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Vollherbst DF, Lücking H, DuPlessis J, Sonnberger M, Maurer C, Kocer N, Killer-Oberpfalzer M, Rautio R, Valvassori L, Berlis A, Gasser S, Gatt S, Dörfler A, Bendszus M, Möhlenbruch MA. The FRESH Study: Treatment of Intracranial Aneurysms with the New FRED X Flow Diverter with Antithrombotic Surface Treatment Technology-First Multicenter Experience in 161 Patients. AJNR Am J Neuroradiol 2023; 44:474-480. [PMID: 36997283 PMCID: PMC10084892 DOI: 10.3174/ajnr.a7834] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 02/23/2023] [Indexed: 04/01/2023]
Abstract
BACKGROUND AND PURPOSE Flow diverters with antithrombotic coatings are increasingly used to improve the safety of flow diverter treatments of intracranial aneurysms. This study aimed to investigate the safety and short-term efficacy of the new FRED X flow diverter. MATERIALS AND METHODS Medical charts and procedural and imaging data of a consecutive series of patients with intracranial aneurysms who were treated with the FRED X at 9 international neurovascular centers were retrospectively analyzed. RESULTS One hundred sixty-one patients (77.6% women; mean age, 55 years) with 184 aneurysms (11.2% acutely ruptured) were included in this study. Most aneurysms were located in the anterior circulation (77.0%), most frequently at the ICA (72.7%). The FRED X was successfully implanted in all procedures. Additional coiling was performed in 29.8%. In-stent balloon angioplasty was necessary in 2.5%. The rate of major adverse events was 3.1%. Thrombotic events occurred in 7 patients (4.3%) with 4 intra- and 4 postprocedural in-stent thromboses, respectively (1 patient had both peri- and postprocedural thrombosis). Of these thrombotic events, only 2 (1.2%) led to major adverse events (ischemic strokes). Postinterventional neurologic morbidity and mortality were observed in 1.9% and 1.2%, respectively. The rate of complete aneurysm occlusion after a mean follow-up of 7.0 months was 66.0%. CONCLUSIONS The new FRED X is a safe and feasible device for aneurysm treatment. In this retrospective multicenter study, the rate of thrombotic complications was low, and the short-term occlusion rates are satisfactory.
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Affiliation(s)
- D F Vollherbst
- From the Department of Neuroradiology (D.F.V., M.B., M.A.M.), Heidelberg University Hospital, Heidelberg, Germany
| | - H Lücking
- Department of Neuroradiology (H.L., A.D.), University of Erlangen-Nuremberg, Erlangen, Germany
| | - J DuPlessis
- Department of Clinical Neurosciences (J.D., S. Gatt), Royal Infirmary of Edinburgh, Edinburgh, UK
| | - M Sonnberger
- Department of Neuroradiology (M.S., S. Gasser), Johannes Kepler University Linz, Linz, Austria
| | - C Maurer
- Department of Diagnostic and Interventional Neuroradiology (C.M., A.B.), University Hospital Augsburg, Augsburg, Germany
| | - N Kocer
- Department of Radiology (N.K.), Division of Neuroradiology, Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - M Killer-Oberpfalzer
- Department of Neurology (M.K.-O.), Institute of Neurointervention, Paracelsus Medizinische Privatuniversität, Salzburg, Austria
| | - R Rautio
- Department of Interventional Radiology (R.R.), Turku University Hospital, Turku, Finland
| | - L Valvassori
- Department of Neuroradiology (L.V.), San Carlo Borromeo Hospital, Milano, Lombardia, Italy
| | - A Berlis
- Department of Diagnostic and Interventional Neuroradiology (C.M., A.B.), University Hospital Augsburg, Augsburg, Germany
| | - S Gasser
- Department of Neuroradiology (M.S., S. Gasser), Johannes Kepler University Linz, Linz, Austria
| | - S Gatt
- Department of Clinical Neurosciences (J.D., S. Gatt), Royal Infirmary of Edinburgh, Edinburgh, UK
| | - A Dörfler
- Department of Neuroradiology (H.L., A.D.), University of Erlangen-Nuremberg, Erlangen, Germany
| | - M Bendszus
- From the Department of Neuroradiology (D.F.V., M.B., M.A.M.), Heidelberg University Hospital, Heidelberg, Germany
| | - M A Möhlenbruch
- From the Department of Neuroradiology (D.F.V., M.B., M.A.M.), Heidelberg University Hospital, Heidelberg, Germany
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Schmitt N, Wucherpfennig L, Hohenstatt S, Karimian-Jazi K, Breckwoldt MO, Kauczor HU, Bendszus M, Möhlenbruch MA, Vollherbst DF. Material-Specific Roadmap Modes Can Improve the Visibility of Liquid Embolic Agents for Endovascular Embolization: A Systematic In Vitro Study. AJNR Am J Neuroradiol 2022; 43:1749-1755. [PMID: 36357152 DOI: 10.3174/ajnr.a7706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 10/12/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND AND PURPOSE Endovascular embolization using liquid embolic agents is a safe and effective treatment option for AVMs and fistulas. Because reliable visibility of these liquid embolic agents is essential for intraprocedural visual control to prevent complications, novel angiographic systems are equipped with material-specific roadmap modes. The aim of this study was the systematic in vitro comparison of conventional and material-specific roadmap modes regarding the visibility of the most used liquid embolic agents. MATERIALS AND METHODS A recently introduced in vitro model, resembling cerebral vessels, was embolized with Onyx 18, Squid 18, PHIL 25%, and n-BCA mixed with iodized oil (n = 4 for each liquid embolic agent), as well as with contrast medium and saline, both serving as a reference. Imaging was performed in conventional and material-specific roadmap modes. The visibility of the liquid embolic agents in both modes was compared quantitatively and qualitatively. RESULTS Significant differences between conventional and material-specific roadmap modes regarding the visibility of the liquid embolic agents were observed for all study groups. All liquid embolic agents were better visible in the material-specific roadmap modes compared with the conventional mode in qualitative and quantitative analyses (eg, Onyx in conventional-versus-material-specific modes along the 1.0-mm sector: mean contrast-to-noise ratio, 5.69 [SD, 0.85] versus 47.18 [SD, 5.72]; P < .001, respectively). CONCLUSIONS In this in vitro study, we demonstrated a better visibility of all investigated liquid embolic agents by using material-specific roadmap modes compared with the conventional roadmap technique. Especially in complex anatomic situations, these novel roadmap modes could improve the visual control and thus the safety and efficacy of embolization procedures in clinical practice.
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Affiliation(s)
- N Schmitt
- From the Departments of Neuroradiology (N.S., S.H., K.K.-J., M.O.B., M.B., M.A.M., D.F.V.)
| | - L Wucherpfennig
- Diagnostic and Interventional Radiology (L.W., H.-U.K.), Heidelberg University Hospital, Heidelberg, Germany
| | - S Hohenstatt
- From the Departments of Neuroradiology (N.S., S.H., K.K.-J., M.O.B., M.B., M.A.M., D.F.V.)
| | - K Karimian-Jazi
- From the Departments of Neuroradiology (N.S., S.H., K.K.-J., M.O.B., M.B., M.A.M., D.F.V.)
| | - M O Breckwoldt
- From the Departments of Neuroradiology (N.S., S.H., K.K.-J., M.O.B., M.B., M.A.M., D.F.V.)
| | - H-U Kauczor
- Diagnostic and Interventional Radiology (L.W., H.-U.K.), Heidelberg University Hospital, Heidelberg, Germany
| | - M Bendszus
- From the Departments of Neuroradiology (N.S., S.H., K.K.-J., M.O.B., M.B., M.A.M., D.F.V.)
| | - M A Möhlenbruch
- From the Departments of Neuroradiology (N.S., S.H., K.K.-J., M.O.B., M.B., M.A.M., D.F.V.)
| | - D F Vollherbst
- From the Departments of Neuroradiology (N.S., S.H., K.K.-J., M.O.B., M.B., M.A.M., D.F.V.)
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Adeeb N, Dibas M, Griessenauer CJ, Cuellar HH, Salem MM, Xiang S, Enriquez-Marulanda A, Hong T, Zhang H, Taussky P, Grandhi R, Waqas M, Aldine AS, Tutino VM, Aslan A, Siddiqui AH, Levy EI, Ogilvy CS, Thomas AJ, Ulfert C, Möhlenbruch MA, Renieri L, Bengzon Diestro JD, Lanzino G, Brinjikji W, Spears J, Vranic JE, Regenhardt RW, Rabinov JD, Harker P, Müller-Thies-Broussalis E, Killer-Oberpfalzer M, Islak C, Kocer N, Sonnberger M, Engelhorn T, Kapadia A, Yang VXD, Salehani A, Harrigan MR, Krings T, Matouk CC, Mirshahi S, Chen KS, Aziz-Sultan MA, Ghorbani M, Schirmer CM, Goren O, Dalal SS, Finkenzeller T, Holtmannspötter M, Buhk JH, Foreman PM, Cress MC, Hirschl RA, Reith W, Simgen A, Janssen H, Marotta TR, Stapleton CJ, Patel AB, Dmytriw AA. Learning Curve for Flow Diversion of Posterior Circulation Aneurysms: A Long-Term International Multicenter Cohort Study. AJNR Am J Neuroradiol 2022; 43:1615-1620. [PMID: 36229166 PMCID: PMC9731249 DOI: 10.3174/ajnr.a7679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 06/28/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND PURPOSE Flow diversion has gradually become a standard treatment for intracranial aneurysms of the anterior circulation. Recently, the off-label use of the flow diverters to treat posterior circulation aneurysms has also increased despite initial concerns of rupture and the suboptimal results. This study aimed to explore the change in complication rates and treatment outcomes across time for posterior circulation aneurysms treated using flow diversion and to further evaluate the mechanisms and variables that could potentially explain the change and outcomes. MATERIALS AND METHODS A retrospective review using a standardized data set at multiple international academic institutions was performed to identify patients with ruptured and unruptured posterior circulation aneurysms treated with flow diversion during a decade spanning January 2011 to January 2020. This period was then categorized into 4 intervals. RESULTS A total of 378 procedures were performed during the study period. Across time, there was an increasing tendency to treat more vertebral artery and fewer large vertebrobasilar aneurysms (P = .05). Moreover, interventionalists have been increasingly using fewer overlapping flow diverters per aneurysm (P = .07). There was a trend toward a decrease in the rate of thromboembolic complications from 15.8% in 2011-13 to 8.9% in 2018-19 (P = .34). CONCLUSIONS This multicenter experience revealed a trend toward treating fewer basilar aneurysms, smaller aneurysms, and increased usage of a single flow diverter, leading to a decrease in the rate of thromboembolic and hemorrhagic complications.
