [mTICI] 2b/3) was found. A reperfusion mTICI 3 was achieved in 18.5% in group 1, 60.7% in group 2, and 57.1% in group 3 (p < 0.001). Patients in group 1 had lower chance of achieving a complete recanalization (mTICI 3) compared to patients in group 2, OR 0.15 (95% CI 0.08-0.29) and in group 3, OR 0.17 (95% CI 0.09-0.32; p < 0.001). CONCLUSIONS Primary IVT in ELVO caused a recanalization rate of 10.6%, making endovascular treatment either unnecessary or impossible. Early recanalization of ELVO with only IVT is associated with a 61.7% independence rate at 90 days and similar successful reperfusion rates (mTICI2b/3) compared to ELVO treated with endovascular treatment, with or without previous IVT. However, recanalization only through IVT achieves a lower rate of mTICI 3 reperfusion when compared to endovascular treatment.
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Affiliation(s)
- Carmen Serna Candel
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany,
| | - Marta Aguilar Pérez
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Victoria Hellstern
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Muhammad AlMatter
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Hansjörg Bäzner
- Neurologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany.,Medical Faculty, University Duisburg-Essen, Essen, Germany
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26
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Kuramatsu JB, Sembill JA, Gerner ST, Sprügel MI, Hagen M, Roeder SS, Endres M, Haeusler KG, Sobesky J, Schurig J, Zweynert S, Bauer M, Vajkoczy P, Ringleb PA, Purrucker J, Rizos T, Volkmann J, Müllges W, Kraft P, Schubert AL, Erbguth F, Nueckel M, Schellinger PD, Glahn J, Knappe UJ, Fink GR, Dohmen C, Stetefeld H, Fisse AL, Minnerup J, Hagemann G, Rakers F, Reichmann H, Schneider H, Wöpking S, Ludolph AC, Stösser S, Neugebauer H, Röther J, Michels P, Schwarz M, Reimann G, Bäzner H, Schwert H, Claßen J, Michalski D, Grau A, Palm F, Urbanek C, Wöhrle JC, Alshammari F, Horn M, Bahner D, Witte OW, Günther A, Hamann GF, Lücking H, Dörfler A, Achenbach S, Schwab S, Huttner HB. Management of therapeutic anticoagulation in patients with intracerebral haemorrhage and mechanical heart valves. Eur Heart J 2019. [PMID: 29529259 PMCID: PMC5950928 DOI: 10.1093/eurheartj/ehy056] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Aims Evidence is lacking regarding acute anticoagulation management in patients after intracerebral haemorrhage (ICH) with implanted mechanical heart valves (MHVs). Our objective was to investigate anticoagulation reversal and resumption strategies by evaluating incidences of haemorrhagic and thromboembolic complications, thereby defining an optimal time-window when to restart therapeutic anticoagulation (TA) in patients with MHV and ICH. Methods and results We pooled individual patient-data (n = 2504) from a nationwide multicentre cohort-study (RETRACE, conducted at 22 German centres) and eventually identified MHV-patients (n = 137) with anticoagulation-associated ICH for outcome analyses. The primary outcome consisted of major haemorrhagic complications analysed during hospital stay according to treatment exposure (restarted TA vs. no-TA). Secondary outcomes comprised thromboembolic complications, the composite outcome (haemorrhagic and thromboembolic complications), timing of TA, and mortality. Adjusted analyses involved propensity-score matching and multivariable cox-regressions to identify optimal timing of TA. In 66/137 (48%) of patients TA was restarted, being associated with increased haemorrhagic (TA = 17/66 (26%) vs. no-TA = 4/71 (6%); P < 0.01) and a trend to decreased thromboembolic complications (TA = 1/66 (2%) vs. no-TA = 7/71 (10%); P = 0.06). Controlling treatment crossovers provided an incidence rate-ratio [hazard ratio (HR) 10.31, 95% confidence interval (CI) 3.67–35.70; P < 0.01] in disadvantage of TA for haemorrhagic complications. Analyses of TA-timing displayed significant harm until Day 13 after ICH (HR 7.06, 95% CI 2.33–21.37; P < 0.01). The hazard for the composite—balancing both complications, was increased for restarted TA until Day 6 (HR 2.51, 95% CI 1.10–5.70; P = 0.03). Conclusion Restarting TA within less than 2 weeks after ICH in patients with MHV was associated with increased haemorrhagic complications. Optimal weighing—between least risks for thromboembolic and haemorrhagic complications—provided an earliest starting point of TA at Day 6, reserved only for patients at high thromboembolic risk. ![]()
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Affiliation(s)
- Joji B Kuramatsu
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Jochen A Sembill
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Stefan T Gerner
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Maximilian I Sprügel
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Manuel Hagen
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Sebastian S Roeder
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Matthias Endres
- Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, Berlin 10117, Germany.,Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Charitéplatz 1, Berlin 10117, Germany.,German Centre for Cardiovascular Research (DZHK), Oudenarder Straße 16, Berlin 13347, Germany.,German Center for Neurodegenerative Diseases (DZNE), partner site Berlin, Charitéplatz 1, Berlin 10117, Germany
| | - Karl Georg Haeusler
- Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, Berlin 10117, Germany.,Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Charitéplatz 1, Berlin 10117, Germany
| | - Jan Sobesky
- Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, Berlin 10117, Germany.,Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Charitéplatz 1, Berlin 10117, Germany
| | - Johannes Schurig
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Charitéplatz 1, Berlin 10117, Germany
| | - Sarah Zweynert
- Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, Berlin 10117, Germany
| | - Miriam Bauer
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Charitéplatz 1, Berlin 10117, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, Berlin 13353, Germany
| | - Peter A Ringleb
- Department of Neurology, Heidelberg University Hospital, INF 400, Heidelberg 69120, Germany
| | - Jan Purrucker
- Department of Neurology, Heidelberg University Hospital, INF 400, Heidelberg 69120, Germany
| | - Timolaos Rizos
- Department of Neurology, Heidelberg University Hospital, INF 400, Heidelberg 69120, Germany
| | - Jens Volkmann
- Department of Neurology, University of Würzburg, Josef-Schneider-Straße 11, Würzburg 97080, Germany
| | - Wolfgang Müllges
- Department of Neurology, University of Würzburg, Josef-Schneider-Straße 11, Würzburg 97080, Germany
| | - Peter Kraft
- Department of Neurology, University of Würzburg, Josef-Schneider-Straße 11, Würzburg 97080, Germany
| | - Anna-Lena Schubert
- Department of Neurology, University of Würzburg, Josef-Schneider-Straße 11, Würzburg 97080, Germany
| | - Frank Erbguth
- Department of Neurology, Community Hospital Nuremberg, Breslauer Str. 201, Nuremberg 90471, Germany
| | - Martin Nueckel
- Department of Neurology, Community Hospital Nuremberg, Breslauer Str. 201, Nuremberg 90471, Germany
| | - Peter D Schellinger
- Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center Minden, UK RUB, Hans-Nolte-Str. 1, Minden 32429, Germany
| | - Jörg Glahn
- Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center Minden, UK RUB, Hans-Nolte-Str. 1, Minden 32429, Germany
| | - Ulrich J Knappe
- Department of Neurosurgery, Johannes Wesling Medical Center Minden, UK RUB, Hans-Nolte-Str. 1, Minden 32429, Germany
| | - Gereon R Fink
- Department of Neurology, University of Cologne, Kerpener Str. 62, Cologne 50937, Germany
| | - Christian Dohmen
- Department of Neurology, University of Cologne, Kerpener Str. 62, Cologne 50937, Germany
| | - Henning Stetefeld
- Department of Neurology, University of Cologne, Kerpener Str. 62, Cologne 50937, Germany
| | - Anna Lena Fisse
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, Münster 48149, Germany
| | - Jens Minnerup
- Department of Neurology, University of Münster, Albert-Schweitzer-Campus 1, Münster 48149, Germany
| | - Georg Hagemann
- Department of Neurology, Community Hospital Helios Klinikum Berlin-Buch, Schwanebecker Chaussee 50, Berlin 13125, Germany
| | - Florian Rakers
- Department of Neurology, Community Hospital Helios Klinikum Berlin-Buch, Schwanebecker Chaussee 50, Berlin 13125, Germany
| | - Heinz Reichmann
- Department of Neurology, University of Dresden, Fetscherstr. 74, Dresden 01307, Germany
| | - Hauke Schneider
- Department of Neurology, University of Dresden, Fetscherstr. 74, Dresden 01307, Germany
| | - Sigrid Wöpking
- Department of Neurology, University of Dresden, Fetscherstr. 74, Dresden 01307, Germany
| | | | - Sebastian Stösser
- Department of Neurology, University of Ulm, Oberer Eselsberg 45, Ulm 89081, Germany
| | - Hermann Neugebauer
- Department of Neurology, University of Ulm, Oberer Eselsberg 45, Ulm 89081, Germany
| | - Joachim Röther
- Department of Neurology, Community Hospital Asklepios Klinik Hamburg Altona, Paul Ehrlich-Strasse 1, Hamburg 22763, Germany
| | - Peter Michels
- Department of Neurology, Community Hospital Asklepios Klinik Hamburg Altona, Paul Ehrlich-Strasse 1, Hamburg 22763, Germany
| | - Michael Schwarz
- Department of Neurology, Community Hospital Klinikum Dortmund, Beurhausstraße 40, Dortmund 44137, Germany
| | - Gernot Reimann
- Department of Neurology, Community Hospital Klinikum Dortmund, Beurhausstraße 40, Dortmund 44137, Germany
| | - Hansjörg Bäzner
- Department of Neurology, Community Hospital Klinikum Stuttgart, Kriegsbergstrasse 60, Stuttgart 70174, Germany
| | - Henning Schwert
- Department of Neurology, Community Hospital Klinikum Stuttgart, Kriegsbergstrasse 60, Stuttgart 70174, Germany
| | - Joseph Claßen
- Department of Neurology, University of Leipzig, Liebigstr. 20, Leipzig 04103, Germany
| | - Dominik Michalski
- Department of Neurology, University of Leipzig, Liebigstr. 20, Leipzig 04103, Germany
| | - Armin Grau
- Department of Neurology, Community Hospital Klinikum der Stadt Ludwigshafen am Rhein, Bremserstraße 79, Ludwigshafen 67063, Germany
| | - Frederick Palm
- Department of Neurology, Community Hospital Klinikum der Stadt Ludwigshafen am Rhein, Bremserstraße 79, Ludwigshafen 67063, Germany
| | - Christian Urbanek
- Department of Neurology, Community Hospital Klinikum der Stadt Ludwigshafen am Rhein, Bremserstraße 79, Ludwigshafen 67063, Germany
| | - Johannes C Wöhrle
- Department of Neurology, Community Hospital Klinikum Koblenz, Kardinal-Krementz-Str. 1-5, Koblenz 56073, Germany
| | - Fahid Alshammari
- Department of Neurology, Community Hospital Klinikum Koblenz, Kardinal-Krementz-Str. 1-5, Koblenz 56073, Germany
| | - Markus Horn
- Department of Neurology, Community Hospital Bad Hersfeld, Seilerweg 29, Bad Hersfeld 36251, Germany
| | - Dirk Bahner
- Department of Neurology, Community Hospital Bad Hersfeld, Seilerweg 29, Bad Hersfeld 36251, Germany
| | - Otto W Witte
- Department of Neurology, University of Jena, Erlanger Allee 101, Jena 07747, Germany
| | - Albrecht Günther
- Department of Neurology, University of Jena, Erlanger Allee 101, Jena 07747, Germany
| | - Gerhard F Hamann
- Department of Neurology and Neurological Rehabilitation, Bezirkskrankenhaus Günzburg, Ludwig-Heilmeyer-Straße 2, 89312 Günzburg, Germany
| | - Hannes Lücking
- Department of Neuroradiology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Arnd Dörfler
- Department of Neuroradiology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Stephan Achenbach
- Department of Cardiology, University of Erlangen-Nuremberg, Ulmenweg 18, Erlangen 91054, Germany
| | - Stefan Schwab
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Hagen B Huttner
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
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27
