Intravenous Thrombolysis Before Endovascular Treatment in Posterior Circulation Occlusions: A MR CLEAN Registry Study

BACKGROUND

The effectiveness of intravenous thrombolysis (IVT) before endovascular treatment (EVT) has been investigated in randomized trials and meta-analyses. These studies mainly concerned anterior circulation occlusions. We aimed to investigate clinical, technical, and safety outcomes of IVT before EVT in posterior circulation occlusions in a nationwide registry.

METHODS

Patients were included from the MR CLEAN Registry (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands), a nationwide, prospective, multicenter registry of patients with acute ischemic stroke due to a large intracranial vessel occlusion receiving EVT between 2014 and 2019. All patients with a posterior circulation occlusion were included. Primary outcome was a shift toward better functional outcome on the modified Rankin Scale at 90 days. Secondary outcomes were favorable functional outcome (modified Rankin Scale scores, 0-3), occurrence of symptomatic intracranial hemorrhages, successful reperfusion (extended Thrombolysis in Cerebral Ischemia ≥2B), first-attempt successful reperfusion, and mortality at 90 days. Regression analyses with adjustments based on univariable analyses and literature were applied.

RESULTS

A total of 248 patients were included, who received either IVT (n=125) or no IVT (n=123) before EVT. Results show no differences in a shift on the modified Rankin Scale (adjusted common odds ratio, 1.04 [95% CI, 0.61-1.76]). Although symptomatic intracranial hemorrhages occurred more often in the IVT group (4.8% versus 2.4%), regression analysis did not show a significant difference (adjusted odds ratio, 1.65 [95% CI, 0.33-8.35]). Successful reperfusion, favorable functional outcome, first-attempt successful reperfusion, and mortality did not differ between patients treated with and without IVT.

CONCLUSIONS

We found no significant differences in clinical, technical, and safety outcomes between patients with a large vessel occlusion in the posterior circulation treated with or without IVT before EVT. Our results are in line with the literature on the anterior circulation.

Endovascular treatment versus no endovascular treatment after 6-24 h in patients with ischaemic stroke and collateral flow on CT angiography (MR CLEAN-LATE) in the Netherlands: a multicentre, open-label, blinded-endpoint, randomised, controlled, phase 3 trial

BACKGROUND

Endovascular treatment for anterior circulation ischaemic stroke is effective and safe within a 6 h window. MR CLEAN-LATE aimed to assess efficacy and safety of endovascular treatment for patients treated in the late window (6-24 h from symptom onset or last seen well) selected on the basis of the presence of collateral flow on CT angiography (CTA).

METHODS

MR CLEAN-LATE was a multicentre, open-label, blinded-endpoint, randomised, controlled, phase 3 trial done in 18 stroke intervention centres in the Netherlands. Patients aged 18 years or older with ischaemic stroke, presenting in the late window with an anterior circulation large-vessel occlusion and collateral flow on CTA, and a neurological deficit score of at least 2 on the National Institutes of Health Stroke Scale were included. Patients who were eligible for late-window endovascular treatment were treated according to national guidelines (based on clinical and perfusion imaging criteria derived from the DAWN and DEFUSE-3 trials) and excluded from MR CLEAN-LATE enrolment. Patients were randomly assigned (1:1) to receive endovascular treatment or no endovascular treatment (control), in addition to best medical treatment. Randomisation was web based, with block sizes ranging from eight to 20, and stratified by centre. The primary outcome was the modified Rankin Scale (mRS) score at 90 days after randomisation. Safety outcomes included all-cause mortality at 90 days after randomisation and symptomatic intracranial haemorrhage. All randomly assigned patients who provided deferred consent or died before consent could be obtained comprised the modified intention-to-treat population, in which the primary and safety outcomes were assessed. Analyses were adjusted for predefined confounders. Treatment effect was estimated with ordinal logistic regression and reported as an adjusted common odds ratio (OR) with a 95% CI. This trial was registered with the ISRCTN, ISRCTN19922220.

FINDINGS

Between Feb 2, 2018, and Jan 27, 2022, 535 patients were randomly assigned, and 502 (94%) patients provided deferred consent or died before consent was obtained (255 in the endovascular treatment group and 247 in the control group; 261 [52%] females). The median mRS score at 90 days was lower in the endovascular treatment group than in the control group (3 [IQR 2-5] vs 4 [2-6]), and we observed a shift towards better outcomes on the mRS for the endovascular treatment group (adjusted common OR 1·67 [95% CI 1·20-2·32]). All-cause mortality did not differ significantly between groups (62 [24%] of 255 patients vs 74 [30%] of 247 patients; adjusted OR 0·72 [95% CI 0·44-1·18]). Symptomatic intracranial haemorrhage occurred more often in the endovascular treatment group than in the control group (17 [7%] vs four [2%]; adjusted OR 4·59 [95% CI 1·49-14·10]).