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Affiliation(s)
- N Adeeb
- From the Departments of Neurosurgery and Interventional Neuroradiology (N.A., M.D., H.H.C., A.S.A., A.A.), Louisiana State University Hospital, Shreveport, Louisiana
| | - M Dibas
- From the Departments of Neurosurgery and Interventional Neuroradiology (N.A., M.D., H.H.C., A.S.A., A.A.), Louisiana State University Hospital, Shreveport, Louisiana
| | - C J Griessenauer
- Departments of Neurosurgery and Radiology (C.J.G., C.M.S., O.G., S.S.D.), Geisinger, Danville, Pennsylvania
- Department of Neurology/Institut of Neurointervention (C.J.G., E.M.-T.-B., M.K.-O.), University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - H H Cuellar
- From the Departments of Neurosurgery and Interventional Neuroradiology (N.A., M.D., H.H.C., A.S.A., A.A.), Louisiana State University Hospital, Shreveport, Louisiana
| | - M M Salem
- Neurosurgical Service (M.M.S., A.E.-M., P.T., C.S.O.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - S Xiang
- Department of Neurosurgery (S.X., H.Z., T.H.), Xuanwu Hospital, Capital Medical University, Beijing, China
| | - A Enriquez-Marulanda
- Neurosurgical Service (M.M.S., A.E.-M., P.T., C.S.O.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - T Hong
- Department of Neurosurgery (S.X., H.Z., T.H.), Xuanwu Hospital, Capital Medical University, Beijing, China
| | - H Zhang
- Department of Neurosurgery (S.X., H.Z., T.H.), Xuanwu Hospital, Capital Medical University, Beijing, China
| | - P Taussky
- Neurosurgical Service (M.M.S., A.E.-M., P.T., C.S.O.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Department of Neurosurgery (P.T., R.G.), University of Utah, Salt Lake City, Utah
| | - R Grandhi
- Department of Neurosurgery (P.T., R.G.), University of Utah, Salt Lake City, Utah
| | - M Waqas
- Department of Neurosurgery (M.W., V.M.T., A.H.S., E.I.L.), State University of New York at Buffalo, Buffalo, New York
| | - A S Aldine
- From the Departments of Neurosurgery and Interventional Neuroradiology (N.A., M.D., H.H.C., A.S.A., A.A.), Louisiana State University Hospital, Shreveport, Louisiana
| | - V M Tutino
- Department of Neurosurgery (M.W., V.M.T., A.H.S., E.I.L.), State University of New York at Buffalo, Buffalo, New York
| | - A Aslan
- From the Departments of Neurosurgery and Interventional Neuroradiology (N.A., M.D., H.H.C., A.S.A., A.A.), Louisiana State University Hospital, Shreveport, Louisiana
| | - A H Siddiqui
- Department of Neurosurgery (M.W., V.M.T., A.H.S., E.I.L.), State University of New York at Buffalo, Buffalo, New York
| | - E I Levy
- Department of Neurosurgery (M.W., V.M.T., A.H.S., E.I.L.), State University of New York at Buffalo, Buffalo, New York
| | - C S Ogilvy
- Neurosurgical Service (M.M.S., A.E.-M., P.T., C.S.O.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - A J Thomas
- Department of Neurological Surgery (A.J.T.), Cooper University Health Care, Cooper Medical School of Rowan University, Camden, New Jersey
| | - C Ulfert
- Department of Neuroradiology (C.U., M.A.M.), Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - M A Möhlenbruch
- Department of Neuroradiology (C.U., M.A.M.), Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - L Renieri
- Department of Interventional Neuroradiology (L.R.), University of Florence, Florence, Italy
| | - J D Bengzon Diestro
- Division of Diagnostic and Therapeutic Neuroradiology (J.D.B.D., J.S., T.R.M.), St. Michael's Hospital, Toronto, Ontario, Canada
| | - G Lanzino
- Department of Neurological Surgery (G.L., W.B.), Mayo Clinic, Rochester, Minnesota
| | - W Brinjikji
- Department of Neurological Surgery (G.L., W.B.), Mayo Clinic, Rochester, Minnesota
| | - J Spears
- Division of Diagnostic and Therapeutic Neuroradiology (J.D.B.D., J.S., T.R.M.), St. Michael's Hospital, Toronto, Ontario, Canada
| | - J E Vranic
- Neuroendovascular Program (J.E.V., R.W.R., J.D.R., P.H., S.M., K.S.C., M.A.A.-S., C.J.S., A.B.P., A.A.D.), Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - R W Regenhardt
- Neuroendovascular Program (J.E.V., R.W.R., J.D.R., P.H., S.M., K.S.C., M.A.A.-S., C.J.S., A.B.P., A.A.D.), Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - J D Rabinov
- Neuroendovascular Program (J.E.V., R.W.R., J.D.R., P.H., S.M., K.S.C., M.A.A.-S., C.J.S., A.B.P., A.A.D.), Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - P Harker
- Neuroendovascular Program (J.E.V., R.W.R., J.D.R., P.H., S.M., K.S.C., M.A.A.-S., C.J.S., A.B.P., A.A.D.), Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - E Müller-Thies-Broussalis
- Department of Neurology/Institut of Neurointervention (C.J.G., E.M.-T.-B., M.K.-O.), University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - M Killer-Oberpfalzer
- Department of Neurology/Institut of Neurointervention (C.J.G., E.M.-T.-B., M.K.-O.), University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - C Islak
- Department of Neuroradiology (C.I., N.K.), Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
| | - N Kocer
- Department of Neuroradiology (C.I., N.K.), Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
| | - M Sonnberger
- Department of Neuroradiology (M.S.), Kepler Universitätsklinikum Linz, Linz, Austria
| | - T Engelhorn
- Department of Neuroradiology (T.E.), University Hospital Erlangen, Erlangen, Germany
| | - A Kapadia
- Departments of Medical Imaging and Neurosurgery (A.K.), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - V X D Yang
- Neurointerventional Program (V.X.D.Y., A.A.D.), Departments of Medical Imaging & Clinical Neurological Sciences, London Health Sciences Centre, Western University, Ontario, Canada
| | - A Salehani
- Department of Neurosurgery (A. Salehani, M.R.H.), University of Alabama at Birmingham, Birmingham, Alabama
| | - M R Harrigan
- Department of Neurosurgery (A. Salehani, M.R.H.), University of Alabama at Birmingham, Birmingham, Alabama
| | - T Krings
- Division of Interventional Neuroradiology (T.K.), Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - C C Matouk
- Department of Neurosurgery (C.C.M.), Yale School of Medicine, New Haven, Connecticut
| | - S Mirshahi
- Neuroendovascular Program (J.E.V., R.W.R., J.D.R., P.H., S.M., K.S.C., M.A.A.-S., C.J.S., A.B.P., A.A.D.), Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - K S Chen
- Neuroendovascular Program (J.E.V., R.W.R., J.D.R., P.H., S.M., K.S.C., M.A.A.-S., C.J.S., A.B.P., A.A.D.), Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - M A Aziz-Sultan
- Neuroendovascular Program (J.E.V., R.W.R., J.D.R., P.H., S.M., K.S.C., M.A.A.-S., C.J.S., A.B.P., A.A.D.), Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - M Ghorbani
- Division of Vascular and Endovascular Neurosurgery (M.G.), Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - C M Schirmer
- Departments of Neurosurgery and Radiology (C.J.G., C.M.S., O.G., S.S.D.), Geisinger, Danville, Pennsylvania
| | - O Goren
- Departments of Neurosurgery and Radiology (C.J.G., C.M.S., O.G., S.S.D.), Geisinger, Danville, Pennsylvania
| | - S S Dalal
- Departments of Neurosurgery and Radiology (C.J.G., C.M.S., O.G., S.S.D.), Geisinger, Danville, Pennsylvania
| | - T Finkenzeller
- Institute of Radiology and Neuroradiology (T.F., M.H.), Klinikum Nuernberg Sued, Paracelsus Medical University Nuernberg, Nuernberg, Germany
| | - M Holtmannspötter
- Institute of Radiology and Neuroradiology (T.F., M.H.), Klinikum Nuernberg Sued, Paracelsus Medical University Nuernberg, Nuernberg, Germany
- Department of Neuroradiology (M.H.), Klinikum Weiden, Weiden, Germany
| | - J-H Buhk
- Department of Neuroradiology (J.-H.B.), University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - P M Foreman
- Neuroscience and Rehabilitation Institute (P.M.F., M.C.C., R.A.H.), Orlando Health, Orlando, Florida
| | - M C Cress
- Neuroscience and Rehabilitation Institute (P.M.F., M.C.C., R.A.H.), Orlando Health, Orlando, Florida
| | - R A Hirschl
- Neuroscience and Rehabilitation Institute (P.M.F., M.C.C., R.A.H.), Orlando Health, Orlando, Florida
| | - W Reith
- Clinic for Diagnostic and Interventional Neuroradiology (W.R., A. Simgen), Universitätsklinikum des Saarlandes, Homburg/Saar, Germany
| | - A Simgen
- Clinic for Diagnostic and Interventional Neuroradiology (W.R., A. Simgen), Universitätsklinikum des Saarlandes, Homburg/Saar, Germany
| | - H Janssen
- Institute for Neuroradiology (H.J.), Klinikum Ingolstadt, Ingolstadt, Germany
| | - T R Marotta
- Division of Diagnostic and Therapeutic Neuroradiology (J.D.B.D., J.S., T.R.M.), St. Michael's Hospital, Toronto, Ontario, Canada
| | - C J Stapleton
- Neuroendovascular Program (J.E.V., R.W.R., J.D.R., P.H., S.M., K.S.C., M.A.A.-S., C.J.S., A.B.P., A.A.D.), Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - A B Patel
- Neuroendovascular Program (J.E.V., R.W.R., J.D.R., P.H., S.M., K.S.C., M.A.A.-S., C.J.S., A.B.P., A.A.D.), Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - A A Dmytriw
- Neurointerventional Program (V.X.D.Y., A.A.D.), Departments of Medical Imaging & Clinical Neurological Sciences, London Health Sciences Centre, Western University, Ontario, Canada
- Neuroendovascular Program (J.E.V., R.W.R., J.D.R., P.H., S.M., K.S.C., M.A.A.-S., C.J.S., A.B.P., A.A.D.), Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Potreck A, Scheidecker E, Weyland CS, Neuberger U, Herweh C, Möhlenbruch MA, Chen M, Nagel S, Bendszus M, Seker F. RAPID CT Perfusion-Based Relative CBF Identifies Good Collateral Status Better Than Hypoperfusion Intensity Ratio, CBV-Index, and Time-to-Maximum in Anterior Circulation Stroke. AJNR Am J Neuroradiol 2022; 43:960-965. [PMID: 35680162 DOI: 10.3174/ajnr.a7542] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 04/27/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND PURPOSE Information of collateral flow may help to determine eligibility for thrombectomy. Our aim was to identify CT perfusion-based surrogate parameters of good collateral status in acute anterior circulation ischemic stroke. MATERIALS AND METHODS In this retrospective study, we assessed the collateral status of 214 patients who presented with acute ischemic stroke due to occlusion of the MCA M1 segment or the carotid terminus. Collaterals were assessed on dynamic CTA images analogous to the multiphase CTA score by Menon et al. CT perfusion parameters (time-to-maximum, relative CBF, hypoperfusion intensity ratio, and CBV-index) were assessed with RAPID software. The Spearman rank correlation and receiver operating characteristic analyses were performed to identify the parameters that correlate with collateral scores and good collateral supply (defined as a collateral score of ≥4). RESULTS The Spearman rank correlation was highest for a relative CBF < 38% volume (ρ = -0.66, P < .001), followed by the hypoperfusion intensity ratio (ρ = -0.49, P < .001), CBV-index (ρ = 0.51, P < .001), and time-to-maximum > 8 seconds (ρ = -0.54, P < .001). Good collateral status was better identified by a relative CBF < 38% at a lesion size <27 mL (sensitivity of 75%, specificity of 80%) compared with a hypoperfusion intensity ratio of <0.4 (sensitivity of 75%, specificity of 62%), CBV-index of >0.8 (sensitivity of 60%, specificity of 78%), and time-to-maximum > 8 seconds (sensitivity of 68%, specificity of 76%). CONCLUSIONS Automated CT perfusion analysis allows accurate identification of collateral status in acute ischemic stroke. A relative CBF < 38% may be a better perfusion-based indicator of good collateral supply compared with time-to-maximum, the hypoperfusion intensity ratio, and the CBV-index.
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Affiliation(s)
- A Potreck
- From the Department of Neuroradiology (A.P., E.S., C.S.W., U.N., C.H., M.A.M., M.B., F.S.)
| | - E Scheidecker
- From the Department of Neuroradiology (A.P., E.S., C.S.W., U.N., C.H., M.A.M., M.B., F.S.)
| | - C S Weyland
- From the Department of Neuroradiology (A.P., E.S., C.S.W., U.N., C.H., M.A.M., M.B., F.S.)
| | - U Neuberger
- From the Department of Neuroradiology (A.P., E.S., C.S.W., U.N., C.H., M.A.M., M.B., F.S.)
| | - C Herweh
- From the Department of Neuroradiology (A.P., E.S., C.S.W., U.N., C.H., M.A.M., M.B., F.S.)
| | - M A Möhlenbruch
- From the Department of Neuroradiology (A.P., E.S., C.S.W., U.N., C.H., M.A.M., M.B., F.S.)
| | - M Chen
- Neurology (M.C., S.N.), Heidelberg University Hospital, Heidelberg, Germany
| | - S Nagel
- Neurology (M.C., S.N.), Heidelberg University Hospital, Heidelberg, Germany
| | - M Bendszus
- From the Department of Neuroradiology (A.P., E.S., C.S.W., U.N., C.H., M.A.M., M.B., F.S.)
| | - F Seker
- From the Department of Neuroradiology (A.P., E.S., C.S.W., U.N., C.H., M.A.M., M.B., F.S.)
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Laible M, Jenetzky E, Möhlenbruch MA, Bendszus M, Ringleb PA, Rizos T. The Impact of Post-contrast Acute Kidney Injury on In-hospital Mortality After Endovascular Thrombectomy in Patients With Acute Ischemic Stroke. Front Neurol 2021; 12:665614. [PMID: 34163423 PMCID: PMC8215575 DOI: 10.3389/fneur.2021.665614] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 04/20/2021] [Indexed: 01/22/2023] Open
Abstract
Background and Purpose: Clinical outcome and mortality after endovascular thrombectomy (EVT) in patients with ischemic stroke are commonly assessed after 3 months. In patients with acute kidney injury (AKI), unfavorable results for 3-month mortality have been reported. However, data on the in-hospital mortality after EVT in this population are sparse. In the present study, we assessed whether AKI impacts in-hospital and 3-month mortality in patients undergoing EVT. Materials and Methods: From a prospectively recruiting database, consecutive acute ischemic stroke patients receiving EVT between 2010 and 2018 due to acute large vessel occlusion were included. Post-contrast AKI (PC-AKI) was defined as an increase of baseline creatinine of ≥0.5 mg/dL or >25% within 48 h after the first measurement at admission. Adjusting for potential confounders, associations between PC-AKI and mortality after stroke were tested in univariate and multivariate logistic regression models. Results: One thousand one hundred sixty-nine patients were included; 166 of them (14.2%) died during the acute hospital stay. Criteria for PC-AKI were met by 29 patients (2.5%). Presence of PC-AKI was associated with a significantly higher risk of in-hospital mortality in multivariate analysis [odds ratio (OR) = 2.87, 95% confidence interval (CI) = 1.16–7.13, p = 0.023]. Furthermore, factors associated with in-hospital mortality encompassed higher age (OR = 1.03, 95% CI = 1.01–1.04, p = 0.002), stroke severity (OR = 1.05, 95% CI = 1.03–1.08, p < 0.001), symptomatic intracerebral hemorrhage (OR = 3.20, 95% CI = 1.69–6.04, p < 0.001), posterior circulation stroke (OR = 2.85, 95% CI = 1.72–4.71, p < 0.001), and failed recanalization (OR = 2.00, 95% CI = 1.35–3.00, p = 0.001). Conclusion: PC-AKI is rare after EVT but represents an important risk factor for in-hospital mortality and for mortality within 3 months after hospital discharge. Preventing PC-AKI after EVT may represent an important and potentially lifesaving effort in future daily clinical practice.