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Kuramatsu JB, Biffi A, Gerner ST, Sembill JA, Sprügel MI, Leasure A, Sansing L, Matouk C, Falcone GJ, Endres M, Haeusler KG, Sobesky J, Schurig J, Zweynert S, Bauer M, Vajkoczy P, Ringleb PA, Purrucker J, Rizos T, Volkmann J, Müllges W, Kraft P, Schubert AL, Erbguth F, Nueckel M, Schellinger PD, Glahn J, Knappe UJ, Fink GR, Dohmen C, Stetefeld H, Fisse AL, Minnerup J, Hagemann G, Rakers F, Reichmann H, Schneider H, Rahmig J, Ludolph AC, Stösser S, Neugebauer H, Röther J, Michels P, Schwarz M, Reimann G, Bäzner H, Schwert H, Claßen J, Michalski D, Grau A, Palm F, Urbanek C, Wöhrle JC, Alshammari F, Horn M, Bahner D, Witte OW, Günther A, Hamann GF, Hagen M, Roeder SS, Lücking H, Dörfler A, Testai FD, Woo D, Schwab S, Sheth KN, Huttner HB. Association of Surgical Hematoma Evacuation vs Conservative Treatment With Functional Outcome in Patients With Cerebellar Intracerebral Hemorrhage. JAMA 2019; 322:1392-1403. [PMID: 31593272 PMCID: PMC6784768 DOI: 10.1001/jama.2019.13014] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 08/07/2019] [Indexed: 01/05/2023]
Abstract
Importance The association of surgical hematoma evacuation with clinical outcomes in patients with cerebellar intracerebral hemorrhage (ICH) has not been established. Objective To determine the association of surgical hematoma evacuation with clinical outcomes in cerebellar ICH. Design, Setting, and Participants Individual participant data (IPD) meta-analysis of 4 observational ICH studies incorporating 6580 patients treated at 64 hospitals across the United States and Germany (2006-2015). Exposure Surgical hematoma evacuation vs conservative treatment. Main Outcomes and Measures The primary outcome was functional disability evaluated by the modified Rankin Scale ([mRS] score range: 0, no functional deficit to 6, death) at 3 months; favorable (mRS, 0-3) vs unfavorable (mRS, 4-6). Secondary outcomes included survival at 3 months and at 12 months. Analyses included propensity score matching and covariate adjustment, and predicted probabilities were used to identify treatment-related cutoff values for cerebellar ICH. Results Among 578 patients with cerebellar ICH, propensity score-matched groups included 152 patients with surgical hematoma evacuation vs 152 patients with conservative treatment (age, 68.9 vs 69.2 years; men, 55.9% vs 51.3%; prior anticoagulation, 60.5% vs 63.8%; and median ICH volume, 20.5 cm3 vs 18.8 cm3). After adjustment, surgical hematoma evacuation vs conservative treatment was not significantly associated with likelihood of better functional disability at 3 months (30.9% vs 35.5%; adjusted odds ratio [AOR], 0.94 [95% CI, 0.81 to 1.09], P = .43; adjusted risk difference [ARD], -3.7% [95% CI, -8.7% to 1.2%]) but was significantly associated with greater probability of survival at 3 months (78.3% vs 61.2%; AOR, 1.25 [95% CI, 1.07 to 1.45], P = .005; ARD, 18.5% [95% CI, 13.8% to 23.2%]) and at 12 months (71.7% vs 57.2%; AOR, 1.21 [95% CI, 1.03 to 1.42], P = .02; ARD, 17.0% [95% CI, 11.5% to 22.6%]). A volume range of 12 to 15 cm3 was identified; below this level, surgical hematoma evacuation was associated with lower likelihood of favorable functional outcome (volume ≤12 cm3, 30.6% vs 62.3% [P = .003]; ARD, -34.7% [-38.8% to -30.6%]; P value for interaction, .01), and above, it was associated with greater likelihood of survival (volume ≥15 cm3, 74.5% vs 45.1% [P < .001]; ARD, 28.2% [95% CI, 24.6% to 31.8%]; P value for interaction, .02). Conclusions and Relevance Among patients with cerebellar ICH, surgical hematoma evacuation, compared with conservative treatment, was not associated with improved functional outcome. Given the null primary outcome, investigation is necessary to establish whether there are differing associations based on hematoma volume.
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Affiliation(s)
- Joji B. Kuramatsu
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Alessandro Biffi
- Department of Neurology, Massachusetts General Hospital, Boston
- Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center, Boston, Massachusetts
| | - Stefan T. Gerner
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Jochen A. Sembill
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | | | - Audrey Leasure
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Lauren Sansing
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Charles Matouk
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Guido J. Falcone
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Matthias Endres
- Department of Neurology, Charité—Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), partner site Berlin, Berlin, Germany
| | - Karl Georg Haeusler
- Department of Neurology, Charité—Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology, University of Würzburg, Würzburg, Germany
| | - Jan Sobesky
- Department of Neurology, Charité—Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Johannes Schurig
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Sarah Zweynert
- Department of Neurology, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Miriam Bauer
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Peter A. Ringleb
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jan Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Timolaos Rizos
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
- Department of Neurology, Alfried Krupp Krankenhaus Essen, Essen, Germany
| | - Jens Volkmann
- Department of Neurology, University of Würzburg, Würzburg, Germany
| | - Wolfgang Müllges
- Department of Neurology, University of Würzburg, Würzburg, Germany
| | - Peter Kraft
- Department of Neurology, University of Würzburg, Würzburg, Germany
| | | | - Frank Erbguth
- Department of Neurology, Community Hospital Nuremberg, Nuremberg, Germany
| | - Martin Nueckel
- Department of Neurology, Community Hospital Nuremberg, Nuremberg, Germany
| | - Peter D. Schellinger
- Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center Minden, UK RUB, Minden, Germany
| | - Jörg Glahn
- Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center Minden, UK RUB, Minden, Germany
| | - Ulrich J. Knappe
- Department of Neurosurgery, Johannes Wesling Medical Center Minden, UK RUB, Minden, Germany
| | - Gereon R. Fink
- Department of Neurology, University of Cologne, Cologne, Germany
| | - Christian Dohmen
- Department of Neurology, University of Cologne, Cologne, Germany
| | | | - Anna Lena Fisse
- Department of Neurology, University of Münster, Münster, Germany
| | - Jens Minnerup
- Department of Neurology, University of Münster, Münster, Germany
| | - Georg Hagemann
- Department of Neurology, Community Hospital Helios Klinikum Berlin-Buch, Berlin, Germany
| | - Florian Rakers
- Department of Neurology, Community Hospital Helios Klinikum Berlin-Buch, Berlin, Germany
| | - Heinz Reichmann
- Department of Neurology, University of Dresden, Dresden, Germany
| | - Hauke Schneider
- Department of Neurology, University of Dresden, Dresden, Germany
- Department of Neurology, Klinikum Augsburg, Augsburg, Germany
| | - Jan Rahmig
- Department of Neurology, University of Dresden, Dresden, Germany
| | | | | | - Hermann Neugebauer
- Department of Neurology, University of Würzburg, Würzburg, Germany
- Department of Neurology, University of Ulm, Ulm, Germany
| | - Joachim Röther
- Department of Neurology, Community Hospital Asklepios Klinik Hamburg Altona, Hamburg, Germany
| | - Peter Michels
- Department of Neurology, Community Hospital Asklepios Klinik Hamburg Altona, Hamburg, Germany
| | - Michael Schwarz
- Department of Neurology, Community Hospital Klinikum Dortmund, Dortmund, Germany
| | - Gernot Reimann
- Department of Neurology, Community Hospital Klinikum Dortmund, Dortmund, Germany
| | - Hansjörg Bäzner
- Department of Neurology, Community Hospital Klinikum Stuttgart, Stuttgart, Germany
| | - Henning Schwert
- Department of Neurology, Community Hospital Klinikum Stuttgart, Stuttgart, Germany
| | - Joseph Claßen
- Department of Neurology, University of Leipzig, Leipzig, Germany
| | | | - Armin Grau
- Department of Neurology, Community Hospital Klinikum der Stadt Ludwigshafen am Rhein, Ludwigshafen, Germany
| | - Frederick Palm
- Department of Neurology, Community Hospital Klinikum der Stadt Ludwigshafen am Rhein, Ludwigshafen, Germany
| | - Christian Urbanek
- Department of Neurology, Community Hospital Klinikum der Stadt Ludwigshafen am Rhein, Ludwigshafen, Germany
| | - Johannes C. Wöhrle
- Department of Neurology, Community Hospital Klinikum Koblenz, Koblenz, Germany
| | - Fahid Alshammari
- Department of Neurology, Community Hospital Klinikum Koblenz, Koblenz, Germany
| | - Markus Horn
- Department of Neurology, Community Hospital Bad Hersfeld, Bad Hersfeld, Germany
| | - Dirk Bahner
- Department of Neurology, Community Hospital Bad Hersfeld, Bad Hersfeld, Germany
| | - Otto W. Witte
- Department of Neurology, University of Jena, Jena, Germany
| | | | - Gerhard F. Hamann
- Department of Neurology and Neurological Rehabilitation, Bezirkskrankenhaus Günzburg, Günzburg, Germany
| | - Manuel Hagen
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Sebastian S. Roeder
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Hannes Lücking
- Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Arnd Dörfler
- Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Fernando D. Testai
- Department of Neurology and Rehabilitation, University of Illinois College of Medicine, Chicago
| | - Daniel Woo
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Stefan Schwab
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Kevin N. Sheth
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Hagen B. Huttner
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
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Ravindren J, Aguilar Pérez M, Hellstern V, Bhogal P, Bäzner H, Henkes H. Predictors of Outcome After Endovascular Thrombectomy in Acute Basilar Artery Occlusion and the 6hr Time Window to Recanalization. Front Neurol 2019; 10:923. [PMID: 31608001 PMCID: PMC6773802 DOI: 10.3389/fneur.2019.00923] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 08/09/2019] [Indexed: 12/20/2022] Open
Abstract
Background and Purpose: Decision algorithms for large vessel occlusions in the anterior circulation remain unconfirmed for acute basilar artery occlusion (aBAO). The aim of this study was to investigate procedural parameters, patient characteristics, functional outcome, and survival in dependency of the time window to recanalization from symptom onset. Furthermore predictors of outcome were identified. Materials and Methods: Retrospectively 231 patients with aBAO treated with endovascular treatment (EVT) between November 2008 and February 2019 were identified in a prospectively maintained single center stroke database. Baseline characteristics such as age, cardiovascular risk factors, NIHSS at admission, pre-interventional PC-ASPECTS, periprocedural parameters such as time to recanalization, duration of treatment, extent of reperfusion, collateral status, and occlusion patterns, as well as post-interventional 24 h NIHSS and post-interventional ICH were evaluated. Target variables were mRS at 90 days and mortality over 90 days. Results: Good outcome (mRS 0–2) was attained in 29.5% (n = 68) of patients, overall mortality was 36.8% (n = 85). In mulitivariate analyses patients with time to reperfusion beyond 6 h had a more than half fold decreased chance of good outcome [OR 0.47 95% CI (0.23–0.95) p < 0.05]. The odds for good outcome were reduced by almost 2/3 if post-interventional imaging revealed intracerebral hemorrhage [OR 0.28 95% CI (0.08–0.98)]. Unfavorable outcome was noted in 100% (n = 14) of patients with symptomatic ICH. Risk for death was reduced by more than 80% if collaterals were present [0.16 95% CI (0.03–0.87)] and if recanalization was successful (TICI 2b-3) [OR 0.19 95% CI (0.05–0.78)]. The odds for survival were 5-fold higher in patients with no post-interventional hemorrhages present [OR 5.35 95% CI (2.2–1.58)]. Conclusion: This study might contribute to explaining the ambiguous findings regarding the validity of the 6 h time window in aBAO, suggesting that collateral status impacts the odds of survival in the time window to recanalization beyond 6 h. In our study recanalization within 6 h from symptom onset was associated with good outcome. Successful recanalization (TICI 2b-3a) was necessary for good outcome and survival, post-interventional ICH was highly associated with unfavorable outcome. This might ease the decision making for EVT.