INTERPRETATION

In this study, endovascular treatment was efficacious and safe for patients with ischaemic stroke caused by an anterior circulation large-vessel occlusion who presented 6-24 h from onset or last seen well, and who were selected on the basis of the presence of collateral flow on CTA. Selection of patients for endovascular treatment in the late window could be primarily based on the presence of collateral flow.

FUNDING

Collaboration for New Treatments of Acute Stroke consortium, Dutch Heart Foundation, Stryker, Medtronic, Cerenovus, Top Sector Life Sciences & Health, and the Netherlands Brain Foundation.

Circle of Willis variation and outcome after intra-arterial treatment

Background

Intra-arterial treatment (IAT) improves outcomes in acute ischaemic stroke. Presence of collaterals increases likelihood of good outcome. We investigated whether variations in the circle of Willis (CoW) and contributing carotid arteries influence outcome in patients who had a stroke treated with IAT.

Methods

CT angiography data on patients who had an acute stroke treated with IAT were retrospectively collected. CoW was regarded complete if the contralateral A1 segment, anterior communicating artery and ipsilateral posterior communicating artery were fully developed, and the P1 segment was visible. Carotid artery contribution was studied with a self-developed carotid artery score ranging from 0 to 2 depending on the number of arteries supplying the occluded side of the CoW. Good clinical outcome was defined as modified Rankin Score ≤2 and measured at discharge and 3 months. We calculated risk ratios for the relation between completeness of the CoW, carotid score and good outcome, and performed a trend analysis for good outcome according to the carotid score.

Results

126 patients were included for analysis. Patients with a complete and incomplete CoW had a comparable risk for good outcome at discharge and 3 months. A higher carotid score was associated with a higher likelihood of good clinical outcome (p for trend 0.24 at discharge and 0.05 at 3 months).

Conclusion

In patients with acute ischaemic stroke treated with IAT, chances of good clinical outcome tended to improve with number of carotid arteries supplying the cerebral circulation. Completeness of the CoW was not related to clinical outcome.

A Randomized Trial of Intravenous Alteplase before Endovascular Treatment for Stroke

BACKGROUND

The value of administering intravenous alteplase before endovascular treatment (EVT) for acute ischemic stroke has not been studied extensively, particularly in non-Asian populations.

METHODS

We performed an open-label, multicenter, randomized trial in Europe involving patients with stroke who presented directly to a hospital that was capable of providing EVT and who were eligible for intravenous alteplase and EVT. Patients were randomly assigned in a 1:1 ratio to receive EVT alone or intravenous alteplase followed by EVT (the standard of care). The primary end point was functional outcome on the modified Rankin scale (range, 0 [no disability] to 6 [death]) at 90 days. We assessed the superiority of EVT alone over alteplase plus EVT, as well as noninferiority by a margin of 0.8 for the lower boundary of the 95% confidence interval for the odds ratio of the two trial groups. Death from any cause and symptomatic intracerebral hemorrhage were the main safety end points.

RESULTS

The analysis included 539 patients. The median score on the modified Rankin scale at 90 days was 3 (interquartile range, 2 to 5) with EVT alone and 2 (interquartile range, 2 to 5) with alteplase plus EVT. The adjusted common odds ratio was 0.84 (95% confidence interval [CI], 0.62 to 1.15; P = 0.28), which showed neither superiority nor noninferiority of EVT alone. Mortality was 20.5% with EVT alone and 15.8% with alteplase plus EVT (adjusted odds ratio, 1.39; 95% CI, 0.84 to 2.30). Symptomatic intracerebral hemorrhage occurred in 5.9% and 5.3% of the patients in the respective groups (adjusted odds ratio, 1.30; 95% CI, 0.60 to 2.81).

CONCLUSIONS

In a randomized trial involving European patients, EVT alone was neither superior nor noninferior to intravenous alteplase followed by EVT with regard to disability outcome at 90 days after stroke. The incidence of symptomatic intracerebral hemorrhage was similar in the two groups. (Funded by the Collaboration for New Treatments of Acute Stroke consortium and others; MR CLEAN-NO IV ISRCTN number, ISRCTN80619088.).