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Affiliation(s)
- Mona Laible
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany.,Department of Neurology, University of Ulm, Ulm, Germany
| | - Ekkehart Jenetzky
- Faculty of Health/School of Medicine, Witten/Herdecke University, Witten, Germany.,Department for Child and Adolescent Psychiatry, Johannes Gutenberg-University, Mainz, Germany
| | | | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Timolaos Rizos
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
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6
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Neuberger U, Vollmuth P, Nagel S, Schönenberger S, Weyland CS, Gumbinger C, Ringleb PA, Bendszus M, Pfaff JAR, Möhlenbruch MA. Optimal thresholds to predict long-term outcome after complete endovascular recanalization in acute anterior ischemic stroke. J Neurointerv Surg 2021; 13:1124-1127. [PMID: 33479038 DOI: 10.1136/neurintsurg-2020-016997] [Citation(s) in RCA: 2] [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: 10/16/2020] [Revised: 12/07/2020] [Accepted: 12/12/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Despite complete endovascular recanalization, a significant percentage of patients with acute anterior stroke do not achieve a good clinical outcome. We analyzed optimal thresholds of relevant parameters to discern functional independence after successful endovascular recanalization and test their predictive performance. METHODS Patients with acute anterior ischemic stroke undergoing endovascular treatment between April 2015 and November 2019 were retrospectively analyzed. Only patients with premorbid modified Rankin Scale (mRS) score <3 and complete recanalization (modified Thrombolysis In Cerebral Infarction 2c/3) were included. Optimal thresholds of the most important variables predicting functional independence (mRS 0-2 after 90 days) were calculated using receiver operating characteristic curves and their predictive performance was tested in an independent dataset using machine learning algorithms. RESULTS Overall, 371 patients met the inclusion criteria. Optimal thresholds for the overall most important variables to predict functional independence were (1) National Institutes of Health Stroke Scale (NIHSS) score ≤5 after 24 hours (area under the curve (AUC) 0.88 (95% CI 0.84 to 0.92)); (2) Alberta Stroke Program Early CT Score (ASPECTS) ≥7 on follow-up CT (AUC 0.72 (95% CI 0.68 to 0.77)); and (3) change in NIHSS score ≥8 after 24 hours (AUC 0.70 (95% CI 0.65 to 0.74)). The performance of these thresholds to predict a good outcome using machine learning in the independent dataset was evaluated for (1) NIHSS score ≤5 after 24 hours (AUC 0.76 (95% CI 0.71 to 0.81)); (2) follow-up ASPECTS ≥7 (AUC 0.64 (95% CI 0.58 to 0.70)); (3) change in NIHSS score ≥8 after 24 hours (AUC 0.61 (95% CI 0.55 to 0.67)); and (4) the combination of all three parameters (AUC 0.84 (95% CI 0.80 to 0.88)). CONCLUSIONS After complete recanalization in acute anterior circulation ischemic stroke, a good long-term outcome could be accurately predicted reaching NIHSS score ≤5 after 24 hours.
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Affiliation(s)
- Ulf Neuberger
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Philipp Vollmuth
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Simon Nagel
- Clinic of Neurology, University Hospital Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Silvia Schönenberger
- Clinic of Neurology, University Hospital Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Charlotte Sabine Weyland
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Christoph Gumbinger
- Clinic of Neurology, University Hospital Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Peter Arthur Ringleb
- Clinic of Neurology, University Hospital Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Johannes Alex Rolf Pfaff
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Markus Alfred Möhlenbruch
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Baden-Württemberg, Germany
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Schmitt N, Floca RO, Paech D, El Shafie RA, Seker F, Bendszus M, Möhlenbruch MA, Vollherbst DF. Imaging Artifacts of Liquid Embolic Agents on Conventional CT in an Experimental in Vitro Model. AJNR Am J Neuroradiol 2021; 42:126-131. [PMID: 33214178 DOI: 10.3174/ajnr.a6867] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 08/14/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND AND PURPOSE Endovascular embolization using liquid embolic agents is a safe and effective treatment option for AVMs and dural arteriovenous fistulas. The aim of this study was to assess the degree of artifact inducement by the most frequently used liquid embolic agents in conventional CT in an experimental in vitro model. MATERIALS AND METHODS Dimethyl-sulfoxide-compatible tubes were filled with the following liquid embolic agents (n = 10, respectively): Onyx 18, all variants of Squid, PHIL 25%, PHIL LV, and n-BCA mixed with iodized oil. After inserting the tubes into a CT imaging phantom, we acquired images. Artifacts were graded quantitatively by the use of Hounsfield units in a donut-shaped ROI using a customized software application that was specifically designed for this study and were graded qualitatively using a 5-point scale. RESULTS Quantitative and qualitative analyses revealed the most artifacts for Onyx 18 and the least artifacts for n-BCA, PHIL 25%, and PHIL LV. Squid caused more artifacts compared with PHIL, both for the low-viscosity and for the extra-low-viscosity versions (eg, quantitative analysis, Squid 18: mean ± SD, 30.3 ± 9.7 HU versus PHIL 25%: mean ± SD, 10.6 ± 0.8 HU; P < .001). Differences between the standard and low-density variants of Squid were observed only quantitatively for Squid 12. There were no statistical differences between the different concentrations of Squid and PHIL. CONCLUSIONS In this systematic in vitro analysis investigating the most commonly used liquid embolic agents, relevant differences in CT imaging artifacts could be demonstrated. Ethylene-vinyl alcohol-based liquid embolic agents induced more artifacts compared with liquid embolic agents that use iodine as a radiopaque component.
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Affiliation(s)
- N Schmitt
- From the Departments of Neuroradiology (N.S., F.S., M.B., M.A.M., D.F.V.)
| | - R O Floca
- Radiation Oncology (R.O.F., R.A.E.S.), Heidelberg University Hospital, Heidelberg, Germany
- Medical and Biological Informatics (R.O.F.)
- Heidelberg Institute for Radiation Oncology and National Center for Radiation Research in Oncology (R.O.F.), Heidelberg, Germany
| | - D Paech
- Department of Radiology (D.P.), German Cancer Research Center, Heidelberg, Germany
| | - R A El Shafie
- Radiation Oncology (R.O.F., R.A.E.S.), Heidelberg University Hospital, Heidelberg, Germany
| | - F Seker
- From the Departments of Neuroradiology (N.S., F.S., M.B., M.A.M., D.F.V.)
| | - M Bendszus
- From the Departments of Neuroradiology (N.S., F.S., M.B., M.A.M., D.F.V.)
| | - M A Möhlenbruch
- From the Departments of Neuroradiology (N.S., F.S., M.B., M.A.M., D.F.V.)
| | - D F Vollherbst
- From the Departments of Neuroradiology (N.S., F.S., M.B., M.A.M., D.F.V.)
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8
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Vollherbst DF, Berlis A, Maurer C, Behrens L, Sirakov S, Sirakov A, Fischer S, Maus V, Holtmannspötter M, Rautio R, Sinisalo M, Poncyljusz W, Janssen H, Wodarg F, Kabbasch C, Trenkler J, Herweh C, Bendszus M, Möhlenbruch MA. Periprocedural Safety and Feasibility of the New LVIS EVO Device for Stent-Assisted Coiling of Intracranial Aneurysms: An Observational Multicenter Study. AJNR Am J Neuroradiol 2020; 42:319-326. [PMID: 33303523 DOI: 10.3174/ajnr.a6887] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 09/07/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND PURPOSE Stent-assisted treatment techniques can be an effective treatment option for intracranial aneurysms. The aim of this study was to evaluate the periprocedural feasibility and safety of the new LVIS EVO stent for the treatment of intracranial aneurysms. MATERIALS AND METHODS Patients with intracranial aneurysms treated with the LVIS EVO in 11 European neurovascular centers were retrospectively reviewed. Patient and aneurysm characteristics, procedural parameters, immediate grade of occlusion, and technical and clinical complications were assessed. RESULTS Fifty-seven patients with 59 aneurysms were treated with the LVIS EVO device; 57.6% of the aneurysms were incidental; 15.3% were acutely ruptured; 15.3% were recanalized or residual aneurysms; and 11.9% were treated for symptoms other than acute hemorrhage. The most frequent aneurysm locations were the middle cerebral artery (25.4%) and the anterior communicating artery (22.0%). The rate of immediate successful deployment was 93.2%. In 6.8% (n = 4) of cases, additional in-stent angioplasty was needed. The immediate complete occlusion rate was 54.2%, while there was a residual aneurysm in 35.6% and a residual neck in 10.2%. Periprocedural technical complications occurred in 7/59 treatments (11.9%; the most frequent technical complication [n = 3] was thrombus formation), which all resolved completely without clinical sequelae. Postprocedural neurologic complications occurred after 4/59 treatments (6.8%; 2 transient ischemic attacks, 1 minor stroke, 1 major stroke), of which only 1 persistent complication was directly related to the procedure (minor stroke in the vascular territory distal to the stent). CONCLUSIONS The LVIS EVO stent is a safe, feasible device for the treatment of intracranial aneurysms.
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Affiliation(s)
- D F Vollherbst
- From the Department of Neuroradiology (D.F.V., C.H., M.B., M.A.M.), Heidelberg University Hospital, Heidelberg, Germany
| | - A Berlis
- Department of Diagnostic and Interventional Radiology and Neuroradiology (A.B., C.M., L.B.), Universitätsklinikum Augsburg, Augsburg, Germany
| | - C Maurer
- Department of Diagnostic and Interventional Radiology and Neuroradiology (A.B., C.M., L.B.), Universitätsklinikum Augsburg, Augsburg, Germany
| | - L Behrens
- Department of Diagnostic and Interventional Radiology and Neuroradiology (A.B., C.M., L.B.), Universitätsklinikum Augsburg, Augsburg, Germany
| | - S Sirakov
- Radiology Department (S.S., A.S.), University Hospital Saint Ivan Rilski, Sofia, Bulgaria
| | - A Sirakov
- Radiology Department (S.S., A.S.), University Hospital Saint Ivan Rilski, Sofia, Bulgaria
| | - S Fischer
- Department of Neuroradiology (S.F., V.M.), Knappschaftskrankenhaus, Recklinghausen, Germany
| | - V Maus
- Department of Neuroradiology (S.F., V.M.), Knappschaftskrankenhaus, Recklinghausen, Germany
| | - M Holtmannspötter
- Institute of Radiology and Neuroradiology (M.H.), Klinikum Nuernberg Sued, Paracelsus Medical University, Nuernberg, Germany
| | - R Rautio
- Department of Interventional Radiology (R.R., M.S.), Turku University Hospital, Turku, Finland
| | - M Sinisalo
- Department of Interventional Radiology (R.R., M.S.), Turku University Hospital, Turku, Finland
| | - W Poncyljusz
- Department of Diagnostic Imaging and Interventional Radiology (W.P.), Pomeranian Medical University, Szczecin, Poland
| | - H Janssen
- Department of Neuroradiology (H.J.), Ingolstadt General Hospital, Ingolstadt, Germany
| | - F Wodarg
- Department of Radiology and Neuroradiology (F.W.), University Hospital Schleswig-Holstein, Kiel, Germany
| | - C Kabbasch
- Institute for Diagnostic and Interventional Radiology (C.K.), Faculty of Medicine, University Hospital Cologne, Cologne, Germany
| | - J Trenkler
- Institute of Neuroradiology (J.T.), Kepler University Hospital, Linz, Austria
| | - C Herweh
- From the Department of Neuroradiology (D.F.V., C.H., M.B., M.A.M.), Heidelberg University Hospital, Heidelberg, Germany
| | - M Bendszus
- From the Department of Neuroradiology (D.F.V., C.H., M.B., M.A.M.), Heidelberg University Hospital, Heidelberg, Germany
| | - M A Möhlenbruch
- From the Department of Neuroradiology (D.F.V., C.H., M.B., M.A.M.), Heidelberg University Hospital, Heidelberg, Germany
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9
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Möhlenbruch MA, Seker F, Özlük E, Kizilkilic O, Broussalis E, Killer-Oberpfalzer M, Griessenauer CJ, Bendszus M, Kocer N. Treatment of Ruptured Blister-Like Aneurysms with the FRED Flow Diverter: A Multicenter Experience. AJNR Am J Neuroradiol 2020; 41:2280-2284. [PMID: 33122212 DOI: 10.3174/ajnr.a6849] [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] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 08/05/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE Treatment of ruptured blister-like aneurysms is technically challenging. This study aimed at analyzing the safety and efficacy of the Flow-Redirection Endoluminal Device (FRED) in the treatment of ruptured blister-like aneurysms. MATERIALS AND METHODS In a retrospective multicenter study, all patients treated with the FRED due to a ruptured intracranial blister-like aneurysm between January 2013 and May 2019 were analyzed. The primary end points for clinical safety were mRS 0-2 at 6 months after treatment and the absence of major ipsilateral stroke or death. The primary end points for efficacy were the absence of rebleeding after treatment and complete angiographic occlusion according to the O'Kelly-Marotta classification at 6 months after treatment. RESULTS In total, 30 patients with 30 ruptured blister-like aneurysms were treated. Immediate complete aneurysm obliteration (O'Kelly-Marotta classification D) with the FRED was achieved in 10 patients (33%). Of the 26 patients with follow-up, complete obliteration was achieved in 21 patients (80%) after 6 months and in 24 patients (92%) in the final follow-up (median, 22 months). Twenty-three patients (77%) achieved mRS 0-2 at 6 months. Major stroke or death occurred in 17%. Two patients died due to pneumonia, and 2 patients died due to infarction following cerebral vasospasm. There was no case of rebleeding after FRED implantation. There was 1 case of delayed asymptomatic stent occlusion. CONCLUSIONS Treatment of ruptured blister-like aneurysms with the FRED is safe and effective.