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Affiliation(s)
- Johannes Ravindren
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany.,Neurological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Marta Aguilar Pérez
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Victoria Hellstern
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Pervinder Bhogal
- Department of Neuroradiology, St Bartholomew's Hospital, London, United Kingdom
| | - Hansjörg Bäzner
- Neurological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany.,Medical Faculty, University Duisburg-Essen, Essen, Germany
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29
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Sprügel MI, Sembill JA, Kuramatsu JB, Gerner ST, Hagen M, Roeder SS, Endres M, Haeusler KG, Sobesky J, Schurig J, Zweynert S, Bauer M, Vajkoczy P, Ringleb PA, Purrucker JC, Rizos T, Volkmann J, Muellges W, Kraft P, Schubert AL, Erbguth F, Nueckel M, Schellinger PD, Glahn J, Knappe UJ, Fink GR, Dohmen C, Stetefeld H, Fisse AL, Minnerup J, Hagemann G, Rakers F, Reichmann H, Schneider H, Wöpking S, Ludolph AC, Stösser S, Neugebauer H, Röther J, Michels P, Schwarz M, Reimann G, Bäzner H, Schwert H, Classen J, Michalski D, Grau A, Palm F, Urbanek C, Wöhrle JC, Alshammari F, Horn M, Bahner D, Witte OW, Guenther A, Hamann GF, Lücking H, Dörfler A, Schwab S, Huttner HB. Heparin for prophylaxis of venous thromboembolism in intracerebral haemorrhage. J Neurol Neurosurg Psychiatry 2019; 90:783-791. [PMID: 30992334 DOI: 10.1136/jnnp-2018-319786] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 01/23/2019] [Accepted: 02/07/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To determine the occurrence of intracranial haemorrhagic complications (IHC) on heparin prophylaxis (low-dose subcutaneous heparin, LDSH) in primary spontaneous intracerebral haemorrhage (ICH) (not oral anticoagulation-associated ICH, non-OAC-ICH), vitamin K antagonist (VKA)-associated ICH and non-vitamin K antagonist oral anticoagulant (NOAC)-associated ICH. METHODS Retrospective cohort study (RETRACE) of 22 participating centres and prospective single-centre study with 1702 patients with VKA-associated or NOAC-associated ICH and 1022 patients with non-OAC-ICH with heparin prophylaxis between 2006 and 2015. Outcomes were defined as rates of IHC during hospital stay among patients with non-OAC-ICH, VKA-ICH and NOAC-ICH, mortality and functional outcome at 3 months between patients with ICH with and without IHC. RESULTS IHC occurred in 1.7% (42/2416) of patients with ICH. There were no differences in crude incidence rates among patients with VKA-ICH, NOAC-ICH and non-OAC-ICH (log-rank p=0.645; VKA-ICH: 27/1406 (1.9%), NOAC-ICH 1/130 (0.8%), non-OAC-ICH 14/880 (1.6%); p=0.577). Detailed analysis according to treatment exposure (days with and without LDSH) revealed no differences in incidence rates of IHC per 1000 patient-days (LDSH: 1.43 (1.04-1.93) vs non-LDSH: 1.32 (0.33-3.58), conditional maximum likelihood incidence rate ratio: 1.09 (0.38-4.43); p=0.953). Secondary outcomes showed differences in functional outcome (modified Rankin Scale=4-6: IHC: 29/37 (78.4%) vs non-IHC: 1213/2048 (59.2%); p=0.019) and mortality (IHC: 14/37 (37.8%) vs non-IHC: 485/2048 (23.7%); p=0.045) in disfavour of patients with IHC. Small ICH volume (OR: volume <4.4 mL: 0.18 (0.04-0.78); p=0.022) and low National Institutes of Health Stroke Scale (NIHSS) score on admission (OR: NIHSS <4: 0.29 (0.11-0.78); p=0.014) were significantly associated with fewer IHC. CONCLUSIONS Heparin administration for venous thromboembolism (VTE) prophylaxis in patients with ICH appears to be safe regarding IHC among non-OAC-ICH, VKA-ICH and NOAC-ICH in this observational cohort analysis. Randomised controlled trials are needed to verify the safety and efficacy of heparin compared with other methods for VTE prevention.
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Affiliation(s)
| | | | | | - Stefan T Gerner
- Neurology, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Manuel Hagen
- Neurology, University of Erlangen-Nürnberg, Erlangen, Germany
| | | | - Matthias Endres
- Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Jan Sobesky
- Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Sarah Zweynert
- Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Miriam Bauer
- Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Vajkoczy
- Neurosurgery, Charité-Universitäts medizin Berlin, Berlin, Germany
| | | | | | - Timolaos Rizos
- Neurology, University of Heidelberg, Heidelberg, Germany
| | - Jens Volkmann
- Neurology, University of Würzburg, Würzburg, Germany
| | | | - Peter Kraft
- Neurology, University of Würzburg, Würzburg, Germany
| | | | - Frank Erbguth
- Neurology, Paracelsus Medical University, Nürnberg, Germany
| | - Martin Nueckel
- Neurology, Paracelsus Medical University, Nürnberg, Germany
| | - Peter D Schellinger
- Neurology, Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany
| | - Jörg Glahn
- Neurology, Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany
| | - Ulrich J Knappe
- Neurosurgery, Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany
| | | | | | | | | | | | - Georg Hagemann
- Neurology, Community Hospital Berlin-Buch, Berlin, Germany
| | - Florian Rakers
- Neurology, Community Hospital Berlin-Buch, Berlin, Germany
| | | | | | | | | | | | | | - Joachim Röther
- Neurology, Community Hospital Hamburg Altona, Hamburg, Germany
| | - Peter Michels
- Neurology, Community Hospital Hamburg Altona, Hamburg, Germany
| | | | - Gernot Reimann
- Neurology, Community Hospital Dortmund, Dortmund, Germany
| | | | | | | | | | - Armin Grau
- Neurology, Community Hospital Ludwigshafen, Ludwigshafen, Germany
| | - Frederick Palm
- Neurology, Community Hospital Ludwigshafen, Ludwigshafen, Germany
| | | | | | | | - Markus Horn
- Neurology, Community Hospital Bad Hersfeld, Bad Hersfeld, Germany
| | - Dirk Bahner
- Neurology, Community Hospital Bad Hersfeld, Bad Hersfeld, Germany
| | | | | | | | - Hannes Lücking
- Neuroradiology, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Arnd Dörfler
- Neuroradiology, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Stefan Schwab
- Neurology, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Hagen B Huttner
- Neurology, University of Erlangen-Nürnberg, Erlangen, Germany
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30
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Bhogal P, AlMatter M, Hellstern V, Pérez MA, Ganslandt O, Bäzner H, Henkes H. Mechanical thrombectomy for recurrent large vessel occlusion. J Clin Neurosci 2019; 66:107-112. [PMID: 31113697 DOI: 10.1016/j.jocn.2019.05.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Revised: 04/13/2019] [Accepted: 05/07/2019] [Indexed: 11/16/2022]
Abstract
Although mechanical thrombectomy (MT) has been shown in numerous trials to be a successful treatment option for patients with large vessel occlusion (LVO), there is limited information on the safety and effectiveness of the technique in cases of recurrent LVO. To this end, we performed a retrospective review of our prospectively maintained database to identify all patients that had undergone more than one MT procedure January 2008 and January 2018. The data collected on these patients included baseline demographics and any history of diabetes mellitus, hypercholesterolaemia, hypertension, atrial fibrillation or smoking. We also recorded when the symptoms had started, the patient's NIHSS and ASPECT scores, the number of passes taken, the patient's final TICI score, any complications which arose and the patient's mRS at 90 days. Our dataset encompassed 25 patients (of which 17 (68%) were female) who had undergone a total number of 52 MT's. Average age at 1st presentation was 70 ± 12.8 years. The median time between one stroke and the next was 71 days (range 1-1059, IQR 183 days). The majority of the strokes were deemed cardioembolic (86.5%) in origin. There was no significant difference in the procedure times, number of passes or TICI scores. There was a significant difference in the mRS after the 1st and 2nd events (p = 0.014) but no significant difference if the 2nd event occurred contralateral to the 1st event (p = 0.66) (n = 22). It is therefore concluded that recurrent thrombectomy can be safely performed with no significant difference in the technical aspects of the procedure.
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Affiliation(s)
- P Bhogal
- The Royal London Hospital, Whitechapel Road, London, UK.
| | - M AlMatter
- Neurological Clinic, Neurocenter, Klinikum Stuttgart, Germany
| | - V Hellstern
- Neurological Clinic, Neurocenter, Klinikum Stuttgart, Germany
| | - M Aguilar Pérez
- Neurological Clinic, Neurocenter, Klinikum Stuttgart, Germany
| | - O Ganslandt
- Neurosurgical Clinic, Neurocenter, Klinikum Stuttgart, Germany
| | - H Bäzner
- Neurological Clinic, Neurocenter, Klinikum Stuttgart, Germany
| | - H Henkes
- Neurological Clinic, Neurocenter, Klinikum Stuttgart, Germany; Medical Faculty, University Duisburg-Essen, Germany
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31
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Gerner ST, Kuramatsu JB, Sembill JA, Sprügel MI, Hagen M, Knappe RU, Endres M, Haeusler KG, Sobesky J, Schurig J, Zweynert S, Bauer M, Vajkoczy P, Ringleb PA, Purrucker JC, Rizos T, Volkmann J, Müllges W, Kraft P, Schubert AL, Erbguth F, Nueckel M, Schellinger PD, Glahn J, Knappe UJ, Fink GR, Dohmen C, Stetefeld H, Fisse AL, Minnerup J, Hagemann G, Rakers F, Reichmann H, Schneider H, Rahmig J, Ludolph AC, Stösser S, Neugebauer H, Röther J, Michels P, Schwarz M, Reimann G, Bäzner H, Schwert H, Claßen J, Michalski D, Grau A, Palm F, Urbanek C, Wöhrle JC, Alshammari F, Horn M, Bahner D, Witte OW, Günther A, Hamann GF, Engelhorn T, Lücking H, Dörfler A, Schwab S, Huttner HB. Characteristics in Non-Vitamin K Antagonist Oral Anticoagulant-Related Intracerebral Hemorrhage. Stroke 2019; 50:1392-1402. [PMID: 31092170 DOI: 10.1161/strokeaha.118.023492] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background and Purpose- Given inconclusive studies, it is debated whether clinical and imaging characteristics, as well as functional outcome, differ among patients with intracerebral hemorrhage (ICH) related to vitamin K antagonists (VKA) versus non-vitamin K antagonist (NOAC)-related ICH. Notably, clinical characteristics according to different NOAC agents and dosages are not established. Methods- Multicenter observational cohort study integrating individual patient data of 1328 patients with oral anticoagulation-associated ICH, including 190 NOAC-related ICH patients, recruited from 2011 to 2015 at 19 tertiary centers across Germany. Imaging, clinical characteristics, and 3-months modified Rankin Scale (mRS) outcomes were compared in NOAC- versus VKA-related ICH patients. Propensity score matching was conducted to adjust for clinically relevant differences in baseline parameters. Subgroup analyses were performed regarding NOAC agent, dosing and present clinically relevant anticoagulatory activity (last intake <12h/24h or NOAC level >30 ng/mL). Results- Despite older age in NOAC patients, there were no relevant differences in clinical and hematoma characteristics between NOAC- and VKA-related ICH regarding baseline hematoma volume (median [interquartile range]: NOAC, 14.7 [5.1-42.3] mL versus VKA, 16.4 [5.8-40.6] mL; P=0.33), rate of hematoma expansion (NOAC, 49/146 [33.6%] versus VKA, 235/688 [34.2%]; P=0.89), and the proportion of patients with unfavorable outcome at 3 months (mRS, 4-6: NOAC 126/179 [70.4%] versus VKA 473/682 [69.4%]; P=0.79). Subgroup analyses revealed that NOAC patients with clinically relevant anticoagulatory effect had higher rates of intraventricular hemorrhage (n/N [%]: present 52/109 [47.7%] versus absent 9/35 [25.7%]; P=0.022) and hematoma expansion (present 35/90 [38.9%] versus absent 5/30 [16.7%]; P=0.040), whereas type of NOAC agent or different NOAC-dosing regimens did not result in relevant differences in imaging characteristics or outcome. Conclusions- If effectively anticoagulated, there are no differences in hematoma characteristics and functional outcome among patients with NOAC- or VKA-related ICH. Clinical Trial Registration- URL: https://www.clinicaltrials.gov . Unique identifier: NCT03093233.