Endovascular Treatment for Posterior Circulation Stroke in Routine Clinical Practice: Results of the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands Registry

BACKGROUND AND PURPOSE

The benefit of endovascular treatment (EVT) for posterior circulation stroke (PCS) remains uncertain, and little is known on treatment outcomes in clinical practice. This study evaluates outcomes of a large PCS cohort treated with EVT in clinical practice. Simultaneous to this observational study, several intervention centers participated in the BASICS trial (Basilar Artery International Cooperation Study), which tested the efficacy of EVT for basilar artery occlusion in a randomized setting. We additionally compared characteristics and outcomes of patients treated outside BASICS in trial centers to those from nontrial centers.

METHODS

We included patients with PCS from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands Registry: a prospective, multicenter, observational study of patients who underwent EVT in the Netherlands between 2014 and 2018. Primary outcome was a score of 0 to 3 on the modified Rankin Scale at 90 days. Secondary outcomes included reperfusion status and symptomatic intracranial hemorrhage. For outcome comparison between patients treated in trial versus nontrial centers, we used ordinal logistic regression analysis.

RESULTS

We included 264 patients of whom 135 (51%) had received intravenous thrombolysis. The basilar artery was most often involved (77%). Favorable outcome (modified Rankin Scale score 0-3) was observed in 115/252 (46%) patients, and 109/252 (43%) patients died. Successful reperfusion was achieved in 178/238 (75%), and symptomatic intracranial hemorrhage occurred in 9/264 (3%). The 154 nontrial patients receiving EVT in BASICS trial centers had similar characteristics and outcomes as the 110 patients treated in nontrial centers (modified Rankin Scale adjusted cOR: 0.77 [95% CI, 0.5-1.2]).

CONCLUSIONS

Our study shows that high rates of favorable clinical outcome and successful reperfusion can be achieved with EVT for PCS, despite high mortality. Characteristics and outcomes of patients treated in trial versus nontrial centers were similar indicating that our cohort is representative of clinical practice in the Netherlands. Randomized studies using modern treatment approaches are needed for further insight in the benefit of EVT for PCS.

Endovascular Therapy for Stroke Due to Basilar-Artery Occlusion

BACKGROUND

The effectiveness of endovascular therapy in patients with stroke caused by basilar-artery occlusion has not been well studied.

METHODS

We randomly assigned patients within 6 hours after the estimated time of onset of a stroke due to basilar-artery occlusion, in a 1:1 ratio, to receive endovascular therapy or standard medical care. The primary outcome was a favorable functional outcome, defined as a score of 0 to 3 on the modified Rankin scale (range, 0 to 6, with 0 indicating no disability, 3 indicating moderate disability, and 6 indicating death) at 90 days. The primary safety outcomes were symptomatic intracranial hemorrhage within 3 days after the initiation of treatment and mortality at 90 days.

RESULTS

A total of 300 patients were enrolled (154 in the endovascular therapy group and 146 in the medical care group). Intravenous thrombolysis was used in 78.6% of the patients in the endovascular group and in 79.5% of those in the medical group. Endovascular treatment was initiated at a median of 4.4 hours after stroke onset. A favorable functional outcome occurred in 68 of 154 patients (44.2%) in the endovascular group and 55 of 146 patients (37.7%) in the medical care group (risk ratio, 1.18; 95% confidence interval [CI], 0.92 to 1.50). Symptomatic intracranial hemorrhage occurred in 4.5% of the patients after endovascular therapy and in 0.7% of those after medical therapy (risk ratio, 6.9; 95% CI, 0.9 to 53.0); mortality at 90 days was 38.3% and 43.2%, respectively (risk ratio, 0.87; 95% CI, 0.68 to 1.12).

CONCLUSIONS

Among patients with stroke from basilar-artery occlusion, endovascular therapy and medical therapy did not differ significantly with respect to a favorable functional outcome, but, as reflected by the wide confidence interval for the primary outcome, the results of this trial may not exclude a substantial benefit of endovascular therapy. Larger trials are needed to determine the efficacy and safety of endovascular therapy for basilar-artery occlusion. (Funded by the Dutch Heart Foundation and others; BASICS ClinicalTrials.gov number, NCT01717755; Netherlands Trial Register number, NL2500.).

Thrombus Migration Paradox in Patients With Acute Ischemic Stroke

Supplemental Digital Content is available in the text.

The location of the thrombus as observed on first digital subtraction angiography during endovascular treatment may differ from the initial observation on initial noninvasive imaging. We studied the incidence of thrombus dynamics, its impact on patient outcomes, and its association with intravenous thrombolytics.