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Affiliation(s)
- M A Möhlenbruch
- From the Department of Neuroradiology (M.A.M., F.S., M.B.), Heidelberg University Hospital, Heidelberg, Germany
| | - F Seker
- From the Department of Neuroradiology (M.A.M., F.S., M.B.), Heidelberg University Hospital, Heidelberg, Germany
| | - E Özlük
- Department of Radiology (E.Ö.), Acibadem University Atakent International Hospital, Istanbul, Turkey
| | - O Kizilkilic
- Division of Neuroradiology (O.K., N.K.), Department of Radiology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - E Broussalis
- Research Institute of Neurointervention (E.B., M.K.-O., C.J.G.), Paracelsus Medical University, Salzburg, Austria
| | - M Killer-Oberpfalzer
- Research Institute of Neurointervention (E.B., M.K.-O., C.J.G.), Paracelsus Medical University, Salzburg, Austria
| | - C J Griessenauer
- Research Institute of Neurointervention (E.B., M.K.-O., C.J.G.), Paracelsus Medical University, Salzburg, Austria
| | - M Bendszus
- From the Department of Neuroradiology (M.A.M., F.S., M.B.), Heidelberg University Hospital, Heidelberg, Germany
| | - N Kocer
- Division of Neuroradiology (O.K., N.K.), Department of Radiology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
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10
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Zaoui K, Jung A, Wimmer W, Engel M, Möhlenbruch MA, Federspil PA. Topographic bone thickness maps to evaluate the intuitive placement of titanium miniplates for nasal prostheses. Int J Oral Maxillofac Surg 2020; 49:1232-1241. [PMID: 32204964 DOI: 10.1016/j.ijom.2020.02.009] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 01/10/2020] [Accepted: 02/26/2020] [Indexed: 11/28/2022]
Abstract
The aim of this study was to evaluate the intuitive placement of titanium miniplates. The hypothesis was that virtual planning can improve miniplate placement. Twenty patients were included in the study. These patients were fitted with 21 titanium miniplates (16 y-plates, three t-plates, and two u-plates) to retain nasal prostheses between 2005 and 2017. Colour-coded topographic bone thickness maps (TBTMs) were created in fused pre- and postoperative computed tomography. Implants were virtually transposed at the position of highest bone thickness. The bone thickness index (BTI) was calculated as the sum of points assigned at each screw (1 point per millimetre up to 4 mm, and 5 points for greater values) divided by the number of screws. One plate broke after 2.8 years, thus plate survival after 5 years was 91% using the Kaplan-Meier method. The BTI for all 21 plates increased from 3.4 to 4.1 points using virtual transposition (P<0.001). No significant changes were observed in t- and u-plates, but the median BTI increased from 3.1 to 4.1 points (P<0.0005) in 16 y-plates. The change was substantial (≥0.5 points) in 9/16 y-plates. Therefore, the hypothesis that virtual planning improves implant placement was accepted.
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Affiliation(s)
- K Zaoui
- Department of Otorhinolaryngology, University Hospital Heidelberg, Germany
| | - A Jung
- Department of Otorhinolaryngology, University Hospital Heidelberg, Germany
| | - W Wimmer
- Hearing Research Laboratory, ARTORG Center for Biomedical Engineering Research, University of Bern, Switzerland; Department of Otolaryngology, Bern University Hospital, Inselspital, University of Bern, Switzerland
| | - M Engel
- Department of Oral and Maxillofacial Surgery, University Hospital Heidelberg, Germany
| | - M A Möhlenbruch
- Department of Neuroradiology, University Hospital Heidelberg, Germany
| | - P A Federspil
- Department of Otorhinolaryngology, University Hospital Heidelberg, Germany.
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11
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Griessenauer CJ, Möhlenbruch MA, Hendrix P, Ulfert C, Islak C, Sonnberger M, Engelhorn T, Müller-Thies-Broussalis E, Finkenzeller T, Holtmannspötter M, Buhk JH, Reith W, Simgen A, Janssen H, Kocer N, Killer-Oberpfalzer M. The FRED for Cerebral Aneurysms of the Posterior Circulation: A Subgroup Analysis of the EuFRED Registry. AJNR Am J Neuroradiol 2020; 41:658-662. [PMID: 32115421 DOI: 10.3174/ajnr.a6447] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 01/14/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Flow diversion for the posterior circulation remains a promising treatment option for selected posterior circulation aneurysms. The Flow-Redirection Intraluminal Device (FRED) system has not been previously assessed in a large cohort of patients with posterior circulation aneurysms. The purpose of the present study was to assess safety and efficacy of FRED in this location. MATERIALS AND METHODS Consecutive patients with posterior circulation aneurysms treated at 8 centers participating in the European FRED study (EuFRED) between April 2012 and January 2019 were retrospectively reviewed. Complication and radiographic and functional outcomes were evaluated. RESULTS Eighty-four patients (median age, 54 years) with 84 posterior circulation aneurysms were treated with the FRED. A total of 25 aneurysms (29.8%) had previously ruptured, even though most aneurysms were diagnosed incidentally (45.2%). The intradural vertebral artery was the most common location (50%), and saccular, the most common morphology (40.5%). The median size was 7 mm. There were 8 (9.5%) symptomatic thromboembolic and no hemorrhagic complications. Thromboembolic complications occurred mostly (90.9%) in nonsaccular aneurysms. On last follow-up at a median of 24 months, 78.2% of aneurysms were completely occluded. Functional outcome at a median of 27 months was favorable in 94% of patients. All mortalities occurred in patients with acute subarachnoid hemorrhage and its sequelae. CONCLUSIONS The largest cohort of posterior circulation aneurysms treated with the FRED to date demonstrated favorable safety and efficacy profiles of the device for this indication. Treatment in the setting of acute subarachnoid hemorrhage was strongly related to mortality, regardless of whether procedural complications occurred.
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Affiliation(s)
- C J Griessenauer
- From the Research Institute of Neurointervention (C.J.G., E.M.-T.-B., M.K.-O.), Paracelsus Medical University, Salzburg, Austria .,Department of Neurosurgery (C.J.G.), Geisinger, Danville, Pennsylvania
| | - M A Möhlenbruch
- Department of Neuroradiology (M.A.M., C.U.), Heidelberg University Hospital, Heidelberg, Germany
| | - P Hendrix
- Department of Neurosurgery (P.H.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg/Saar, Germany
| | - C Ulfert
- Department of Neuroradiology (M.A.M., C.U.), Heidelberg University Hospital, Heidelberg, Germany
| | - C Islak
- Department of Neuroradiology (C.I., N.K.), Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
| | - M Sonnberger
- Department of Neuroradiology (M.S.), Kepler Universitätsklinikum, Linz, Austria
| | - T Engelhorn
- Department of Neuroradiology (T.E.), University Hospital Erlangen, Erlangen, Germany
| | - E Müller-Thies-Broussalis
- From the Research Institute of Neurointervention (C.J.G., E.M.-T.-B., M.K.-O.), Paracelsus Medical University, Salzburg, Austria
| | - T Finkenzeller
- Institute of Radiology and Neuroradiology (T.F., M.H.), Klinikum Nuernberg Sued, Paracelsus Medical University, Nuernberg, Germany.,Department of Neuroradiology (T.F.), Klinikum Weiden, Weiden, Bavaria, Germany
| | - M Holtmannspötter
- Institute of Radiology and Neuroradiology (T.F., M.H.), Klinikum Nuernberg Sued, Paracelsus Medical University, Nuernberg, Germany
| | - J-H Buhk
- Department of Neuroradiology (J.-H.B.), University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - W Reith
- Clinic for Diagnostic and Interventional Neuroradiology (W.R., A.S.), Universitätsklinikum des Saarlandes, Homburg/Saar, Homburg, Saarland, Germany
| | - A Simgen
- Clinic for Diagnostic and Interventional Neuroradiology (W.R., A.S.), Universitätsklinikum des Saarlandes, Homburg/Saar, Homburg, Saarland, Germany
| | - H Janssen
- Institute for Neuroradiology (H.J.), Klinikum Ingolstadt, Ingolstadt, Germany
| | - N Kocer
- Department of Neuroradiology (C.I., N.K.), Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
| | - M Killer-Oberpfalzer
- From the Research Institute of Neurointervention (C.J.G., E.M.-T.-B., M.K.-O.), Paracelsus Medical University, Salzburg, Austria
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12
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Neuberger U, Nagel S, Pfaff J, Ringleb PA, Herweh C, Bendszus M, Möhlenbruch MA, Kickingereder P. Impact of slice thickness on clinical utility of automated Alberta Stroke Program Early Computed Tomography Scores. Eur Radiol 2020; 30:3137-3145. [DOI: 10.1007/s00330-019-06616-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 11/14/2019] [Accepted: 12/11/2019] [Indexed: 11/24/2022]
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13
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Maurer CJ, Dobrocky T, Joachimski F, Neuberger U, Demerath T, Brehm A, Cianfoni A, Gory B, Berlis A, Gralla J, Möhlenbruch MA, Blackham KA, Psychogios MN, Zickler P, Fischer S. Endovascular Thrombectomy of Calcified Emboli in Acute Ischemic Stroke: A Multicenter Study. AJNR Am J Neuroradiol 2020; 41:464-468. [PMID: 32029470 DOI: 10.3174/ajnr.a6412] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 12/23/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND PURPOSE Large intracranial vessel occlusion due to calcified emboli is a rare cause of major stroke. We assessed the prevalence, imaging appearance, the effectiveness of mechanical thrombectomy, and clinical outcome of patients with large-vessel occlusion due to calcified emboli. MATERIALS AND METHODS We performed a retrospective analysis of clinical and procedural data of consecutive patients who underwent mechanical thrombectomy due to calcified emboli in 7 European stroke centers. RESULTS We screened 2969 patients, and 40 patients matched the inclusion criteria, accounting for a prevalence of 1.3%. The mean maximal density of the thrombus was 327 HU (range, 150-1200 HU), and the mean thrombus length was 9.2 mm (range, 4-20 mm). Four patients had multiple calcified emboli, and 2 patients had an embolic event during an endovascular intervention. A modified TICI score of ≥2b was achieved in 57.5% (23/40), with minimal-to-no reperfusion (modified TICI 0-1) in 32.5% (13/40) and incomplete reperfusion (modified TICI 2a) in 10% (4/40). Excellent outcome (mRS 0-1) was achieved in only 20.6%, functional independence (mRS 0-2) in 26.5% and 90-day mortality was 55.9%. CONCLUSIONS Acute ischemic stroke with large-vessel occlusion due to calcified emboli is a rare entity in patients undergoing thrombectomy, with considerably worse angiographic outcome and a higher mortality compared with patients with noncalcified thrombi. Good functional recovery at 3 months can still be achieved in about a quarter of patients.