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Affiliation(s)
- Stefan T Gerner
- From the Department of Neurology (S.T.G., J.B.K., J.A.S., M.I.S., M. Hagen, R.U.K., S. Schwab, H.B.H.), University of Erlangen-Nuremberg, Germany
| | - Joji B Kuramatsu
- From the Department of Neurology (S.T.G., J.B.K., J.A.S., M.I.S., M. Hagen, R.U.K., S. Schwab, H.B.H.), University of Erlangen-Nuremberg, Germany
| | - Jochen A Sembill
- From the Department of Neurology (S.T.G., J.B.K., J.A.S., M.I.S., M. Hagen, R.U.K., S. Schwab, H.B.H.), University of Erlangen-Nuremberg, Germany
| | - Maximilian I Sprügel
- From the Department of Neurology (S.T.G., J.B.K., J.A.S., M.I.S., M. Hagen, R.U.K., S. Schwab, H.B.H.), University of Erlangen-Nuremberg, Germany
| | - Manuel Hagen
- From the Department of Neurology (S.T.G., J.B.K., J.A.S., M.I.S., M. Hagen, R.U.K., S. Schwab, H.B.H.), University of Erlangen-Nuremberg, Germany
| | - Ruben U Knappe
- From the Department of Neurology (S.T.G., J.B.K., J.A.S., M.I.S., M. Hagen, R.U.K., S. Schwab, H.B.H.), University of Erlangen-Nuremberg, Germany
| | - Matthias Endres
- Department of Neurology (M.E., K.G.H., J. Sobesky, S.Z.), Charité-Universitätsmedizin Berlin, Germany.,Center for Stroke Research Berlin, Berlin, Germany (M.E., K.G.H., J. Sobesky, J. Schurig, M.B.).,German Centre for Cardiovascular Research (DZHK), Oudenarder Straße, Berlin (M.E.).,German Center for Neurodegenerative Diseases (DZNE), partner site Berlin (M.E.)
| | - Karl Georg Haeusler
- Department of Neurology (M.E., K.G.H., J. Sobesky, S.Z.), Charité-Universitätsmedizin Berlin, Germany.,Center for Stroke Research Berlin, Berlin, Germany (M.E., K.G.H., J. Sobesky, J. Schurig, M.B.).,Department of Neurology, University of Würzburg, Germany (K.G.H., J.V., W.M., P.K., A.-L.S.)
| | - Jan Sobesky
- Department of Neurology (M.E., K.G.H., J. Sobesky, S.Z.), Charité-Universitätsmedizin Berlin, Germany.,Center for Stroke Research Berlin, Berlin, Germany (M.E., K.G.H., J. Sobesky, J. Schurig, M.B.)
| | - Johannes Schurig
- Center for Stroke Research Berlin, Berlin, Germany (M.E., K.G.H., J. Sobesky, J. Schurig, M.B.)
| | - Sarah Zweynert
- Department of Neurology (M.E., K.G.H., J. Sobesky, S.Z.), Charité-Universitätsmedizin Berlin, Germany
| | - Miriam Bauer
- Center for Stroke Research Berlin, Berlin, Germany (M.E., K.G.H., J. Sobesky, J. Schurig, M.B.)
| | - Peter Vajkoczy
- Department of Neurosurgery (P.V.), Charité-Universitätsmedizin Berlin, Germany
| | - Peter A Ringleb
- Department of Neurology, Heidelberg University Hospital, Germany (P.A.R., J.C.B., T.R.)
| | - Jan C Purrucker
- Department of Neurology, Heidelberg University Hospital, Germany (P.A.R., J.C.B., T.R.)
| | - Timolaos Rizos
- Department of Neurology, Heidelberg University Hospital, Germany (P.A.R., J.C.B., T.R.)
| | - Jens Volkmann
- Department of Neurology, University of Würzburg, Germany (K.G.H., J.V., W.M., P.K., A.-L.S.)
| | - Wolfgang Müllges
- Department of Neurology, University of Würzburg, Germany (K.G.H., J.V., W.M., P.K., A.-L.S.)
| | - Peter Kraft
- Department of Neurology, University of Würzburg, Germany (K.G.H., J.V., W.M., P.K., A.-L.S.)
| | - Anna-Lena Schubert
- Department of Neurology, University of Würzburg, Germany (K.G.H., J.V., W.M., P.K., A.-L.S.)
| | - Frank Erbguth
- Department of Neurology, Community Hospital Nuremberg, Germany (F.E., M.N.)
| | - Martin Nueckel
- Department of Neurology, Community Hospital Nuremberg, Germany (F.E., M.N.)
| | | | - Jörg Glahn
- Department of Neurology and Neurogeriatry (P.D.S., J.G.)
| | - Ulrich J Knappe
- Department of Neurosurgery, Johannes Wesling Medical Center Minden, University Clinic Ruhr University Bochum, Germany (U.J.K.)
| | - Gereon R Fink
- Department of Neurology, University of Cologne, Germany (G.R.F. C.D., H. Stetefeld)
| | - Christian Dohmen
- Department of Neurology, University of Cologne, Germany (G.R.F. C.D., H. Stetefeld).,Department of Neurology, LVR Klinik Bonn, Germany (C.D.)
| | - Henning Stetefeld
- Department of Neurology, University of Cologne, Germany (G.R.F. C.D., H. Stetefeld)
| | - Anna Lena Fisse
- Department of Neurology, University of Münster, Germany (A.L.F., J.M.)
| | - Jens Minnerup
- Department of Neurology, University of Münster, Germany (A.L.F., J.M.)
| | - Georg Hagemann
- Department of Neurology, Community Hospital Helios Klinikum Berlin-Buch, Germany (G.H., F.R.)
| | - Florian Rakers
- Department of Neurology, Community Hospital Helios Klinikum Berlin-Buch, Germany (G.H., F.R.)
| | - Heinz Reichmann
- Department of Neurology, University of Dresden, Germany (H.R., H. Schneider, J. Rahmig).,Department of Neurology, Klinikum Augsburg, Germany (H. Schneider)
| | - Hauke Schneider
- Department of Neurology, University of Dresden, Germany (H.R., H. Schneider, J. Rahmig)
| | - Jan Rahmig
- Department of Neurology, University of Dresden, Germany (H.R., H. Schneider, J. Rahmig)
| | | | - Sebastian Stösser
- Department of Neurology, University of Ulm, Germany (A.C.L., S. Stösser, H.N.)
| | - Hermann Neugebauer
- Department of Neurology, University of Ulm, Germany (A.C.L., S. Stösser, H.N.)
| | - Joachim Röther
- Department of Neurology, Community Hospital Asklepios Klinik Hamburg Altona, Germany (J. Röther, P.M.)
| | - Peter Michels
- Department of Neurology, Community Hospital Asklepios Klinik Hamburg Altona, Germany (J. Röther, P.M.)
| | - Michael Schwarz
- Department of Neurology, Community Hospital Klinikum Dortmund, Germany (M.S., G.R.)
| | - Gernot Reimann
- Department of Neurology, Community Hospital Klinikum Dortmund, Germany (M.S., G.R.)
| | - Hansjörg Bäzner
- Department of Neurology, Community Hospital Klinikum Stuttgart, Germany (H.B., H. Schwert)
| | - Henning Schwert
- Department of Neurology, Community Hospital Klinikum Stuttgart, Germany (H.B., H. Schwert)
| | - Joseph Claßen
- Department of Neurology, University of Leipzig, Germany (J.C., D.M.)
| | - Dominik Michalski
- Department of Neurology, University of Leipzig, Germany (J.C., D.M.)
| | - Armin Grau
- Department of Neurology, Community Hospital Klinikum der Stadt Ludwigshafen am Rhein, Germany (A. Grau, F.P., C.U.)
| | - Frederick Palm
- Department of Neurology, Community Hospital Klinikum der Stadt Ludwigshafen am Rhein, Germany (A. Grau, F.P., C.U.)
| | - Christian Urbanek
- Department of Neurology, Community Hospital Klinikum der Stadt Ludwigshafen am Rhein, Germany (A. Grau, F.P., C.U.)
| | - Johannes C Wöhrle
- Department of Neurology, Community Hospital Klinikum Koblenz, Germany (J.C.W., F.A.)
| | - Fahid Alshammari
- Department of Neurology, Community Hospital Klinikum Koblenz, Germany (J.C.W., F.A.)
| | - Markus Horn
- Department of Neurology, Community Hospital Bad Hersfeld, Germany (M. Horn, D.B.)
| | - Dirk Bahner
- Department of Neurology, Community Hospital Bad Hersfeld, Germany (M. Horn, D.B.)
| | - Otto W Witte
- Department of Neurology, University of Jena, Germany (O.W.W., A. Günther)
| | - Albrecht Günther
- Department of Neurology, University of Jena, Germany (O.W.W., A. Günther)
| | - Gerhard F Hamann
- Department of Neurology and Neurological Rehabilitation, Bezirkskrankenhaus Günzburg, Germany (J.F.H.)
| | - Tobias Engelhorn
- Department of Neuroradiology (T.E., H.L., A.D.), University of Erlangen-Nuremberg, Germany
| | - Hannes Lücking
- Department of Neuroradiology (T.E., H.L., A.D.), University of Erlangen-Nuremberg, Germany
| | - Arnd Dörfler
- Department of Neuroradiology (T.E., H.L., A.D.), University of Erlangen-Nuremberg, Germany
| | - Stefan Schwab
- From the Department of Neurology (S.T.G., J.B.K., J.A.S., M.I.S., M. Hagen, R.U.K., S. Schwab, H.B.H.), University of Erlangen-Nuremberg, Germany
| | - Hagen B Huttner
- From the Department of Neurology (S.T.G., J.B.K., J.A.S., M.I.S., M. Hagen, R.U.K., S. Schwab, H.B.H.), University of Erlangen-Nuremberg, Germany
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32
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Bhogal P, AlMatter M, Hellstern V, Pérez MA, Lehmberg J, Ganslandt O, Bäzner H, Henkes H. Basilar artery perforator aneurysms: Report of 9 cases and review of the literature. J Clin Neurosci 2019; 63:122-129. [PMID: 30732987 DOI: 10.1016/j.jocn.2019.01.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Revised: 12/18/2018] [Accepted: 01/18/2019] [Indexed: 10/27/2022]
Abstract
Basilar perforator artery aneurysms (BAPA's) are an under-recognised cause of sub-arachnoid haemorrhage (SAH). We present our single centre experience of BAPA's and review of the literature. We performed a retrospective review of our prospectively maintained database to identify all BAPA's that presented acute SAH between February 2009 and February 2018. We identified 9 patients (male = 7), each with a single aneurysm, and average age 55 ± 9.7 years. All aneurysms were small, 2.1 ± 0.5 mm (range 1-3 mm). Three aneurysms were not detected on initial angiography. Six aneurysms were treated with flow diversion, 3 were managed conservatively. No repeat haemorrhage occurred in the flow diverted patients. One patient treated conservatively suffered a repeat haemorrhage and died (mRS 6). Follow up imaging (n = 7), at average 5.6 months (range 3-12 months), showed complete occlusion in all the flow-diverted aneurysms and no change in one conservatively managed patient. There was no evidence of perforator infarction on the follow-up post treatment imaging. Clinical follow-up data was available in 8 patients, 6 of whom (75%) had a good outcome (mRS ≤ 2). A high index of suspicion is required to diagnose BAPA. Flow diversion can be used to treat BAPA's with acceptable risk of perforator infarction and low risk of repeat haemorrhage.