Operator Versus Core Lab Adjudication of Reperfusion After Endovascular Treatment of Acute Ischemic Stroke

Background and Purpose- The modified Treatment In Cerebral Ischemia (mTICI) score is the standard method to quantify the degree of reperfusion after endovascular treatment in acute ischemic stroke. In clinical practice, it is commonly assessed by local operators after the procedure. In clinical trials and registries, mTICI is evaluated by an imaging core lab. The aim of this study was to compare operator mTICI with core lab mTICI scores in patients included in the MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry. Methods- All patients with an intracranial carotid or middle cerebral artery occlusion with anteroposterior and lateral digital subtraction angiography runs were included. Operators determined the mTICI score immediately after endovascular treatment. Core lab neuroradiologists were blinded to clinical characteristics and assessed mTICI scores based on pre- and postintervention digital subtraction angiography. The agreement between operator and core lab mTICI scores and their value in the prediction of outcome (score on modified Rankin Scale at 90 days) was determined. Results- In total, 1130 patients were included. The proportion of agreement between operator and core lab mTICI score was 56% (95% CI, 54%-59%). In 33% (95% CI, 31%-36%), mTICI was overestimated by operators. Operators reported a higher rate of successful reperfusion than the core lab (77% versus 67%; difference 10% [95% CI, 6%-14%]; P<0.001). In 252 (33%) of 763 patients scored as incomplete reperfusion by the core lab (mTICI <3), the local read was mTICI 3. Multivariable logistic regression models containing either core lab scored or operator scored successful reperfusion predicted outcome on the full (C statistic of both models: 0.76) or dichotomized modified Rankin Scale (modified Rankin Scale, 0-2; C statistic of both models: 0.83) equally well. Conclusions- Operators tend to overestimate the degree of reperfusion compared with the core lab although this does not affect the accuracy of outcome prediction.

Midterm Single-Center Results of Endovascular Aneurysm Repair With Additional EndoAnchors

PURPOSE

To review midterm clinical outcomes of EndoAnchor placement during or after endovascular aneurysm repair (EVAR) or chimney EVAR (ch-EVAR).

MATERIALS AND METHODS

A retrospective analysis was conducted of 51 consecutive patients [median age 75 years; 38 men] who underwent EVAR/ch-EVAR with EndoAnchor placement between June 2010 and December 2016 to prevent seal failures (31, 61%) or to treat type Ia endoleak and/or migration (20, 39%). Median aortic neck diameter was 27.7 mm and median neck length was 9.0 mm. Thirty-three (65%) had a conical neck; 48 (94%) had at least 1 hostile neck characteristic. Thirty-two (63%) patients had severe comorbidities (ASA score ⩾III). Eight patients had a single ch-EVAR procedure. Baseline patient characteristics, anatomic variables, procedure details, early and late complications, reinterventions, and aneurysm-related and all-cause mortality rates were recorded. Follow-up imaging was performed with computed tomography angiography (CTA) or duplex ultrasonography.

RESULTS

Median procedure time was 100 minutes; a median of 6 EndoAnchors were implanted. There were 10 (10%) residual type Ia endoleaks at the end of the procedure; 9 had resolved by the first postoperative CTA. One residual and 2 new type Ia endoleaks were identified at the first postoperative imaging. Median follow-up for the entire cohort was 24.0 months, during which 3 new type Ia endoleaks were identified. Five of the 6 type Ia endoleaks were treated, 1 resolved spontaneously. There was 1 endograft limb occlusion without clinical consequences, 1 chimney graft occlusion without possibilities for a reintervention, 1 rupture after type IV endoleak (a Nellix device was successfully deployed within the main device), and 1 complete graft explantation for infection. There was no new-onset hemodialysis. Kaplan-Meier estimates of freedom from type Ia endoleak, proximal neck-related reinterventions, and aneurysm-related mortality at 2 years were 87.3%, 92.2%, and 94.0%, respectively.

CONCLUSION

EndoAnchors are helpful in the endovascular treatment of unfavorable proximal aortic necks, with fair midterm results.

Accuracy of CT Angiography for Differentiating Pseudo-Occlusion from True Occlusion or High-Grade Stenosis of the Extracranial ICA in Acute Ischemic Stroke: A Retrospective MR CLEAN Substudy

BACKGROUND AND PURPOSE

The absence of opacification on CTA in the extracranial ICA in acute ischemic stroke may be caused by atherosclerotic occlusion, dissection, or pseudo-occlusion. The latter is explained by sluggish or stagnant flow in a patent artery caused by a distal intracranial occlusion. This study aimed to explore the accuracy of CTA for differentiating pseudo-occlusion from true occlusion of the extracranial ICA.