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Affiliation(s)
- C J Maurer
- From the Departments of Diagnostic and Interventional Radiology and Neuroradiology (C.J.M., F.J., A.Berlis)
| | - T Dobrocky
- University Institute of Diagnostic and Interventional Neuroradiology (T.Dobrocky, J.G.), University of Bern, Inselspital, Bern, Switzerland
| | - F Joachimski
- From the Departments of Diagnostic and Interventional Radiology and Neuroradiology (C.J.M., F.J., A.Berlis)
| | - U Neuberger
- Department of Neuroradiology (U.N., M.A.M.), University of Heidelberg, Heidelberg, Germany
| | - T Demerath
- Department of Neuroradiology (T.Demerath, A.Brehm, K.A.B., M.N.P.), Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - A Brehm
- Department of Neuroradiology (T.Demerath, A.Brehm, K.A.B., M.N.P.), Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland.,Department of Neuroradiology (A.Brehm, M.N.P.), University Medical Center Göttingen, Göttingen, Germany
| | - A Cianfoni
- Department of Neuroradiology (A.C.), Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - B Gory
- Department of Diagnostic and Therapeutic Neuroradiology (B.G.), University Hospital of Nancy, Institut National de la Santé et de la Recherche Médicale U1254, Nancy, France
| | - A Berlis
- From the Departments of Diagnostic and Interventional Radiology and Neuroradiology (C.J.M., F.J., A.Berlis)
| | - J Gralla
- University Institute of Diagnostic and Interventional Neuroradiology (T.Dobrocky, J.G.), University of Bern, Inselspital, Bern, Switzerland
| | - M A Möhlenbruch
- Department of Neuroradiology (U.N., M.A.M.), University of Heidelberg, Heidelberg, Germany
| | - K A Blackham
- Department of Neuroradiology (T.Demerath, A.Brehm, K.A.B., M.N.P.), Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - M N Psychogios
- Department of Neuroradiology (T.Demerath, A.Brehm, K.A.B., M.N.P.), Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland.,Department of Neuroradiology (A.Brehm, M.N.P.), University Medical Center Göttingen, Göttingen, Germany
| | - P Zickler
- Neurology and Neurophysiology (P.Z.), Universitätsklinikum Augsburg, Augsburg, Germany
| | - S Fischer
- Institut für Diagnostische und Interventionelle Radiologie, Neuroradiologie (S.F.), Nuklearmedizin, Knappschaftskrankenhaus Bochum-Langendreer, Universitätsklinik, Bochum, Germany
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Vollherbst DF, Herweh C, Schönenberger S, Seker F, Nagel S, Ringleb PA, Bendszus M, Möhlenbruch MA. The Influence of Angioarchitectural Features on the Success of Endovascular Embolization of Cranial Dural Arteriovenous Fistulas with Onyx. AJNR Am J Neuroradiol 2019; 40:2130-2136. [PMID: 31753837 DOI: 10.3174/ajnr.a6326] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 09/26/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND PURPOSE Endovascular embolization can be an effective treatment for cranial dural arteriovenous fistulas. However, a considerable number of dural arteriovenous fistulas still cannot be treated sufficiently. The purpose of this study was to report our single-center experience of endovascular embolization of dural arteriovenous fistulas with Onyx, including the investigation of the influence of angioarchitectural features on the treatment success. MATERIALS AND METHODS Clinical data, angioarchitectural features, complications, treatment success (defined as complete symptom remission for low-grade dural arteriovenous fistulas and complete occlusion for high-grade dural arteriovenous fistulas), and occlusion rates were assessed. The influence of various angioarchitectural features (including location, pattern of venous drainage, and quantity and origin of feeding arteries) was investigated using multivariable backward logistic regression. RESULTS One hundred four patients with 110 dural arteriovenous fistulas were treated in 132 treatment procedures. Treatment success and complete occlusion rates were 81.8% and 90.9%, respectively. After a mean follow-up of 23.6 months, 95.5% of the patients showed complete symptom remission or symptom relief. The overall complication rate was 8.3% (4.5% asymptomatic, 2.3% transient, and 1.5% permanent complications). Logistic regression showed that ≥10 feeding arteries (P = .041) and involvement of the ascending pharyngeal artery (P = .039) significantly lowered the probability of treatment success. Treatment success tended to be lower for low-grade dural arteriovenous fistulas, Cognard type I dural arteriovenous fistulas, and dural arteriovenous fistulas with involvement of dural branches of the internal carotid artery, however without reaching statistical significance in the multivariable model. CONCLUSIONS The presence of multiple feeding arteries and involvement of the pharyngeal artery negatively influence the treatment success of endovascular embolization of cranial dural arteriovenous fistulas with Onyx.
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Affiliation(s)
- D F Vollherbst
- From the Departments of Neuroradiology (D.F.V., C.H., F.S., M.B., M.A.M.)
| | - C Herweh
- From the Departments of Neuroradiology (D.F.V., C.H., F.S., M.B., M.A.M.)
| | - S Schönenberger
- Neurology (S.S., S.N., P.A.R.), Heidelberg University Hospital, Heidelberg, Germany
| | - F Seker
- From the Departments of Neuroradiology (D.F.V., C.H., F.S., M.B., M.A.M.)
| | - S Nagel
- Neurology (S.S., S.N., P.A.R.), Heidelberg University Hospital, Heidelberg, Germany
| | - P A Ringleb
- Neurology (S.S., S.N., P.A.R.), Heidelberg University Hospital, Heidelberg, Germany
| | - M Bendszus
- From the Departments of Neuroradiology (D.F.V., C.H., F.S., M.B., M.A.M.)
| | - M A Möhlenbruch
- From the Departments of Neuroradiology (D.F.V., C.H., F.S., M.B., M.A.M.)
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15
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Neuberger U, Seker F, Schönenberger S, Nagel S, Ringleb PA, Bendszus M, Pfaff JAR, Möhlenbruch MA. Prediction of intracranial hemorrhages after mechanical thrombectomy of basilar artery occlusion. J Neurointerv Surg 2019; 11:1181-1186. [DOI: 10.1136/neurintsurg-2019-014939] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 04/24/2019] [Accepted: 04/28/2019] [Indexed: 12/30/2022]
Abstract
BackgroundMechanical thrombectomy (MT) achieves high recanalization rates in basilar artery occlusion (BAO). A severe complication of MT in BAO is intracranial hemorrhage (ICH). Yet, knowledge of risk factors for ICH after MT in BAO is limited.ObjectiveTo evaluate clinical and procedural parameters of patients treated with MT owing to BAO to identify potential risk factors for ICH—in particular, symptomatic ICH (sICH), and assess their clinical relevance.MethodsWe conducted a retrospective analysis of 101 consecutive patients presenting with BAO, who were treated with MT in our centre. Important clinical and procedural parameters were analysed as possible predictors for any ICH and sICH according to the Heidelberg Bleeding Classification using univariate tests and multivariate logistic regressions.ResultsICH occurred in 25 (24.8%) patients, with a total of 7 (6.9%) developing sICH. Treatment with glycoprotein IIb/IIIa (GPIIb/IIIa) inhibitors was independently associated with any ICH (OR=24.67, 95% CI 4.90 to 124.03) and sICH (OR=7.08, 95% CI 1.36 to 36.78). Also, a longer onset-to-recanalization time increased the risk of both any ICH (OR=1.17, 95% CI 1.07 to 1.31) and sICH (OR=1.22, 95% CI 1.08 to 1.42). Higher serum glucose levels were associated with a higher incidence of any ICH (OR=1.39, 95% CI 1.06 to 1.85) and a higher risk of a fatal outcome (OR=1.03, 95% CI 1.01 to 1.05).ConclusionAdministration of GPIIb/IIIa inhibitor during the course of MT of BAO was identified as an important risk factor in the development of any ICH and sICH.
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Seker F, Pfaff J, Schönenberger S, Herweh C, Nagel S, Ringleb PA, Bendszus M, Möhlenbruch MA. Clinical Outcome after Thrombectomy in Patients with Stroke with Premorbid Modified Rankin Scale Scores of 3 and 4: A Cohort Study with 136 Patients. AJNR Am J Neuroradiol 2018; 40:283-286. [PMID: 30573460 DOI: 10.3174/ajnr.a5920] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 11/07/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE We aimed to analyze the clinical outcome after mechanical thrombectomy in patients with premorbid mRS 3 and 4 because there are currently no data on this patient group. MATERIALS AND METHODS Between January 2009 and November 2017, all patients with premorbid mRS 3 or 4 undergoing mechanical thrombectomy due to anterior circulation stroke were selected. Good outcome was defined as a clinical recovery to the status before stroke onset (ie, equal premorbid mRS and mRS at 90 days). In addition, mortality at discharge and at 90 days was analyzed. RESULTS One hundred thirty-six patients were included, of whom 81.6% presented with premorbid mRS 3; and 18.4%, with premorbid mRS 4; 24.0% of patients with premorbid mRS 4 achieved clinical recovery compared with 20.7% of patients with premorbid mRS 3 (P = .788). However, the proportion of hospital mortality and mortality at 90 days was nonsignificant, but markedly higher in patients with premorbid mRS 4. Multivariate analysis identified low NIHSS scores (OR, 0.92; 95% CI, 0.85-0.99; P = .040), high ASPECTS (OR, 1.45; 95% CI, 1.02-2.16; P = .049), and TICI 2b-3 (OR, 7.11; 95% CI, 1.73-49.90; P = .017) as independent predictors of good outcome. CONCLUSIONS Good outcome in patients with premorbid mRS 3 and 4 is less frequent compared with premorbid mRS 0-2. Nevertheless, about 20% of the patients return to their premorbid mRS, which may justify endovascular treatment. The most important predictor of good outcome is successful recanalization.
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Affiliation(s)
- F Seker
- From the Departments of Neuroradiology (F.S., J.P., C.H., M.B., M.A.M.)
| | - J Pfaff
- From the Departments of Neuroradiology (F.S., J.P., C.H., M.B., M.A.M.)
| | - S Schönenberger
- Neurology (S.S., S.N., P.A.R.), Heidelberg University Hospital, Heidelberg, Germany
| | - C Herweh
- From the Departments of Neuroradiology (F.S., J.P., C.H., M.B., M.A.M.)
| | - S Nagel
- Neurology (S.S., S.N., P.A.R.), Heidelberg University Hospital, Heidelberg, Germany
| | - P A Ringleb
- Neurology (S.S., S.N., P.A.R.), Heidelberg University Hospital, Heidelberg, Germany
| | - M Bendszus
- From the Departments of Neuroradiology (F.S., J.P., C.H., M.B., M.A.M.)
| | - M A Möhlenbruch
- From the Departments of Neuroradiology (F.S., J.P., C.H., M.B., M.A.M.)
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17
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Abstract
Intracranial vascular malformations range from incidental asymptomatic vascular alterations up to life-threatening vascular disorders. Arteriovenous malformations and dural arteriovenous fistulas are cerebral vascular malformations with arteriovenous shunting of blood. In the majority of cases they are accompanied by an elevated risk of intracerebral hemorrhage and can cause severe symptoms. They can be treated conservatively or interventionally via microneurosurgery, endovascular embolization and radiation therapy. Cavernous malformations, developmental venous anomalies (DVA) and capillary telangiectasia are cerebral vascular malformations without arteriovenous shunting. Cavernous malformations are rarely symptomatic in the form of cerebral hemorrhage, headache or seizures and in such cases an operative treatment can be indicated. The DVA and capillary telangiectasia are usually asymptomatic and do not require treatment.
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Affiliation(s)
- D F Vollherbst
- Abteilung für Neuroradiologie, Neurologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland
| | - M Bendszus
- Abteilung für Neuroradiologie, Neurologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland
| | - M A Möhlenbruch
- Abteilung für Neuroradiologie, Neurologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland.
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18
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Vollherbst DF, Otto R, Hantz M, Ulfert C, Kauczor HU, Bendszus M, Sommer CM, Möhlenbruch MA. Investigation of a New Version of the Liquid Embolic Agent PHIL with Extra-Low-Viscosity in an Endovascular Embolization Model. AJNR Am J Neuroradiol 2018; 39:1696-1702. [PMID: 30093480 DOI: 10.3174/ajnr.a5750] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 06/12/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND PURPOSE The type and composition of an embolic agent have a relevant influence on the performance of endovascular embolization. The aim of this study was to investigate a new version of the liquid embolic agent precipitating hydrophobic injectable liquid (PHIL) with extra-low-viscosity in an in vivo embolization model. MATERIALS AND METHODS Twenty-four embolization procedures were performed in the porcine rete mirabile. Eight embolizations were performed with PHIL 25% low viscosity, Squid 12, and standard PHIL 25%, respectively. Procedure time, required volume of embolic agent, visibility of the embolic agent, embolization control, embolization extent (ie, penetration of the rete mirabile), amount of reflux, and degree of embolization distal to the rete mirabile were assessed. RESULTS All embolic agents were adequately visible. The embolization extent was not significantly different among the 3 investigated agents; however, there was a tendency toward a higher embolization extent for PHIL 25% low viscosity (median embolization extent: 88% [PHIL 25% low viscosity]; 65% [Squid 12]; 60% [PHIL 25%]; P = .146). The amount of reflux was significantly lower for the extra-low-viscosity agents PHIL 25% low viscosity and Squid 12 compared with the standard PHIL 25% (median reflux distance: 8 mm [PHIL 25% low viscosity]; 6 mm [Squid 12]; 17 mm [PHIL 25%]; P = .011). All other embolization features did not differ among agents. CONCLUSIONS PHIL 25% low viscosity is a promising liquid embolic agent for endovascular embolization, featuring effective distal penetration, adequate visibility, a low amount of reflux, and good flow control.
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Affiliation(s)
- D F Vollherbst
- From the Department of Neuroradiology (D.F.V., R.O., M.H., C.U., M.B., M.A.M.)
- Clinic for Diagnostic and Interventional Radiology (D.F.V., H.U.K., C.M.S.), Heidelberg University Hospital, Heidelberg, Germany
| | - R Otto
- From the Department of Neuroradiology (D.F.V., R.O., M.H., C.U., M.B., M.A.M.)
| | - M Hantz
- From the Department of Neuroradiology (D.F.V., R.O., M.H., C.U., M.B., M.A.M.)
| | - C Ulfert
- From the Department of Neuroradiology (D.F.V., R.O., M.H., C.U., M.B., M.A.M.)
| | - H U Kauczor
- Clinic for Diagnostic and Interventional Radiology (D.F.V., H.U.K., C.M.S.), Heidelberg University Hospital, Heidelberg, Germany
| | - M Bendszus
- From the Department of Neuroradiology (D.F.V., R.O., M.H., C.U., M.B., M.A.M.)
| | - C M Sommer
- Clinic for Diagnostic and Interventional Radiology (D.F.V., H.U.K., C.M.S.), Heidelberg University Hospital, Heidelberg, Germany
- Clinic for Diagnostic and Interventional Radiology (C.M.S.), Klinikum Stuttgart, Stuttgart, Germany
| | - M A Möhlenbruch
- From the Department of Neuroradiology (D.F.V., R.O., M.H., C.U., M.B., M.A.M.)