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Affiliation(s)
- P Bhogal
- Department of Interventional Neuroradiology, The Royal London Hospital, London, UK.
| | - M AlMatter
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Germany
| | - V Hellstern
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Germany
| | - M Aguilar Pérez
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Germany
| | - J Lehmberg
- Klinik für Neurochirurgie, Westpfalz-Klinikum, Kaiserslautern, Germany
| | - O Ganslandt
- Neurochirurgische Klinik, Neurozentrum, Klinikum Stuttgart, Germany
| | - H Bäzner
- Neurologische Klinik, Neurozentrum, Klinikum Stuttgart, Germany
| | - H Henkes
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Germany; Medical Faculty, University Duisburg-Essen, Germany
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Bücke P, Aguilar Pérez M, AlMatter M, Hellstern V, Bäzner H, Henkes H. Functional Outcome and Safety of Intracranial Thrombectomy After Emergent Extracranial Stenting in Acute Ischemic Stroke Due to Tandem Occlusions. Front Neurol 2018; 9:940. [PMID: 30524353 PMCID: PMC6256428 DOI: 10.3389/fneur.2018.00940] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Accepted: 10/17/2018] [Indexed: 12/23/2022] Open
Abstract
Background and Purpose: Various endovascular approaches to treat acute ischemic stroke caused by extra- intracranial tandem occlusions (TO) exist: percutaneous transluminal angioplasty with or without emergent extracranial carotid stenting (ECS) due to high-grade stenosis preceded or followed by intracranial mechanical and/or aspiration thrombectomy (MT). Which treatment strategy to use is still a matter of debate. Methods: From our ongoing prospective stroke registry we retrospectively analyzed 1,071 patients with anterior circulation stroke getting endovascular treatment within 6 h of symptom onset. ECS prior to intracranial MT for TO (n = 222) was compared to MT as standard of care (control group; acute intracranial vessel occlusion without concomitant ipsilateral ICA-occlusion or high-grade stenosis [C; n = 849]). Good functional outcome (mRS ≤ 2 at 3 months), mortality rates, frequencies of symptomatic intracranial hemorrhage (sICH) and successful recanalization (Thrombolysis in Cerebral Infarction Score [TICI] 2b or 3) were assessed. In subgroup analyses we tried to detect possible influences of stroke etiology, dual inhibition of platelet aggregation (IPA; clopidogrel [CLO]: n = 83; ticagrelor [TIC]: n = 137; in combination with Aspirin) and intravenous thrombolysis (IVT). Results: Functional outcome was superior in TO (mRS 0–2: 44.6%) when compared with controls (36.0%; OR [95% CI]: 3.49 [1.59–7.67]; p = 0.002). There was no difference in all-cause mortality at 3 months (TO: 21.6%; C: 27.7%; 0.78 [0.47–1.29]; p = 0.324), in-hospital mortality (0.76 [0.45–1.30]; p = 0.324), sICH (TO: 3.2%; C: 5.0%; 0.70 [0.30–1.59]; p = 0.389), and TICI 2b/3 (TO: 89.1%; C: 88.3%; p = 0.813). In subgroup-analysis, TIC and CLO did not differ in functional outcome (TIC: 45.3%; CLO: 44.6%; 1.04 [0.51–2.09]; p = 0.920) and mortality rates (all-cause mortality: TIC: 23.4%; CLO: 16.9%; 0.75 [0.27–2.13]; p = 0.594). sICH was more frequent in TIC (n = 7 [5.1%]) vs. CLO (n = 0; p = 0.048). Conclusion: In our pre-selected cohort, ECS prior to intracranial MT in TO allowed for a good functional outcome that was superior compared to a control population. Mortality rates did not differ. Despite a dual IPA in TO, there was no increase in sICH. CLO and TIC for dual IPA did not differ in terms out outcome and mortality rates. A significant increase in sICH was observed after initial loading with TIC.
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Affiliation(s)
- Philipp Bücke
- Neurologische Klinik, Klinikum Stuttgart, Stuttgart, Germany
| | | | | | | | - Hansjörg Bäzner
- Neurologische Klinik, Klinikum Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Klinik für Neuroradiologie, Klinikum Stuttgart, Stuttgart, Germany
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Bhogal P, Hellstern V, AlMatter M, Ganslandt O, Bäzner H, Aguilar Pérez M, Henkes H. Mechanical thrombectomy in children and adolescents: report of five cases and literature review. Stroke Vasc Neurol 2018; 3:245-252. [PMID: 30637131 PMCID: PMC6312071 DOI: 10.1136/svn-2018-000181] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 10/01/2018] [Accepted: 10/03/2018] [Indexed: 12/20/2022] Open
Abstract
Background Paediatric arterial ischaemic stroke is an important cause of morbidity and mortality among children. Currently, there are no recommendations regarding mechanical thrombectomy in children despite overwhelming evidence of improved outcomes in adults. Therefore, the need for individual case reports and case series is important to highlight potential advantages and disadvantages in this approach. Case descriptions We retrospectively searched our prospectively maintained database of patients undergoing mechanical thrombectomy for ischaemic stroke. We describe five children, aged between 7 and 17, who underwent mechanical thrombectomy for acute ischaemic stroke. We provide an account of their clinical presentations, operative treatment and postoperative outcome. Discussion Mechanical thrombectomy in children, especially older children, can be performed safely and with existing devices. Although a randomised controlled trial would provide compelling evidence of the potential advantages to this technique, the lack of this should not prevent the use of this procedure by trained neurointerventionists.
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Affiliation(s)
- Pervinder Bhogal
- Department of Interventional Neuroradiology, Royal London Hospital, London, UK
| | - Victoria Hellstern
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Muhammad AlMatter
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Oliver Ganslandt
- Neurosurgical Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Hansjörg Bäzner
- Neurosurgical Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Marta Aguilar Pérez
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany.,Medical Faculty, University Duisburg-Essen, Duisburg, Germany
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Bhogal P, Henkes E, Schob S, AlMatter M, Hellstern V, Bäzner H, Ganslandt O, Henkes H, Pérez MA. The use of flow diverters to treat small (≤5 mm) ruptured, saccular aneurysms. Surg Neurol Int 2018; 9:216. [PMID: 30505618 PMCID: PMC6219287 DOI: 10.4103/sni.sni_243_18] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 08/30/2018] [Indexed: 11/08/2022] Open
Abstract
Background: There is limited published literature on the use of flow diverting stents (FDS) to treat ruptured intracranial aneurysms in the acute stage. We present our experience of using FDS to treat small (≤5 mm) ruptured aneurysms. Methods: We retrospectively identified all patients with ≤5 mm ruptured aneurysms treated exclusively with FDS between February 2009 and February 2016. We recorded demographic data, the Hunt and Hess score, aneurysm location and size, therapeutic intervention, immediate angiographic and clinical result, and clinical and radiological follow-up information. Results: We identified seven patients (four females) with average age 59.8 ± 10 years (range 48–75). The average aneurysm fundus size was 2.7 ± 0.76 mm (range 1–4 mm). The average time from ictus to treatment was 6.3 days (range 1–14 days) and there were no cases of repeat rupture prior to treatment or intraoperative rupture. Angiographic follow-up was available in five patients. At initial follow-up, aneurysms (100%) were completely occluded raymond roy classification 1 (RRC 1). None of the aneurysms re-ruptured following treatment. Clinically, six patients were discharged with good functional outcome modified Rankin Score (mRS ≤2). There were no mortalities. Conclusion: The use of FDS to treat small, ruptured, saccular aneurysms is feasible; however, the use of FDS should not be considered first-line treatment. Further studies are required to determine the safety and efficacy of the use of FDS in the acute situation.
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Affiliation(s)
- Pervinder Bhogal
- Department of Neuroradiology, The Royal London Hospital, London, UK
| | - Elina Henkes
- Neuroradiological Clinic, Neurocenter, Leipzig, Germany
| | - Stefan Schob
- Department for Neuroradiology, University Hospital Leipzig, Leipzig, Germany
| | | | | | | | - Oliver Ganslandt
- Neurosurgical Clinic, Neurocenter, Klinikum Stuttgart, Leipzig, Germany
| | - Hans Henkes
- Neuroradiological Clinic, Neurocenter, Leipzig, Germany.,Medical Faculty, University Duisburg-Essen, Duisburg, Germany
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Bhogal P, AlMatter M, Hellstern V, Bäzner H, Ganslandt O, Henkes H, Aguilar Pérez M. High-Grade Dural Arteriovenous Fistulas : Use of Kaneka ED Coils with the Marathon Microcatheter for Transvenous Coil Embolization. Clin Neuroradiol 2018; 29:653-660. [PMID: 30167712 DOI: 10.1007/s00062-018-0724-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 08/13/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Dural arteriovenous fistulas (DAVF) are commonly encountered lesions that can be treated both transvenously, transarterially or using a combined approach. OBJECTIVE Transvenous coil embolization of DAVF is a recognized treatment option but can be challenging. In this context this article presents clinical experience using the Kaneka ED10 ExtraSoft coils in combination with the Marathon microcatheter to treat high grade DAVF. The physical properties of these coils and the microcatheter were also determined. MATERIAL AND METHODS All patients with high grade DAVF treated with the Marathon and the Kaneka ED COIL ∞10 ExtraSoft coils were retrospectively identified. The clinical presentation, location, grade of the lesion, clinical and radiological follow-up data were recorded. Bench side studies were performed to determine the physical properties of the Marathon catheter in comparison to the SL10 and Headway Duo as well the maximum width of the Kaneka pusher wire in comparison to Hypersoft, Target and Axium Prime coils. RESULTS A total of 8 patients with 9 DAVF with 3 Cognard 3 and 6 Cognard 4 lesions were identified. All the DAVF's were occluded either at the end of the procedure or on follow-up imaging. On bench side tests the Marathon microcatheter had the most flexible distal tip and distal shaft in comparison to the SL10 and Headway Duo. The proximal shaft of the Marathon was stiffer than the SL10. The Kaneka ED COIL ∞10 ExtraSoft had the smallest distal width and were the only coils tested that could be deployed through a Marathon microcatheter. CONCLUSION The combination of the Marathon microcatheter and Kaneka ED COIL ∞10 ExtraSoft is useful for the treatment of high grade DAVF.
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Affiliation(s)
- P Bhogal
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany. .,Neurological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany.
| | - M AlMatter
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - V Hellstern
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - H Bäzner
- Neurological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - O Ganslandt
- Neurosurgical Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - H Henkes
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany.,Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - M Aguilar Pérez
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
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Horvath-Rizea D, Surov A, Hoffmann KT, Garnov N, Vörkel C, Kohlhof-Meinecke P, Ganslandt O, Bäzner H, Gihr GA, Kalman M, Henkes E, Henkes H, Schob S. The value of whole lesion ADC histogram profiling to differentiate between morphologically indistinguishable ring enhancing lesions-comparison of glioblastomas and brain abscesses. Oncotarget 2018; 9:18148-18159. [PMID: 29719596 PMCID: PMC5915063 DOI: 10.18632/oncotarget.24454] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Accepted: 01/30/2018] [Indexed: 12/17/2022] Open
Abstract
Background Morphologically similar appearing ring enhancing lesions in the brain parenchyma can be caused by a number of distinct pathologies, however, they consistently represent life-threatening conditions. The two most frequently encountered diseases manifesting as such are glioblastoma multiforme (GBM) and brain abscess (BA), each requiring disparate therapeutical approaches. As a result of their morphological resemblance, essential treatment might be significantly delayed or even ommited, in case results of conventional imaging remain inconclusive. Therefore, our study aimed to investigate, whether ADC histogram profiling reliably can distinguish between both entities, thus enhancing the differential diagnostic process and preventing treatment failure in this highly critical context. Methods 103 patients (51 BA, 52 GBM) with histopathologically confirmed diagnosis were enrolled. Pretreatment diffusion weighted imaging (DWI) was obtained in a 1.5T system using b values of 0, 500, and 1000 s/mm2. Whole lesion ADC volumes were analyzed using a histogram-based approach. Statistical analysis was performed using SPSS version 23. Results All investigated parameters were statistically different in comparison of both groups. Most importantly, ADCp10 was able to differentiate reliably between BA and GBM with excellent accuracy (0.948) using a cutpoint value of 70 × 10−5 mm2 × s−1. Conclusions ADC whole lesion histogram profiling provides a valuable tool to differentiate between morphologically indistinguishable mass lesions. Among the investigated parameters, the 10th percentile of the ADC volume distinguished best between GBM and BA.
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Affiliation(s)
| | - Alexey Surov
- Clinic for Diagnostic and Interventional Radiology, University Hospital Leipzig, Leipzig, Germany
| | - Karl-Titus Hoffmann
- Department for Neuroradiology, University Hospital Leipzig, Leipzig, Germany
| | | | - Cathrin Vörkel
- Clinic for Diagnostic and Interventional Radiology, University Hospital Leipzig, Leipzig, Germany
| | | | - Oliver Ganslandt
- Clinic for Neurosurgery, Katharinenhospital Stuttgart, Stuttgart, Germany
| | - Hansjörg Bäzner
- Clinic for Neurology, Katherinenhospital Stuttgart, Stuttgart, Germany
| | | | - Marcell Kalman
- Clinic for Neuroradiology, Katharinenhospital Stuttgart, Stuttgart, Germany
| | - Elina Henkes
- Clinic for Neuroradiology, Katharinenhospital Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Clinic for Neuroradiology, Katharinenhospital Stuttgart, Stuttgart, Germany
| | - Stefan Schob
- Department for Neuroradiology, University Hospital Leipzig, Leipzig, Germany
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AlMatter M, Bhogal P, Aguilar Pérez M, Hellstern V, Bäzner H, Ganslandt O, Henkes H. Evaluation of safety, efficacy and clinical outcome after endovascular treatment of aneurysmal subarachnoid hemorrhage in coil-first setting. A 10-year series from a single center. J Neuroradiol 2018; 45:349-356. [PMID: 29544998 DOI: 10.1016/j.neurad.2018.02.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 01/20/2018] [Accepted: 02/24/2018] [Indexed: 10/17/2022]
Abstract
INTRODUCTION The endovascular treatment (EVT) of ruptured cerebral aneurysms has been widely adopted after the publication of the International Subarachnoid Aneurysm Trial. In this study, we sought to evaluate the safety and efficacy of the EVT for ruptured aneurysms based on 10-year series from a single center with coil-first strategy. METHODS All patients with aneurysmal subarachnoid hemorrhage (aSAH) treated between 2007 and 2016 were retrospectively reviewed and divided according to initial treatment into an EVT and a microsurgical clipping (MSC) group. Clinical and radiological findings at presentation, treatment modalities and procedural complications were recorded. The angiographic and clinical outcome was compared between the two groups. RESULTS A total of 587 patients with aSAH were reviewed (452 EVT, 135 MSC). There were no significant differences in mean age or the Hunt and Hess grades. Parenchymal hemorrhage (PH) was more frequent in the MSC. Procedure related complications of the acute treatment were recorded in 5.5% and 32% in the EVT and MSC, respectively. The rate of retreatment was 21.9% in the EVT and 5.9% in the MSC. Late rehemorrhage was not observed in either group. There was no significant difference in the clinical outcome between the two treatment groups after adjustment for other prognostic factors. CONCLUSION The majority of ruptured intracranial aneurysms can be managed via an endovascular approach in the acute phase with excellent safety profile and good efficacy. Despite the high rate of reperfusion after primary endovascular approach, retreatment has a very low rate of complications and the rate of recurrent hemorrhage is very low.
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Affiliation(s)
| | | | | | | | | | | | - Hans Henkes
- Neuroradiologische Klinik, Klinikum Stuttgart, Germany; Medizinische Fakultät, Universitätsklinikum Essen, Essen, Germany
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Bhogal P, Ganslandt O, Bäzner H, Henkes H, Aguilar Perez M. Treatment of Unruptured, Saccular, Anterior Choroidal Artery Aneurysms with Flow Diversion : A Single Centre Experience. Clin Neuroradiol 2018. [PMID: 29516113 PMCID: PMC6710236 DOI: 10.1007/s00062-018-0677-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background The region of the brain supplied by the anterior choroidal artery (AChoA) is exquisitely eloquent. Aneurysms arising at or close to the origin of the vessel are not uncommon and damage or occlusion to the vessel can result in devastating consequences. The optimal treatment strategy is yet to be determined. Objective We sought to determine the efficacy of flow diversion for the treatment of unruptured AChoA aneurysms. Method A retrospective review of our prospectively maintained database was performed to identify all patients with unruptured aneurysms of the AChoA between March 2009 and May 2017. The fundus size, number and type of flow-diverting stent (FD), complications and follow-up data were recorded. Results We identified 30 patients (60% female), average age 52.8 ± 10.8 years (range 27–73), with 30 aneurysms. The aneurysms were generally small with a mean fundus diameter of 3.4 mm (range 1–7 mm). Early angiographic follow-up data were available for all patients at which point 15 aneurysms were completely occluded (50%). Delayed angiographic follow-up was available in 24 patients and occlusion was seen in 21 patients (87.5%). Of the patients one developed transient ischemic symptoms after interruption of the antiplatelet medication and another patient had a small embolic infarct with transient symptoms in the periprocedural period. Conclusion Flow diversion can be used to successfully treat aneurysms of the AChoA. The treatment carries a high rate of technical and radiological success with a good safety profile.
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Affiliation(s)
- P Bhogal
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany.
| | - O Ganslandt
- Neurosurgical Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - H Bäzner
- Neurological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - H Henkes
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany.,Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - M Aguilar Perez
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
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Wendl CM, Aguilar Pérez M, Felber S, Stroszczynski C, Bäzner H, Henkes H. Paraspinal arteriovenous fistula: Stuttgart classification based on experience and a review of the literature. Br J Radiol 2018; 91:20170337. [PMID: 29376731 DOI: 10.1259/bjr.20170337] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The term "paraspinal arteriovenous shunts" (PAVSs) summarizes an inhomogeneous variety of rare vascular disorders. PAVSs have been observed as congenital or acquired lesions. The clinical course of PAVSs may be asymptomatic or present with life-threatening symptoms. Based on a collection of individual cases from three institutions and a literature evaluation, we propose the following classification: PAVSs that are part of a genetic syndrome are separated from "isolated" PAVSs. Isolated PAVSs are subdivided into "acquired", "traumatic" and "congenital" without an identifiable genetic hereditary disorder. The subgroups are differentiated by the route of venous drainage, being exclusively extraspinal or involving intraspinal veins. PAVSs associated to a genetic syndrome may either have a metameric link or occur together with a systemic genetic disorder. Again extra-vs intraspinal venous drainage is differentiated. The indication for treatment is based on individual circumstances (e.g. myelon compression, vascular bruit, high volume output cardiac failure). Most PAVSs can be treated by endovascular means using detachable coils, liquid embolic agents or stents and derivates.
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Affiliation(s)
- C M Wendl
- 1 Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart , Stuttgart , Germany.,2 Institut für Röntgendiagnostik, Universitätsklinikum Regensburg , Regensburg , Germany
| | - M Aguilar Pérez
- 1 Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart , Stuttgart , Germany
| | - S Felber
- 3 Institut für Diagnostische und Interventionelle Radiologie und Neuroradiologie, Gemeinschaftsklinikum Mittelrhein , Koblenz , Germany
| | - C Stroszczynski
- 2 Institut für Röntgendiagnostik, Universitätsklinikum Regensburg , Regensburg , Germany
| | - H Bäzner
- 4 Neurologische Klinik, Neurozentrum, Klinikum Stuttgart , Stuttgart , Germany
| | - H Henkes
- 1 Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart , Stuttgart , Germany.,5 Medizinische Fakultät der Universität Duisburg-Essen , Essen , Germany
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Bhogal P, AlMatter M, Hellstern V, Ganslandt O, Bäzner H, Henkes H, Aguilar-Pérez M. The Combined Use of Intraluminal and Intrasaccular Flow Diversion for the Treatment of Intracranial Aneurysms: Report of 25 Cases. Neurointervention 2018; 13:20-31. [PMID: 29535895 PMCID: PMC5847887 DOI: 10.5469/neuroint.2018.13.1.20] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Revised: 02/23/2018] [Accepted: 02/26/2018] [Indexed: 11/29/2022] Open
Abstract
PURPOSE The Medina Embolic Device (MED) is a new intrasaccular device with promising early results. Previously we documented our initial experience of this device both alone and in combination with other devices including flow diverter stents (FDS). We sought to determine the effect of the MED + FDS strategy for the treatment of selected aneurysms. MATERIALS AND METHODS We performed a retrospective analysis of prospectively collected data to identify all patients with aneurysms treated using both the MED and intraluminal FDS. We present our technical success rate, early and mid-term angiographic follow-up, and clinical outcome data. RESULTS We identified 25 non-consecutive patients. The treatment was staged in 9 patients and in a single session 16 patients. The average age was 61±12.8 years (range 40-82). The average fundus height was 11±3.6 mm and average fundus width was 10.1±3.4 mm. In the staged cohort (n=9) at delayed angiography (mean 10 mths) 8 aneurysms (89%) showed complete exclusion (mRRC 1) and in one patient there was a parent vessel occlusion. In the simultaneous cohort delayed angiography (n=10, mean 8.1 months) demonstrated complete occlusion (mRRC 1) in 6 aneurysms (60%), 3 neck remnants (mRRC 2) (30%) and 1 patient (10%) showed persistent aneurysmal filling (mRRC 3a). There were 5 complications with permanent morbidity (mRS >2) in two patients. There were no mortalities. CONCLUSION The MED can be successfully used in combination with intraluminal FDS and in selected aneurysms this may represent an alternative to FDS and adjunctive coiling.
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Affiliation(s)
- Pervinder Bhogal
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Germany
| | | | | | | | - Hansjörg Bäzner
- Neurological Clinic, Neurocenter, Klinikum Stuttgart, Germany
| | - Hans Henkes
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Germany
- Medical Faculty, University Duisburg-Essen, Germany
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Nave AH, Kufner A, Bücke P, Siebert E, Kliesch S, Grittner U, Bäzner H, Liebig T, Endres M, Fiebach JB, Nolte CH, Ebinger M, Henkes H. Hyperintense Vessels, Collateralization, and Functional Outcome in Patients With Stroke Receiving Endovascular Treatment. Stroke 2018; 49:675-681. [DOI: 10.1161/strokeaha.117.019588] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 01/09/2018] [Accepted: 01/17/2018] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Fluid-attenuated inversion recovery hyperintense vessels (FHV) are frequently observed on magnetic resonance imaging in acute stroke patients with proximal vessel occlusion. Whether FHV can serve as a surrogate for the collateral status and predict functional outcome of patients is still a matter of debate.
Methods—
Acute ischemic stroke patients with M1-middle cerebral artery occlusion who received magnetic resonance imaging before endovascular treatment in 3 hospitals in Germany between January 2007 and June 2016 were eligible. Quantification of FHV was performed using an FHV–Alberta Stroke Program Early CT Score (ASPECTS) rating system. Functional outcome was evaluated with the modified Rankin Scale 3 months after stroke. Collateral status of patients was graded on baseline angiography using the American Society of Interventional and Therapeutic Neuroradiology grading system. Odds for good outcome (modified Rankin Scale score, 0–2) were determined using logistic regression analyses.
Results—
Overall, 116 patients were analyzed (median age, 74; interquartile range [IQR], 64–79; median National Institutes of Health Stroke Scale, 14; IQR, 10–19). The median FHV-ASPECTS was 2 (IQR, 1–3). Good collateral status (American Society of Interventional and Therapeutic Neuroradiology grade 3–4) on angiography was more frequently observed in patients with FHV-ASPECTS ≤2 (83% versus 57%;
P
=0.025). Patients with an FHV-ASPECTS ≤2 had a better functional outcome after 3 months (median modified Rankin Scale score, 2; IQR, 0–5), compared with patients with an FHV-ASPECTS >2 (median modified Rankin Scale score, 4; IQR, 3–6;
P
=0.015). In multiple regression analyses, FHV-ASPECTS ≤2 was independently associated with good functional outcome (adjusted odds ratio, 5.3; 95% confidence interval, 1.5–18.2).
Conclusions—
Low FHV-ASPECTS is associated with both better collateral status and better 3-month functional outcome in acute stroke patients with M1 vessel occlusion.