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Boujan T, Neuberger U, Pfaff J, Nagel S, Herweh C, Bendszus M, Möhlenbruch MA. Value of Contrast-Enhanced MRA versus Time-of-Flight MRA in Acute Ischemic Stroke MRI. AJNR Am J Neuroradiol 2018; 39:1710-1716. [PMID: 30115678 DOI: 10.3174/ajnr.a5771] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Accepted: 06/17/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Vessel imaging in acute ischemic stroke is essential to select patients with large-vessel occlusion for mechanical thrombectomy. Our aim was to compare the diagnostic accuracy of time-of-flight MR angiography and contrast-enhanced MR angiography for identification of vessel occlusion and collateral status in acute ischemic stroke. MATERIALS AND METHODS One hundred twenty-three patients with stroke with large-vessel occlusion before thrombectomy were included in this retrospective study. Before thrombectomy, 3T MR imaging, including conventional 3D TOF-MRA of the intracranial arteries and contrast-enhanced MRA of intra- and extracranial arteries, was performed. Both techniques were assessed independently by 2 neuroradiologists for location of the occlusion, imaging quality, and collateral status. Findings were compared, with subsequent DSA as the reference standard. RESULTS Both techniques had good interrater agreement of κ = 0.74 (95% CI, 0.66-0.83) for TOF-MRA and κ = 0.72 (95% CI, 0.63-0.80) for contrast-enhanced MRA. Occlusion localization differed significantly on TOF-MRA compared with DSA (P < .001), while no significant difference was observed between DSA and contrast-enhanced MRA (P = .75). Assessment of collaterals showed very good agreement between contrast-enhanced MRA and DSA (94.9% with P = .25), but only fair agreement between TOF-MRA and DSA (23.2% with P < .001). CONCLUSIONS Contrast-enhanced MRA offers better diagnostic accuracy than TOF-MRA in acute ischemic stroke. Contrast-enhanced MRA was superior in localizing vessel occlusion within a shorter acquisition time while providing a larger coverage, including extracranial vessels, and a more accurate assessment of collateral status. These results support inclusion of contrast-enhanced MRA in acute stroke MR imaging, perhaps making TOF-MRA superfluous.
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Affiliation(s)
- T Boujan
- From the Departments of Neuroradiology (T.B., U.N., J.P., C.H., M.B., M.M.)
| | - U Neuberger
- From the Departments of Neuroradiology (T.B., U.N., J.P., C.H., M.B., M.M.)
| | - J Pfaff
- From the Departments of Neuroradiology (T.B., U.N., J.P., C.H., M.B., M.M.)
| | - S Nagel
- Neurology (S.N.), University of Heidelberg Medical Center, Heidelberg, Germany
| | - C Herweh
- From the Departments of Neuroradiology (T.B., U.N., J.P., C.H., M.B., M.M.)
| | - M Bendszus
- From the Departments of Neuroradiology (T.B., U.N., J.P., C.H., M.B., M.M.)
| | - M A Möhlenbruch
- From the Departments of Neuroradiology (T.B., U.N., J.P., C.H., M.B., M.M.)
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Vollherbst DF, Ulfert C, Neuberger U, Herweh C, Laible M, Nagel S, Bendszus M, Möhlenbruch MA. Endovascular Treatment of Dural Arteriovenous Fistulas Using Transarterial Liquid Embolization in Combination with Transvenous Balloon-Assisted Protection of the Venous Sinus. AJNR Am J Neuroradiol 2018; 39:1296-1302. [PMID: 29724762 DOI: 10.3174/ajnr.a5651] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 03/05/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND PURPOSE Sinus-preserving endovascular embolization was described as a promising treatment technique for dural arteriovenous fistulas. Our aim was to report our single-center experience in patients with dural arteriovenous fistulas who were treated with transarterial liquid embolization in combination with transvenous balloon-assisted protection of the affected venous sinus. MATERIALS AND METHODS A retrospective analysis of a prospectively collected data base was performed. Demographic and clinical data, angiographic features of the dural arteriovenous fistulas, procedural parameters, complications, treatment success, follow-up imaging, and clinical outcome were assessed. RESULTS Twenty-two patients were treated in 25 procedures. All patients were symptomatic, of whom 81.8% presented with tinnitus; 9.1%, with ocular symptoms; and 9.1%, with headache. Most fistulas were located at the transverse and/or sigmoid sinus. The most frequent fistula type was Cognard IIa+b (40.9%), followed by Cognard I (31.8%) and Cognard IIa (27.3%)/Borden I (59.1%), followed by Borden II (40.9%). The affected sinus could be preserved in all except for 1 patient in whom it was sacrificed in a second treatment procedure by coil embolization. The overall complete occlusion rate was 86.4%. The overall complication rate was 20%, with transient and permanent morbidity and mortality of 8%, 0%, and 0%, respectively. After a mean follow-up of 18 months, most patients (68.2%) achieved complete symptom remission, 27.3% showed symptom relief, and 4.6% had stable symptoms. CONCLUSIONS Transarterial liquid embolization of dural arteriovenous fistulas in combination with transvenous balloon-assisted protection of the venous sinus is feasible and safe and offers high rates of occlusion and of symptom remission.
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Affiliation(s)
- D F Vollherbst
- From the Departments of Neuroradiology (D.F.V., C.U., U.N., C.H., M.B., M.A.M.)
| | - C Ulfert
- From the Departments of Neuroradiology (D.F.V., C.U., U.N., C.H., M.B., M.A.M.)
| | - U Neuberger
- From the Departments of Neuroradiology (D.F.V., C.U., U.N., C.H., M.B., M.A.M.)
| | - C Herweh
- From the Departments of Neuroradiology (D.F.V., C.U., U.N., C.H., M.B., M.A.M.)
| | - M Laible
- Neurology (M.L., S.N.), Heidelberg University Hospital, Heidelberg, Germany
| | - S Nagel
- Neurology (M.L., S.N.), Heidelberg University Hospital, Heidelberg, Germany
| | - M Bendszus
- From the Departments of Neuroradiology (D.F.V., C.U., U.N., C.H., M.B., M.A.M.)
| | - M A Möhlenbruch
- From the Departments of Neuroradiology (D.F.V., C.U., U.N., C.H., M.B., M.A.M.)
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21
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Pfaff JAR, Schönenberger S, Nagel S, Ringleb PA, Hacke W, Bendszus M, Bösel J, Möhlenbruch MA. Effect of General Anesthesia versus Conscious Sedation for Stroke Thrombectomy on Angiographic Workflow in a Randomized Trial: A Post Hoc Analysis of the SIESTA Trial. Radiology 2018; 286:1016-1021. [DOI: 10.1148/radiol.2017171002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Johannes A. R. Pfaff
- From the Departments of Neuroradiology (J.A.R.P., M.B., M.A.M.) and Neurology (S.S., S.N., P.A.R., W.H., J.B.), Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Silvia Schönenberger
- From the Departments of Neuroradiology (J.A.R.P., M.B., M.A.M.) and Neurology (S.S., S.N., P.A.R., W.H., J.B.), Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Simon Nagel
- From the Departments of Neuroradiology (J.A.R.P., M.B., M.A.M.) and Neurology (S.S., S.N., P.A.R., W.H., J.B.), Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Peter A. Ringleb
- From the Departments of Neuroradiology (J.A.R.P., M.B., M.A.M.) and Neurology (S.S., S.N., P.A.R., W.H., J.B.), Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Werner Hacke
- From the Departments of Neuroradiology (J.A.R.P., M.B., M.A.M.) and Neurology (S.S., S.N., P.A.R., W.H., J.B.), Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Martin Bendszus
- From the Departments of Neuroradiology (J.A.R.P., M.B., M.A.M.) and Neurology (S.S., S.N., P.A.R., W.H., J.B.), Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Julian Bösel
- From the Departments of Neuroradiology (J.A.R.P., M.B., M.A.M.) and Neurology (S.S., S.N., P.A.R., W.H., J.B.), Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Markus Alfred Möhlenbruch
- From the Departments of Neuroradiology (J.A.R.P., M.B., M.A.M.) and Neurology (S.S., S.N., P.A.R., W.H., J.B.), Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
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Pfaff J, Rohde S, Engelhorn T, Doerfler A, Bendszus M, Möhlenbruch MA. Mechanical Thrombectomy Using the new Solitaire™ Platinum Stent-retriever : Reperfusion Results, Complication Rates and Early Neurological Outcome. Clin Neuroradiol 2018; 29:311-319. [PMID: 29322232 DOI: 10.1007/s00062-017-0657-x] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 12/18/2017] [Indexed: 01/14/2023]
Abstract
BACKGROUND AND PURPOSE The application of radiopaque markers to the Solitaire™ stent-retriever for better visibility during mechanical thrombectomy (MT) has the potential to alter the well-known characteristics of the device; however, it is uncertain whether this adjustment influences efficacy or safety of the enhanced stent-retriever. METHODS Retrospective analysis of stroke databases of three comprehensive stroke centers. Our investigation was focused on technical and angiographic parameters, including procedure times, reperfusion results (thrombolysis in cerebral infarction, TICI), periprocedural complications and favorable early neurological recovery at discharge (modified Rankin scale ≤2 or National Institutes of Health Stroke Scale, NIHSS = 0 or ∆NIHSS ≥ 10), from consecutive patients with acute anterior circulation ischemic stroke treated with a Solitaire™ Platinum stent-retriever between October 2016 and March 2017. RESULTS A total of 75 patients (male: n = 27, 36%, age in years: mean (SD): 75 (±12), median baseline NIHSS: 17 (interquartile range IQR: 11-21), n = 41, 54.7% received additional i. v. thrombolytics) were treated with a median number of 2 device passes (range: 1-5). The median time from groin puncture to final TICI was 56 min (IQR: 41-79). In 69 patients (92%) TICI 2b-3 was achieved. Early neurological recovery was seen in 47 (62.7%) patients. The following periprocedural complications occurred: vasospasms (n = 7, 9.3%), emboli into a new territory (n = 4, 5.3%), symptomatic intracranial hemorrhage (n = 3, 4%), difficulties during device delivery/deployment (n = 1, 1.3%). CONCLUSION The usage of the Solitaire™ Platinum stent-retriever for MT in acute ischemic stroke patients was highly effective and was not accompanied by an increased periprocedural complication rate.
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Affiliation(s)
- Johannes Pfaff
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Stefan Rohde
- Department of Radiology and Neuroradiology, Klinikum Dortmund, Dortmund, Germany
| | - Tobias Engelhorn
- Department of Neuroradiology, Erlangen University Hospital, Erlangen, Germany
| | - Arnd Doerfler
- Department of Neuroradiology, Erlangen University Hospital, Erlangen, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus Alfred Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany. .,, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
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Laible M, Möhlenbruch MA, Pfaff J, Jenetzky E, Ringleb PA, Bendszus M, Rizos T. Influence of Renal Function on Treatment Results after Stroke Thrombectomy. Cerebrovasc Dis 2017; 44:351-358. [DOI: 10.1159/000481147] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 08/29/2017] [Indexed: 01/11/2023] Open
Abstract
Background: Renal dysfunction (RD) may be associated with poor outcome in ischemic stroke patients treated with mechanical thrombectomy (MT), but data concerning this important and emerging comorbidity do not exist so far. Here, we investigated the influence of RD on postprocedural intracerebral hemorrhage (ICH), clinical outcome, and mortality in a large prospectively collected cohort of acute ischemic stroke patients treated with MT. Methods: Consecutive patients with anterior-circulation stroke treated with MT between October 2010 and January 2016 were included. RD was defined as glomerular filtration rate (GFR) <60 mL/min/1.73 m2. In a prospective database, clinical characteristics were recorded and brain images were analyzed for the presence of ICH after treatment in all patients. Clinical outcome was assessed by the modified Rankin Scale (mRS) after 3 months. To evaluate associations between clinical factors and outcomes uni- and multivariate regression analyses were conducted. Results: In total, 505 patients fulfilled all inclusion criteria (female: 49.7%, mean age: 71.0 years). RD at admission was present in 20.2%. RD patients were older and had cardiovascular risk factors more often. Multivariate regression analysis after adjustment for age, stroke severity, diabetes, hypertension, GFR, previous stroke, MT alone, or additional thrombolysis and recanalization results revealed that lower GFR was not independently associated with poor outcome (mRS 3-6; OR 1.13, 95% CI 0.99-1.28; p = 0.072) or ICH. However, lower GFR at admission was associated with a higher risk of mortality (OR 1.15, 95% CI 1.01-1.31; p = 0.038). Compared to admission, GFR values were higher at discharge (mean: 77.9 vs. 80.8 mL/min/1.73 m2; p = 0.046). Conclusions: We did not find evidence for an association of lower GFR with an increased risk of poor outcome and ICH, but lower GFR was a determinant of 90-day mortality after endovascular stroke treatment. Our findings encourage also performing MT in this relevant subgroup of acute ischemic stroke patients.