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Affiliation(s)
- Alexander H. Nave
- From the Center for Stroke Research Berlin (A.H.N., A.K., U.G., M. Endres, J.B.F., C.H.N., M. Ebinger), Klinik und Hochschulambulanz für Neurologie (A.H.N., M. Endres, C.H.N.), Institut für Neuroradiologie (E.S., S.K., T.L., J.B.F.), and Department of Biostatistics and Clinical Epidemiology (U.G.), Charité–Universitätsmedizin Berlin, Germany; German Center for Cardiovascular Research (A.H.N., M. Endres,) and German Center for Neurodegenerative Disease (M. Endres), partner site Berlin; Berlin
| | - Anna Kufner
- From the Center for Stroke Research Berlin (A.H.N., A.K., U.G., M. Endres, J.B.F., C.H.N., M. Ebinger), Klinik und Hochschulambulanz für Neurologie (A.H.N., M. Endres, C.H.N.), Institut für Neuroradiologie (E.S., S.K., T.L., J.B.F.), and Department of Biostatistics and Clinical Epidemiology (U.G.), Charité–Universitätsmedizin Berlin, Germany; German Center for Cardiovascular Research (A.H.N., M. Endres,) and German Center for Neurodegenerative Disease (M. Endres), partner site Berlin; Berlin
| | - Philipp Bücke
- From the Center for Stroke Research Berlin (A.H.N., A.K., U.G., M. Endres, J.B.F., C.H.N., M. Ebinger), Klinik und Hochschulambulanz für Neurologie (A.H.N., M. Endres, C.H.N.), Institut für Neuroradiologie (E.S., S.K., T.L., J.B.F.), and Department of Biostatistics and Clinical Epidemiology (U.G.), Charité–Universitätsmedizin Berlin, Germany; German Center for Cardiovascular Research (A.H.N., M. Endres,) and German Center for Neurodegenerative Disease (M. Endres), partner site Berlin; Berlin
| | - Eberhard Siebert
- From the Center for Stroke Research Berlin (A.H.N., A.K., U.G., M. Endres, J.B.F., C.H.N., M. Ebinger), Klinik und Hochschulambulanz für Neurologie (A.H.N., M. Endres, C.H.N.), Institut für Neuroradiologie (E.S., S.K., T.L., J.B.F.), and Department of Biostatistics and Clinical Epidemiology (U.G.), Charité–Universitätsmedizin Berlin, Germany; German Center for Cardiovascular Research (A.H.N., M. Endres,) and German Center for Neurodegenerative Disease (M. Endres), partner site Berlin; Berlin
| | - Stefan Kliesch
- From the Center for Stroke Research Berlin (A.H.N., A.K., U.G., M. Endres, J.B.F., C.H.N., M. Ebinger), Klinik und Hochschulambulanz für Neurologie (A.H.N., M. Endres, C.H.N.), Institut für Neuroradiologie (E.S., S.K., T.L., J.B.F.), and Department of Biostatistics and Clinical Epidemiology (U.G.), Charité–Universitätsmedizin Berlin, Germany; German Center for Cardiovascular Research (A.H.N., M. Endres,) and German Center for Neurodegenerative Disease (M. Endres), partner site Berlin; Berlin
| | - Ulrike Grittner
- From the Center for Stroke Research Berlin (A.H.N., A.K., U.G., M. Endres, J.B.F., C.H.N., M. Ebinger), Klinik und Hochschulambulanz für Neurologie (A.H.N., M. Endres, C.H.N.), Institut für Neuroradiologie (E.S., S.K., T.L., J.B.F.), and Department of Biostatistics and Clinical Epidemiology (U.G.), Charité–Universitätsmedizin Berlin, Germany; German Center for Cardiovascular Research (A.H.N., M. Endres,) and German Center for Neurodegenerative Disease (M. Endres), partner site Berlin; Berlin
| | - Hansjörg Bäzner
- From the Center for Stroke Research Berlin (A.H.N., A.K., U.G., M. Endres, J.B.F., C.H.N., M. Ebinger), Klinik und Hochschulambulanz für Neurologie (A.H.N., M. Endres, C.H.N.), Institut für Neuroradiologie (E.S., S.K., T.L., J.B.F.), and Department of Biostatistics and Clinical Epidemiology (U.G.), Charité–Universitätsmedizin Berlin, Germany; German Center for Cardiovascular Research (A.H.N., M. Endres,) and German Center for Neurodegenerative Disease (M. Endres), partner site Berlin; Berlin
| | - Thomas Liebig
- From the Center for Stroke Research Berlin (A.H.N., A.K., U.G., M. Endres, J.B.F., C.H.N., M. Ebinger), Klinik und Hochschulambulanz für Neurologie (A.H.N., M. Endres, C.H.N.), Institut für Neuroradiologie (E.S., S.K., T.L., J.B.F.), and Department of Biostatistics and Clinical Epidemiology (U.G.), Charité–Universitätsmedizin Berlin, Germany; German Center for Cardiovascular Research (A.H.N., M. Endres,) and German Center for Neurodegenerative Disease (M. Endres), partner site Berlin; Berlin
| | - Matthias Endres
- From the Center for Stroke Research Berlin (A.H.N., A.K., U.G., M. Endres, J.B.F., C.H.N., M. Ebinger), Klinik und Hochschulambulanz für Neurologie (A.H.N., M. Endres, C.H.N.), Institut für Neuroradiologie (E.S., S.K., T.L., J.B.F.), and Department of Biostatistics and Clinical Epidemiology (U.G.), Charité–Universitätsmedizin Berlin, Germany; German Center for Cardiovascular Research (A.H.N., M. Endres,) and German Center for Neurodegenerative Disease (M. Endres), partner site Berlin; Berlin
| | - Jochen B. Fiebach
- From the Center for Stroke Research Berlin (A.H.N., A.K., U.G., M. Endres, J.B.F., C.H.N., M. Ebinger), Klinik und Hochschulambulanz für Neurologie (A.H.N., M. Endres, C.H.N.), Institut für Neuroradiologie (E.S., S.K., T.L., J.B.F.), and Department of Biostatistics and Clinical Epidemiology (U.G.), Charité–Universitätsmedizin Berlin, Germany; German Center for Cardiovascular Research (A.H.N., M. Endres,) and German Center for Neurodegenerative Disease (M. Endres), partner site Berlin; Berlin
| | - Christian H. Nolte
- From the Center for Stroke Research Berlin (A.H.N., A.K., U.G., M. Endres, J.B.F., C.H.N., M. Ebinger), Klinik und Hochschulambulanz für Neurologie (A.H.N., M. Endres, C.H.N.), Institut für Neuroradiologie (E.S., S.K., T.L., J.B.F.), and Department of Biostatistics and Clinical Epidemiology (U.G.), Charité–Universitätsmedizin Berlin, Germany; German Center for Cardiovascular Research (A.H.N., M. Endres,) and German Center for Neurodegenerative Disease (M. Endres), partner site Berlin; Berlin
| | - Martin Ebinger
- From the Center for Stroke Research Berlin (A.H.N., A.K., U.G., M. Endres, J.B.F., C.H.N., M. Ebinger), Klinik und Hochschulambulanz für Neurologie (A.H.N., M. Endres, C.H.N.), Institut für Neuroradiologie (E.S., S.K., T.L., J.B.F.), and Department of Biostatistics and Clinical Epidemiology (U.G.), Charité–Universitätsmedizin Berlin, Germany; German Center for Cardiovascular Research (A.H.N., M. Endres,) and German Center for Neurodegenerative Disease (M. Endres), partner site Berlin; Berlin
| | - Hans Henkes
- From the Center for Stroke Research Berlin (A.H.N., A.K., U.G., M. Endres, J.B.F., C.H.N., M. Ebinger), Klinik und Hochschulambulanz für Neurologie (A.H.N., M. Endres, C.H.N.), Institut für Neuroradiologie (E.S., S.K., T.L., J.B.F.), and Department of Biostatistics and Clinical Epidemiology (U.G.), Charité–Universitätsmedizin Berlin, Germany; German Center for Cardiovascular Research (A.H.N., M. Endres,) and German Center for Neurodegenerative Disease (M. Endres), partner site Berlin; Berlin
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Bücke P, Pérez MA, Hellstern V, AlMatter M, Bäzner H, Henkes H. Endovascular Thrombectomy in Wake-Up Stroke and Stroke with Unknown Symptom Onset. AJNR Am J Neuroradiol 2018; 39:494-499. [PMID: 29439123 DOI: 10.3174/ajnr.a5540] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 11/13/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Mechanical thrombectomy in acute ischemic stroke within 6 hours of symptom onset is effective and safe. However, in many patients, information on the beginning of symptoms is not available. Patients can be divided into those with wake-up stroke and daytime-unwitnessed stroke. Evidence on outcome and complications after mechanical thrombectomy in wake-up stroke and daytime-unwitnessed stroke is rare. A potential beneficial effect of mechanical thrombectomy in selected patients with wake-up stroke or daytime-unwitnessed stroke is suspected. MATERIALS AND METHODS We analyzed 1073 patients with anterior circulation stroke undergoing mechanical thrombectomy between 2010 and 2016. Patients with wake-up stroke and daytime-unwitnessed stroke were compared with controls receiving mechanical thrombectomy as the standard of care. We assessed good functional outcome (mRS ≤ 2 at 3 months), mortality rates, and frequencies of symptomatic intracranial hemorrhage. Subgroup analyses tried to detect influences of patient selection via further imaging modalities (MR imaging, CTP; wake-up stroke [advanced], daytime-unwitnessed stroke [advanced]) on outcome and safety. RESULTS There was no significant difference in good functional outcome between patients with wake-up stroke and controls (35.9% versus 38.3%, P = .625). Outcome in patients with daytime-unwitnessed stroke was inferior compared with controls (27.3%, P = .007). Groups did not differ in all-cause mortality at day 90 (P = .224) and the rate of symptomatic intracranial hemorrhage (P = .292). Advanced imaging improved the frequency of good functional outcome (non-wake-up stroke [advanced] versus wake-up stroke [advanced]: OR, 2.92; 95% CI, 1.32-6.45; non-daytime-unwitnessed stroke [advanced] versus daytime-unwitnessed stroke [advanced]: OR, 2.09; 95% CI, 1.03-4.25) with an additional reduction in all-cause mortality (non-daytime-unwitnessed stroke [advanced] versus daytime-unwitnessed stroke [advanced]: OR, 0.42; 95% CI, 0.20-0.88). CONCLUSIONS Mechanical thrombectomy in selected patients with wake-up stroke allows a good functional outcome comparable with that of controls. Outcome after mechanical thrombectomy in daytime-unwitnessed stroke seems to be inferior compared with that in controls. Advanced imaging modalities may increase the frequency of good functional outcome in both patients with wake-up stroke and daytime-unwitnessed stroke.
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Affiliation(s)
- P Bücke
- From the Psychiatric University Hospital Zurich (P.B.), University of Zurich, Zurich, Switzerland .,Neurological Clinic (P.B., H.B.)
| | - M Aguilar Pérez
- Neuroradiological Clinic (M.A.P., V.H., M.A., H.H.), Klinikum Stuttgart, Stuttgart, Germany
| | - V Hellstern
- Neuroradiological Clinic (M.A.P., V.H., M.A., H.H.), Klinikum Stuttgart, Stuttgart, Germany
| | - M AlMatter
- Neuroradiological Clinic (M.A.P., V.H., M.A., H.H.), Klinikum Stuttgart, Stuttgart, Germany
| | - H Bäzner
- Neurological Clinic (P.B., H.B.)
| | - H Henkes
- Neuroradiological Clinic (M.A.P., V.H., M.A., H.H.), Klinikum Stuttgart, Stuttgart, Germany.,Medical Faculty (H.H.), University Duisburg-Essen, Essen, Germany
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Bhogal P, AlMatter M, Hellstern V, Ganslandt O, Bäzner H, Henkes H, Pérez MA. Difference in aneurysm characteristics between ruptured and unruptured aneurysms in patients with multiple intracranial aneurysms. Surg Neurol Int 2018; 9:1. [PMID: 29399373 PMCID: PMC5778729 DOI: 10.4103/sni.sni_339_17] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 11/08/2017] [Indexed: 12/25/2022] Open
Abstract
Background: The risk of aneurysmal rupture is dependent upon numerous factors, however, there are inconsistencies in the results between studies, which may be due to confounding factors. This can be avoided by comparing the characteristics of ruptured and unruptured aneurysms within the same patient. We sought to analyze the aneurysm characteristics of patients with acute aneurysmal subarachnoid hemorrhage (SAH) and multiple intracranial aneurysms. Methods: We reviewed our prospectively maintained institutional database, between 01/10/2007 and 01/01/2017, for all patients with confirmed SAH and >1 aneurysm. We recorded the size, location, and morphology and calculated secondary geometric indices such as bottleneck factor and aspect ratio. Results: During the study period, a total of 694 patients with aneurysmal SAH were admitted to our institution. We identified 113 patients (74.3% female, average age 51.7 ± 12.3). The majority of patients had only one associate unruptured aneurysm (79.6%). The average unruptured aneurysm was 3.1 ± 1.5 mm and the average ruptured aneurysm was 5.7 ± 2.7 mm (P < 0.001). In the multivariate analysis, aneurysm location, aneurysm morphology, and size were independently associated with rupture. A complex aneurysm morphology was the strongest risk factor for rupture (OR, 29.27; 95% CI 14.33–59.78; P < 0.001) with size >7 mm (OR, 17.74; 95% CI 4.07–77.35; P < 0.001), and AcomA location also showing a strong independent association. Conclusion: Size plays an important part in determining rupture risk, however, other factors such as location and in particular morphology must also be considered. We believe that the introduction of vessel wall imaging will help to risk stratify aneurysms.