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Möhlenbruch MA, Kizilkilic O, Killer-Oberpfalzer M, Baltacioglu F, Islak C, Bendszus M, Cekirge S, Saatci I, Kocer N. Multicenter Experience with FRED Jr Flow Re-Direction Endoluminal Device for Intracranial Aneurysms in Small Arteries. AJNR Am J Neuroradiol 2017; 38:1959-1965. [PMID: 28798217 DOI: 10.3174/ajnr.a5332] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 05/24/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Flow diverters are emerging as an endovascular treatment alternative for proximally located intracranial aneurysms. However, treatment of aneurysms at and beyond the circle of Willis is not well-established. We assessed the clinical safety and efficacy of the Flow Re-Direction Endoluminal Device Jr (FRED Jr) dedicated to small-vessel diameters between 2.0 and 3.0 mm. MATERIALS AND METHODS This was a multicenter observational clinical study of 42 patients with 47 aneurysms treated by a flow-direction technique with the FRED Jr. The primary end point for clinical safety was the absence of death, major or minor stroke, and TIA. The primary end point for treatment efficacy was complete and near-complete occlusion according to the O'Kelly-Marotta grading scale at follow-up after 1, 6, and 12 months. RESULTS The FRED Jr deployment was technically successful in all cases. In 39/42 (93%) patients, the primary safety end point was reached; in the 3 remaining patients, 1 disabling ischemic stroke, 1 minor stroke with complete recovery at discharge, and 1 TIA were observed. Two asymptomatic, completely reversible side-branch occlusions occurred. Angiographic (DSA or flat panel CT) and clinical follow-up were available after 1 month in 41/47 (87%), 6 months in 27/47 (57%), and 12 months in 11/47 (23%) aneurysms. The primary efficacy end point was reached at 1 month in 27/41 (66%), at 6 months in 21/27 (78%), and at 12 months in 11/11 (100%) aneurysms. CONCLUSIONS Deployment of the FRED Jr is safe and effective in the treatment of intracranial aneurysms located in small vessels.
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Affiliation(s)
- M A Möhlenbruch
- From the Department of Neuroradiology (M.A.M., M.B.), Heidelberg University Hospital, Heidelberg, Germany
| | - O Kizilkilic
- Department of Neuroradiology (O.K., C.I., N.K.), Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - M Killer-Oberpfalzer
- Department of Neurology/Research Institute of Neurointervention (M.K.-O.), Paracelsus Medical University, Salzburg, Austria
| | - F Baltacioglu
- Department of Radiology (F.B.), Marmara University School of Medicine, Istanbul, Turkey
| | - C Islak
- Department of Neuroradiology (O.K., C.I., N.K.), Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - M Bendszus
- From the Department of Neuroradiology (M.A.M., M.B.), Heidelberg University Hospital, Heidelberg, Germany
| | - S Cekirge
- Department of Radiology (S.C.), Koru and Bayindir Hospital, Ankara, Turkey.,Department of Radiology (S.C., I.S.), Yüksek Ihtisas University, Koru Hospital, Ankara, Turkey
| | - I Saatci
- Department of Radiology (S.C., I.S.), Yüksek Ihtisas University, Koru Hospital, Ankara, Turkey
| | - N Kocer
- Department of Neuroradiology (O.K., C.I., N.K.), Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
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25
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Schönenberger S, Pfaff J, Uhlmann L, Klose C, Nagel S, Ringleb PA, Hacke W, Kieser M, Bendszus M, Möhlenbruch MA, Bösel J. The Impact of Conscious Sedation versus General Anesthesia for Stroke Thrombectomy on the Predictive Value of Collateral Status: A Post Hoc Analysis of the SIESTA Trial. AJNR Am J Neuroradiol 2017; 38:1580-1585. [PMID: 28596192 DOI: 10.3174/ajnr.a5243] [Citation(s) in RCA: 9] [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] [Received: 03/02/2017] [Accepted: 03/17/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Radiologic selection criteria to identify patients likely to benefit from endovascular stroke treatment are still controversial. In this post hoc analysis of the recent randomized Sedation versus Intubation for Endovascular Stroke TreAtment (SIESTA) trial, we aimed to investigate the impact of sedation mode (conscious sedation versus general anesthesia) on the predictive value of collateral status. MATERIALS AND METHODS Using imaging data from SIESTA, we assessed collateral status with the collateral score of Tan et al and graded it from absent to good collaterals (0-3). We examined the association of collateral status with 24-hour improvement of the NIHSS score, infarct volume, and mRS at 3 months according to the sedation regimen. RESULTS In a cohort of 104 patients, the NIHSS score improved significantly in patients with moderate or good collaterals (2-3) compared with patients with no or poor collaterals (0-1) (P = .011; mean, -5.8 ± 7.6 versus -1.1 ± 10.7). Tan 2-3 was also associated with significantly higher ASPECTS before endovascular stroke treatment (median, 9 versus 7; P < .001) and smaller mean infarct size after endovascular stroke treatment (median, 35.0 versus 107.4; P < .001). When we differentiated the population according to collateral status (0.1 versus 2.3), the sedation modes conscious sedation and general anesthesia were not associated with significant differences in the predictive value of collateral status regarding infarction size or functional outcome. CONCLUSIONS The sedation mode, conscious sedation or general anesthesia, did not influence the predictive value of collaterals in patients with large-vessel occlusion anterior circulation stroke undergoing thrombectomy in the SIESTA trial.
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Affiliation(s)
- S Schönenberger
- From the Departments of Neurology (S.S., S.N., P.A.R., W.H., J.B.)
| | - J Pfaff
- Neuroradiology (J.P., M.B., M.A.M.), Heidelberg University Hospital, Heidelberg, Germany
| | - L Uhlmann
- Institute of Medical Biometry and Informatics (L.U., C.K., M.K.), University of Heidelberg, Heidelberg, Germany
| | - C Klose
- Institute of Medical Biometry and Informatics (L.U., C.K., M.K.), University of Heidelberg, Heidelberg, Germany
| | - S Nagel
- From the Departments of Neurology (S.S., S.N., P.A.R., W.H., J.B.)
| | - P A Ringleb
- From the Departments of Neurology (S.S., S.N., P.A.R., W.H., J.B.)
| | - W Hacke
- From the Departments of Neurology (S.S., S.N., P.A.R., W.H., J.B.)
| | - M Kieser
- Institute of Medical Biometry and Informatics (L.U., C.K., M.K.), University of Heidelberg, Heidelberg, Germany
| | - M Bendszus
- Neuroradiology (J.P., M.B., M.A.M.), Heidelberg University Hospital, Heidelberg, Germany
| | - M A Möhlenbruch
- Neuroradiology (J.P., M.B., M.A.M.), Heidelberg University Hospital, Heidelberg, Germany
| | - J Bösel
- From the Departments of Neurology (S.S., S.N., P.A.R., W.H., J.B.)
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26
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Messer MP, Schönenberger S, Möhlenbruch MA, Pfaff J, Herweh C, Ringleb PA, Nagel S. Minor Stroke Syndromes in Large-Vessel Occlusions: Mechanical Thrombectomy or Thrombolysis Only? AJNR Am J Neuroradiol 2017; 38:1177-1179. [PMID: 28408627 DOI: 10.3174/ajnr.a5164] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 01/31/2017] [Indexed: 11/07/2022]
Abstract
While mechanical thrombectomy for large-vessel occlusions is now an evidence-based treatment, its efficacy and safety in minor stroke syndromes (NIHSS ≤ 5) is not proved. We identified, in our prospective data base, 378 patients with minor strokes in the anterior circulation; 54 (14.2%) of these had proved large-vessel occlusions. Eight of 54 (14.8%) were immediately treated with mechanical thrombectomy, 6/54 (11.1%) after early neurologic deterioration, and the rest were treated with standard thrombolysis only. Rates of successful recanalization were similar between the 2 mechanical thrombectomy groups (75% versus 100%). Rates of excellent outcome (modified Rankin Scale 0-1) were higher in patients with immediate thrombectomy (75%) compared with patients with delayed thrombectomy (33.3%) and thrombolysis only (55%). No symptomatic intracranial hemorrhage occurred in either group. These descriptive data are encouraging, and further analysis of large registries or even randomized controlled trials in this patient subgroup should be performed.
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Affiliation(s)
- M P Messer
- From the Departments of Neurology (M.P.M., S.S., P.A.R., S.N.)
| | - S Schönenberger
- From the Departments of Neurology (M.P.M., S.S., P.A.R., S.N.)
| | - M A Möhlenbruch
- Neuroradiology (M.A.M., J.P., C.H.), University of Heidelberg, Heidelberg, Germany
| | - J Pfaff
- Neuroradiology (M.A.M., J.P., C.H.), University of Heidelberg, Heidelberg, Germany
| | - C Herweh
- Neuroradiology (M.A.M., J.P., C.H.), University of Heidelberg, Heidelberg, Germany
| | - P A Ringleb
- From the Departments of Neurology (M.P.M., S.S., P.A.R., S.N.)
| | - S Nagel
- From the Departments of Neurology (M.P.M., S.S., P.A.R., S.N.)
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27
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Vollherbst DF, Sommer CM, Ulfert C, Pfaff J, Bendszus M, Möhlenbruch MA. Liquid Embolic Agents for Endovascular Embolization: Evaluation of an Established (Onyx) and a Novel (PHIL) Embolic Agent in an In Vitro AVM Model. AJNR Am J Neuroradiol 2017; 38:1377-1382. [PMID: 28522669 DOI: 10.3174/ajnr.a5203] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 02/23/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Embolization plays a key role in the treatment of arteriovenous malformations. The aim of this study was to evaluate an established (Onyx) and a novel (precipitating hydrophobic injectable liquid [PHIL]) liquid embolic agent in an in vitro AVM model. MATERIALS AND METHODS An AVM model was integrated into a circuit system. The artificial nidus (subdivided into 28 honeycomb-like sections) was embolized with Onyx 18 (group Onyx; n = 8) or PHIL 25 (group PHIL; n = 8) with different pause times between the injections (30 and 60 seconds, n = 4 per study group) by using a 1.3F microcatheter. Procedure times, number of injections, embolization success (defined as the number of filled sections of the artificial nidus), volume of embolic agent, and frequency and extent of reflux and draining vein embolization were assessed. RESULTS Embolization success was comparable between Onyx and PHIL. Shorter pause times resulted in a significantly higher embolization success for PHIL (median embolization score, 28 versus 18; P = .011). Compared with Onyx, lower volumes of PHIL were required for the same extent of embolization (median volume per section of the artificial nidus, 15.5 versus 3.6 μL; P < .001). CONCLUSIONS While the embolization success was comparable for Onyx and PHIL, pause time had a considerable effect on the embolization success in an in vitro AVM model. Compared with Onyx, lower volumes of PHIL were required for the same extent of embolization.
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Affiliation(s)
- D F Vollherbst
- From the Department of Neuroradiology (D.F.V., C.U., J.P., M.B., M.A.M.)
| | - C M Sommer
- Clinic for Diagnostic and Interventional Radiology (C.M.S.), University Hospital Heidelberg, Heidelberg, Germany.,Clinic for Diagnostic and Interventional Radiology (C.M.S.), Klinikum Stuttgart, Stuttgart, Germany
| | - C Ulfert
- From the Department of Neuroradiology (D.F.V., C.U., J.P., M.B., M.A.M.)
| | - J Pfaff
- From the Department of Neuroradiology (D.F.V., C.U., J.P., M.B., M.A.M.)
| | - M Bendszus
- From the Department of Neuroradiology (D.F.V., C.U., J.P., M.B., M.A.M.)
| | - M A Möhlenbruch
- From the Department of Neuroradiology (D.F.V., C.U., J.P., M.B., M.A.M.)
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28
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Seker F, Pfaff J, Wolf M, Ringleb PA, Nagel S, Schönenberger S, Herweh C, Möhlenbruch MA, Bendszus M, Pham M. Correlation of Thrombectomy Maneuver Count with Recanalization Success and Clinical Outcome in Patients with Ischemic Stroke. AJNR Am J Neuroradiol 2017; 38:1368-1371. [PMID: 28473346 DOI: 10.3174/ajnr.a5212] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 03/03/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE In the treatment of acute thromboembolic stroke, the effectiveness and success of thrombus removal when using stent retrievers is variable. In this study, we analyzed the correlation of thrombectomy maneuver count with a good clinical outcome and recanalization success. MATERIALS AND METHODS One hundred and four patients with acute occlusion of the middle cerebral artery or the terminal internal carotid artery who were treated with thrombectomy were included in this retrospective study. A good clinical outcome was defined as a 90-day mRS of ≤2, and successful recanalization was defined as TICI 2b-3. RESULTS The maneuver count ranged between 1-10, with a median of 2. Multivariate logistic regression analyses identified an increasing number of thrombectomy maneuvers as an independent predictor of poor outcome (adjusted OR, 0.59; 95% CI, 0.38-0.87; P = .011) and unsuccessful recanalization (adjusted OR, 0.48; 95% CI, 0.32-0.66; P < .001). A good outcome was significantly more likely if finished within 2 maneuvers compared with 3 or 4 maneuvers, or even more than 4 maneuvers (P < .001). CONCLUSIONS An increasing maneuver count correlates strongly with a decreasing probability of both good outcome and recanalization. The probability of successful recanalization decreases below 50% if not achieved within 5 thrombectomy maneuvers. Patients who are recanalized within 2 maneuvers have the best chance of achieving a good clinical outcome.
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Affiliation(s)
- F Seker
- From the Departments of Neuroradiology (F.S., J.P., M.W., C.H., M.A.M., M.B., M.P.)
| | - J Pfaff
- From the Departments of Neuroradiology (F.S., J.P., M.W., C.H., M.A.M., M.B., M.P.)
| | - M Wolf
- From the Departments of Neuroradiology (F.S., J.P., M.W., C.H., M.A.M., M.B., M.P.)
| | - P A Ringleb
- Neurology (P.A.R., S.N., S.S.), Heidelberg University Hospital, Heidelberg, Germany
| | - S Nagel
- Neurology (P.A.R., S.N., S.S.), Heidelberg University Hospital, Heidelberg, Germany
| | - S Schönenberger
- Neurology (P.A.R., S.N., S.S.), Heidelberg University Hospital, Heidelberg, Germany
| | - C Herweh
- From the Departments of Neuroradiology (F.S., J.P., M.W., C.H., M.A.M., M.B., M.P.)
| | - M A Möhlenbruch
- From the Departments of Neuroradiology (F.S., J.P., M.W., C.H., M.A.M., M.B., M.P.)
| | - M Bendszus
- From the Departments of Neuroradiology (F.S., J.P., M.W., C.H., M.A.M., M.B., M.P.)
| | - M Pham
- From the Departments of Neuroradiology (F.S., J.P., M.W., C.H., M.A.M., M.B., M.P.).,Department of Neuroradiology (M.P.), Würzburg University Hospital, Würzburg, Germany
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29
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Neuberger U, Möhlenbruch MA, Herweh C, Ulfert C, Bendszus M, Pfaff J. Classification of Bleeding Events: Comparison of ECASS III (European Cooperative Acute Stroke Study) and the New Heidelberg Bleeding Classification. Stroke 2017; 48:1983-1985. [PMID: 28455322 DOI: 10.1161/strokeaha.117.016735] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [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: 01/21/2017] [Revised: 03/08/2017] [Accepted: 03/24/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Intracranial hemorrhage (ICH) after acute ischemic stroke treatments represents a feared complication with possible prognostic implications. In recent years, ICHs were commonly classified according to the ECASS (European Cooperative Acute Stroke Study). To improve the clinical applicability and relevance, the new Heidelberg Bleeding Classification (HBC) has been proposed in 2015. Here, we compared the ECASS and HBC classification with regard to observed events and prognostic relevance. METHODS A retrospective analysis of a prospectively compiled database of patients with acute ischemic stroke in the anterior circulation who received mechanical thrombectomy between February 2011 and March 2016 was performed. Presence of ICH after mechanical thrombectomy was evaluated on postinterventional computed tomographic imaging. ICHs were specified according to both ECASS III and HBC classification and analyzed with regard to their symptoms and outcome. RESULTS ICHs were observed in 156 of 768 patients (20.3%). Using ECASS III classification, 101 ICHs could be unambiguously assigned, of which 28 (27.7%; 3.6% of all treated patients) were symptomatic ICHs. Using HBC, 55 additional ICHs could be categorized. Of these total 156 ICHs, 29 (18.6%; 3.8% of all treated patients) were classified as symptomatic according to HBC. CONCLUSIONS Classification of ICH by ECASS III and HBC criteria show distinct differences. These differences warrant special attention during interpretation and comparison of scientific publications.
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Affiliation(s)
- Ulf Neuberger
- From the Department of Neuroradiology, Heidelberg University Hospital, Germany
| | | | - Christian Herweh
- From the Department of Neuroradiology, Heidelberg University Hospital, Germany
| | - Christian Ulfert
- From the Department of Neuroradiology, Heidelberg University Hospital, Germany
| | - Martin Bendszus
- From the Department of Neuroradiology, Heidelberg University Hospital, Germany
| | - Johannes Pfaff
- From the Department of Neuroradiology, Heidelberg University Hospital, Germany.
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30
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Mundiyanapurath S, Diatschuk S, Loebel S, Pfaff J, Pham M, Möhlenbruch MA, Wick W, Bendszus M, Ringleb PA, Radbruch A. Outcome of patients with proximal vessel occlusion of the anterior circulation and DWI-PWI mismatch is time-dependent. Eur J Radiol 2017. [PMID: 28629575 DOI: 10.1016/j.ejrad.2017.03.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [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] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND PURPOSE Patients with ischemic stroke and large vessel occlusion are assumed to benefit from endovascular therapy (ET) independent of the symptom onset-to-treatment time (OTT) if they present with a mismatch of diffusion- and perfusion-weighted imaging (DWI-PWI mismatch). We aimed at studying the influence of OTT on clinical outcome in these patients. METHODS Retrospective database review in a tertiary care university hospital. All patients presented with proximal vessel occlusion of the anterior circulation and DWI-PWI mismatch. Primary outcome was the influence of OTT on modified Rankin scale (mRS) score three months after treatment, dichotomized in favourable (0-2) and unfavourable outcome (3-6). Secondary outcome was the effect of OTT on the shift of the mRS score. Patients treated within an early time window (<340min) and a late time window (≥340min) were compared. RESULTS 139 patients were included. The rate of favourable outcome was significantly higher in patients who were treated in an early compared to those treated in a late time window (31 [49%] vs. 20 patients [27%], p=0.005). Adjusted multivariate logistic regression revealed that late treatment was an independent negative predictor of favourable outcome (odds ratio 0.39, confidence interval [0.18-0.84]; p=0.016). A shift towards higher mRS scores for late treatment was evident (p=0.015). In sensitivity analysis, OTT remained an independent predictor when evaluated as continuous variable. These findings were confirmed in patients with a comparable DWI-PWI mismatch according to the definitions from large trials (DEFUSE 2, DEFUSE 3, SWIFT-PRIME, EXTEND-IA). CONCLUSION Outcome of patients with comparable DWI-PWI mismatch is time-dependent.
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Affiliation(s)
| | - Sascha Diatschuk
- German Cancer Research Centre, Department of Radiology, Heidelberg, Germany
| | - Sarah Loebel
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Johannes Pfaff
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Mirko Pham
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany; Institute for Diagnostic and Interventional Neuroradiology, University Hospital Würzburg, Germany
| | | | - Wolfgang Wick
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany; CCU Neurooncology, German Cancer Consortium (DKTK) & German Cancer Research Centre (DKFZ), Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Peter A Ringleb
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Alexander Radbruch
- German Cancer Research Centre, Department of Radiology, Heidelberg, Germany; Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
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Mundiyanapurath S, Tillmann A, Möhlenbruch MA, Bendszus M, Ringleb PA. Endovascular stroke therapy may be safe in patients with elevated international normalized ratio. J Neurointerv Surg 2016; 9:1187-1190. [DOI: 10.1136/neurintsurg-2016-012757] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 10/31/2016] [Accepted: 11/02/2016] [Indexed: 11/03/2022]
Abstract
IntroductionEndovascular therapy in acute ischemic stroke is safe and efficient. However, patients receiving oral anticoagulation were excluded in the larger trials.ObjectiveTo analyze the safety of endovascular therapy in patients with acute ischemic stroke and elevated international normalized ratio (INR) values.MethodsRetrospective database review of a tertiary care university hospital for patients with anterior circulation stroke treated with endovascular therapy. Patients with anticoagulation other than vitamin K antagonists were excluded. The primary safety endpoint was defined as symptomatic intracranial hemorrhage (sICH; ECASS II definition). The efficacy endpoint was the modified Rankin scale (mRS) score after 3 months, dichotomized into favorable outcome (mRS 0–2) and unfavorable outcome (mRS 3–6).Results435 patients were included. 90% were treated with stent retriever. 27 (6.2%) patients with an INR of 1.2–1.7 and 21 (4.8%) with an INR >1.7. 33 (7.6%) had sICH and 149 patients (34.3%) had a favorable outcome. Patients with an elevated INR did not have an increased risk for sICH or unfavorable outcome in multivariable analysis. The additional use of IV thrombolysis in patients with an INR of 1.2–1.7 did not increase the risk of sICH or unfavorable outcome. These results were replicated in a sensitivity analysis introducing an error of the INR of ±5%. They were also confirmed using other sICH definitions (Safe Implementation of Thrombolysis in Stroke (SITS), National Institute of neurological Disorders and Stroke (NINDS), Heidelberg bleeding classification).ConclusionsEndovascular therapy in patients with an elevated INR is safe and efficient. Patients with an INR of 1.2–1.7 may be treated with combined IV thrombolysis and endovascular therapy.
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Abstract
Acute ischemic stroke is the leading cause of acquired disability and its treatment is still a major challenge. For more than a decade, various mechanical devices have been developed for the recanalization of proximal artery occlusions in acute ischemic stroke but most of them have been approved for clinical use, only on the basis of uncontrolled case series. Intravenous thrombolysis with recombinant tissue-specific plasminogen activator administered (iv rtPA) within 4.5 h of symptom onset is so far the only approved medicinal treatment in the acute phase of cerebral infarction. With the introduction of stent retrievers, mechanical thrombectomy has demonstrated substantial rates of partial or complete arterial recanalization and improved outcomes compared with iv rtPA and best medical treatment alone in multiple randomized clinical trials in select patients with acute ischemic stroke and proximal artery occlusions. This review discusses the evolution of endovascular stroke therapy followed by a discussion of the current technical standards of mechanical thrombectomy that have to be considered during endovascular stroke therapy and the updated treatment recommendations of the ESO Karolinska stroke update.
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Affiliation(s)
- M A Möhlenbruch
- Abt. Neuroradiologie, Neurologische Klinik, Universität Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland.
| | - M Bendszus
- Abt. Neuroradiologie, Neurologische Klinik, Universität Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland
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Möhlenbruch MA, Herweh C, Jestaedt L, Stampfl S, Schönenberger S, Ringleb PA, Bendszus M, Pham M. The FRED flow-diverter stent for intracranial aneurysms: clinical study to assess safety and efficacy. AJNR Am J Neuroradiol 2015; 36:1155-61. [PMID: 25721079 DOI: 10.3174/ajnr.a4251] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Accepted: 12/03/2014] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Flow-diverter stents are emerging for the endovascular treatment of difficult-to-treat or otherwise untreatable cerebral aneurysms (wide-neck, fusiform, dissecting, blisterlike, or giant). We assessed the clinical safety and efficacy of the Flow-Redirection Endoluminal Device. MATERIALS AND METHODS This was an institutional review board-approved single-center observational clinical study in 29 patients with 34 aneurysms elected to be treated by endovascular intervention. After providing informed consent, patients were included according to the following criteria: aneurysm fundus-to-neck ratio <2 or neck diameter >4 mm, fusiform, dissecting, or giant aneurysms. The primary end point for clinical safety was the absence of death, absence of major or minor stroke, and absence of transient ischemic attack. The primary end point for treatment efficacy was complete angiographic occlusion according to the O'Kelly Marotta grading scale immediately after the procedure and at follow-up after 3 and 6 months (O'Kelly Marotta D: complete occlusion). RESULTS The Flow-Redirection Intraluminal Device deployment was technically successful in all cases. In 26/29 (89%) of patients, the primary end point of safety was reached; in the 3 remaining patients, 1 disabling ischemic stroke and 2 minor strokes with complete recovery at follow-up were observed. Angiographic (DSA and MRA) and clinical follow-up were available after 3 months in 29/29 (100%) and after 6 months in 25/29 (86%) patients (after 6 months, only MRA follow-up was performed according to our study protocol and institutional standard). At 3-month follow-up, complete occlusion was reached in 19/34 aneurysms (O'Kelly Marotta D: 19/34; 56%). At 6-month follow-up, aneurysm occlusion was complete in 22/30 aneurysms (O'Kelly Marotta D: 22/30; 73%). CONCLUSIONS Deployment of the Flow-Redirection Intraluminal Device flow-diverter stent is safe and effective in the treatment of difficult-to-treat or otherwise untreatable intracranial aneurysms.
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Affiliation(s)
- M A Möhlenbruch
- From the Departments of Neuroradiology (M.A.M., C.H., L.J., S. Stampfl, M.B., M.P.)
| | - C Herweh
- From the Departments of Neuroradiology (M.A.M., C.H., L.J., S. Stampfl, M.B., M.P.)
| | - L Jestaedt
- From the Departments of Neuroradiology (M.A.M., C.H., L.J., S. Stampfl, M.B., M.P.)
| | - S Stampfl
- From the Departments of Neuroradiology (M.A.M., C.H., L.J., S. Stampfl, M.B., M.P.)
| | - S Schönenberger
- Neurology (S. Schönenberger, P.A.R.); University of Heidelberg Medical Center, Heidelberg, Germany
| | - P A Ringleb
- Neurology (S. Schönenberger, P.A.R.); University of Heidelberg Medical Center, Heidelberg, Germany
| | - M Bendszus
- From the Departments of Neuroradiology (M.A.M., C.H., L.J., S. Stampfl, M.B., M.P.)
| | - M Pham
- From the Departments of Neuroradiology (M.A.M., C.H., L.J., S. Stampfl, M.B., M.P.)
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