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Affiliation(s)
- P Bhogal
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Germany
| | - M AlMatter
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Germany
| | - V Hellstern
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Germany
| | - O Ganslandt
- Neurosurgical Clinic, Neurocenter, Klinikum Stuttgart, Germany
| | - H Bäzner
- Neurological Clinic, Neurocenter, Klinikum Stuttgart, Germany
| | - H Henkes
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Germany.,Medical Faculty, University Duisburg-Essen, Germany
| | - M Aguilar Pérez
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Germany
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45
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Hellstern V, Aguilar Pérez M, Kohlhof-Meinecke P, Bäzner H, Ganslandt O, Henkes H. Concomitant Retroperitoneal and Subarachnoid Hemorrhage Due to Segmental Arterial Mediolysis : Case Report and Review of the Literature. Clin Neuroradiol 2017; 28:445-450. [PMID: 29101412 PMCID: PMC6105144 DOI: 10.1007/s00062-017-0641-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 10/12/2017] [Indexed: 11/26/2022]
Affiliation(s)
- V Hellstern
- Neuroradiologische Klinik, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany.
| | - M Aguilar Pérez
- Neuroradiologische Klinik, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | | | - H Bäzner
- Neurologische Klinik, Klinikum Stuttgart, Stuttgart, Germany
| | - O Ganslandt
- Neurochirurgische Klinik, Klinikum Stuttgart, Stuttgart, Germany
| | - H Henkes
- Neuroradiologische Klinik, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
- Medizinische Fakultät, Universität Duisburg-Essen, Essen, Germany
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Bhogal P, Pérez MA, Wendl C, Bäzner H, Ganslandt O, Henkes H. Paediatric aneurysms – Review of endovascular treatment strategies. J Clin Neurosci 2017; 45:54-59. [DOI: 10.1016/j.jocn.2017.08.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Accepted: 08/10/2017] [Indexed: 10/18/2022]
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AlMatter M, Bhogal P, Aguilar Pérez M, Schob S, Hellstern V, Bäzner H, Ganslandt O, Henkes H. The Size of Ruptured Intracranial Aneurysms : A 10-Year Series from a Single Center. Clin Neuroradiol 2017; 29:125-133. [PMID: 29080036 DOI: 10.1007/s00062-017-0632-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 09/21/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE There is a controversy concerning the risk of rupture of small intracranial aneurysms. We sought to determine the size and morphological features of ruptured intracranial aneurysms. MATERIAL AND METHODS The hospital files and images from all patients referred during one decade (2007-2016) to a specialized neurovascular center were retrospectively reviewed. Neck diameter, fundus depth and width as well as neck width based on catheter angiography were measured. Aneurysm morphology was classified as either regular, lobulated, irregular or fusiform. RESULTS A total of 694 consecutive patients with aneurysmal subarachnoid hemorrhage (aSAH) were identified (65.9% female, median age 54.3 years). The anterior communicating artery (AcomA) was the most frequent location of ruptured aneurysms. The medians for aneurysm depth, width and neck diameter were 5 mm, 4.5 mm and 3 mm, respectively. A regular contour of the aneurysm sac was found in 19%. CONCLUSION The majority of aSAH are caused by small intracranial aneurysms. There is no safety margin in terms of small aneurysm size of regular shape without daughter aneurysms. Treatment should also be offered to patients with small, regularly shaped intracranial aneurysms, together with an empirical risk-benefit assessment.
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Affiliation(s)
| | - P Bhogal
- Neuroradiologische Klinik, Klinikum Stuttgart, Stuttgart, Germany
| | - M Aguilar Pérez
- Neuroradiologische Klinik, Klinikum Stuttgart, Stuttgart, Germany
| | - S Schob
- Abteilung für Neuroradiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - V Hellstern
- Neuroradiologische Klinik, Klinikum Stuttgart, Stuttgart, Germany
| | - H Bäzner
- Neurologische Klinik, Klinikum Stuttgart, Stuttgart, Germany
| | - O Ganslandt
- Neurochirurgische Klinik, Klinikum Stuttgart, Stuttgart, Germany
| | - H Henkes
- Neuroradiologische Klinik, Klinikum Stuttgart, Stuttgart, Germany.,Medizinische Fakultät, Universität Duisburg-Essen, Essen, Germany
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Bhogal P, Hellstern V, Bäzner H, Ganslandt O, Henkes H, Aguilar Pérez M. The Use of Flow Diverting Stents to Treat Para-Ophthalmic Aneurysms. Front Neurol 2017; 8:381. [PMID: 28824537 PMCID: PMC5545935 DOI: 10.3389/fneur.2017.00381] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 07/18/2017] [Indexed: 11/13/2022] Open
Abstract
Background and purpose Few publications have dealt exclusively with the use of flow diverter stents for the treatment of para-ophthalmic aneurysms. We sought to determine the efficacy of flow diverting stents (FDSs) to treat aneurysms in this specific location. Methods We retrospectively reviewed our database of prospectively collected information for all patients treated with flow diversion for an unruptured saccular para-ophthalmic aneurysm between September 2009 and January 2016. The aneurysm fundus size, neck size, number and type of FDS, complications, and follow-up data were recorded. Results We identified 74 patients that matched our inclusion criteria. Of these patients, 18 patients were male (24.3%). The average fundus size was 4.8 mm, 11 aneurysms had previous coil occlusions and 63 were treated solely with flow diversion. At an initial angiographic follow-up (mean avg. 3.2 months), 71.8% of the aneurysms were occluded, and at the last follow-up (mean avg. 31.8 months), 88.9% of aneurysms were occluded. One patient suffered permanent morbidity (1.36%) secondary to interruption of the antiplatelet medication and another died (1.36%) secondary to in-stent thrombosis that was also due to an interruption in the antiplatelet medication. Conclusion Treatment of saccular para-ophthalmic aneurysms with FDS is feasible and carries a high degree of technical success with low complication rates and excellent rates of aneurysm exclusion.
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Affiliation(s)
| | | | | | | | - Hans Henkes
- Neurocentrum, Klinikum Stuttgart, Stuttgart, Germany
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Bhogal P, Bücke P, AlMatter M, Ganslandt O, Bäzner H, Henkes H, Aguilar Pérez M. A Comparison of Mechanical Thrombectomy in the M1 and M2 Segments of the Middle Cerebral Artery: A Review of 585 Consecutive Patients. Interv Neurol 2017; 6:191-198. [PMID: 29118796 DOI: 10.1159/000475535] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background Mechanical thrombectomy for anterior-circulation large-vessel occlusion has shown benefit; however, the question of whether this technique is safe and effective in the distal vasculature remains unanswered. We sought to compare the outcome data from mechanical thrombectomy of the M2 branches of the middle cerebral artery (MCA) with those of the M1 segment. Methods We performed a retrospective analysis of prospectively collected data of patients with acute ischaemic stroke undergoing mechanical thrombectomy of isolated M1 or M2 branches of the MCA between August 2008 and August 2016. Results We identified 585 patients, 479 with M1 occlusions and 106 with M2 occlusions. The average age was 72 ± 12.8 and 68 ± 13.8 years, respectively (p = 0.007). The baseline Alberta Stroke Program Early Computed Tomographic (ASPECT) score was similar in both cohorts, but patients with M1 occlusions presented with higher mean National Institutes of Health Stroke Scale (NIHSS) scores of 15.7 compared to 11.8 (p < 0.001). There was no significant difference in the average procedure time for each cohort; fewer thrombectomy attempts were required in the M2 cohort (2.3 vs. 1.8, p = 0.0004), but the overall time to recanalization was longer in the M2 cohort (353 vs. 399 min, p < 0.001). Similar rates of successful reperfusion (Thrombolysis in Ischaemic Stroke score [TICI] ≥2b 88.5 vs. 90.5%, p = 0.612) were seen, but food outcome (modified Rankin Scale ≤2) was lower in M1 occlusions (37.2 vs. 54.3%, p < 0.001). Rates of symptomatic intracranial haemorrhage were similar. Conclusion Good clinical outcomes can be achieved for both groups with no significant differences in procedure length, final TICI recanalization rates or intracranial haemorrhage between the M1 and M2 cohorts.
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Affiliation(s)
- Pervinder Bhogal
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Philipp Bücke
- Neurological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Muhammad AlMatter
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Oliver Ganslandt
- Neurosurgical Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Hansjörg Bäzner
- Neurological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany.,Medical Faculty, University Duisburg-Essen, Duisburg, Germany
| | - Marta Aguilar Pérez
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
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50
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Bhogal P, Aguilar Pérez M, Sauder G, Bäzner H, Ganslandt O, Henkes H. [Management of paraophthalmic aneurysms : Review of endovascular treatment strategies]. Ophthalmologe 2017; 115:114-122. [PMID: 28439656 DOI: 10.1007/s00347-017-0497-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Aneurysms of the cerebral vessels are relatively common and aneurysms of the ophthalmic segment of the internal carotid artery (ICA) represent approximately 10% of intradural aneurysms. ANATOMICAL ASPECTS The ophthalmic segment of the ICA extends from the origin of the ophthalmic artery to the origin of the posterior communicating artery. Aneurysms can originate from the ophthalmic artery itself or directly from the ICA at a distance from the ophthalmic artery. The various anatomic configurations can alter the risks of treatment. SURGICAL TREATMENT Surgical treatment of aneurysms of the ophthalmic segment poses unique challenges for the neurosurgeon, given the deep location and complex nearby structures and optic nerve. The necessity to remove the clinoid process can make the operation technically challenging. ENDOVASCULAR TREATMENT Endovascular treatment of paraophthalmic aneurysms includes coil occlusion, and also stent- or balloon-assisted coil occlusion. More recently, hemodynamically active flow diverter stents improved the treatment results. CONCLUSION The management of paraophthalmic aneurysms is associated with specific risks. Careful consideration of the available techniques is necessary before each invention. Coil-occlusion remains the first choice for ruptured paraophthalmic aneurysms. For unruptured paraophthalmic aneurysms flow diversion offers improved results. The overall complication rates of these procedures are low; however, cerebral ischemia, intracranial hemorrhage and visual complications must be considered in advance and the patient must be informed of the risks.
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Affiliation(s)
- P Bhogal
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Kriegsbergstr. 60, 70174, Stuttgart, Deutschland.
| | - M Aguilar Pérez
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Kriegsbergstr. 60, 70174, Stuttgart, Deutschland
| | - G Sauder
- Charlottenklinik, Stuttgart, Deutschland
| | - H Bäzner
- Neurologische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Deutschland
| | - O Ganslandt
- Neurochirurgische Klinik, Neurozentrum, Klinikum Stuttgart, Stuttgart, Deutschland
| | - H Henkes
- Neuroradiologische Klinik, Neurozentrum, Klinikum Stuttgart, Kriegsbergstr. 60, 70174, Stuttgart, Deutschland.,Medizinische Fakultät, Universität Duisburg-Essen, Essen, Deutschland
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