MATERIALS AND METHODS

All patients from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) with an apparent ICA occlusion on CTA and available DSA images were included. Two independent observers classified CTA images as atherosclerotic cause (occlusion/high-grade stenosis), dissection, or suspected pseudo-occlusion. Pseudo-occlusion was suspected if CTA showed a gradual contrast decline located above the level of the carotid bulb, especially in the presence of an occluded intracranial ICA bifurcation (T-occlusion). DSA images, classified into the same 3 categories, were used as the criterion standard.

RESULTS

In 108 of 476 patients (23%), CTA showed an apparent extracranial carotid occlusion. DSA was available in 46 of these, showing an atherosclerotic cause in 13 (28%), dissection in 16 (35%), and pseudo-occlusion in 17 (37%). The sensitivity for detecting pseudo-occlusion on CTA was 82% (95% CI, 57-96) for both observers; specificity was 76% (95% CI, 56-90) and 86% (95% CI, 68-96) for observers 1 and 2, respectively. The κ value for interobserver agreement was .77, indicating substantial agreement. T-occlusions were more frequent in pseudo- than true occlusions (82% versus 21%, P < .001).

CONCLUSIONS

On CTA, extracranial ICA pseudo-occlusions can be differentiated from true carotid occlusions.

Abstract 35: MR CLEAN Registry: A Post-trial Multicenter Registry of Intra-arterial Treatment for Acute Ischemic Stroke in the Netherlands

Background & Purpose: Intra-arterial therapy (IAT) is being implemented worldwide as the main treatment option for acute ischemic stroke (AIS). We wondered whether effectiveness and safety results that have been reported in randomized clinical trials can be reproduced in everyday clinical practice. We will report results of the Dutch National post MR CLEAN IAT registry including work flow parameters, primary and secondary outcomes, as well as serious adverse events.

Methods: The MR CLEAN Registry is a prospective registry of all patients undergoing IAT for AIS in the Netherlands, started after completion of the MR CLEAN trial in March 2014. Registration was required for reimbursement. A core set was defined, with inclusion criteria similar to those of the MR CLEAN trial, including a proven anterior circulation occlusion and treatment possible withing 6 hours from onset. The primary study outcome is the score on the modified Rankin Scale (mRS) at 90 days. The secondary clinical outcome is NIHSS after 24 to 48 hours. Secondary radiological outcomes include the mTICI score on DSA and final infarct volume and major bleeding on follow up NCCT. We used a propensity weighted and an unadjusted ordinal logistic regression model to compare outcomes in the MR CLEAN Registry core and total dataset with the treatment arm of MR CLEAN.

Results: Between March 2014 and August 2016 the inclusion rate of the MR CLEAN Registry has been increasing steadily to an average of 79 (SD 22) per month for a cumulative inclusion of 1548 patients in July 2016 (Figure 1).

Conclusions: The MR CLEAN registry data is now being analyzed. Results will be reported at the conference.

Percutaneous Transluminal Angioplasty and Drug-Eluting Stents for Infrapopliteal Lesions in Critical Limb Ischemia (PADI) Trial

Supplemental Digital Content is available in the text.

Background—

Endovascular infrapopliteal treatment of patients with critical limb ischemia using percutaneous transluminal angioplasty (PTA) and bail-out bare metal stenting (BMS) is hampered by restenosis. In interventional cardiology, drug-eluting stents (DES) have shown better patency rates and are standard practice nowadays. An investigator-initiated, multicenter, randomized trial was conducted to assess whether DES also improve patency and clinical outcome of infrapopliteal lesions.

Methods and Results—

Adults with critical limb ischemia (Rutherford category ≥4) and infrapopliteal lesions were randomized to receive PTA±BMS or DES with paclitaxel. Primary end point was 6-month primary binary patency of treated lesions, defined as ≤50% stenosis on computed tomographic angiography. Stenosis >50%, retreatment, major amputation, and critical limb ischemia–related death were regarded as treatment failure. Severity of failure was assessed with an ordinal score, ranging from vessel stenosis through occlusion to the clinical failures. Seventy-four limbs (73 patients) were treated with DES and 66 limbs (64 patients) received PTA±BMS. Six-month patency rates were 48.0% for DES and 35.1% for PTA±BMS (P=0.096) in the modified-intention-to-treat and 51.9% and 35.1% (P=0.037) in the per-protocol analysis. The ordinal score showed significantly worse treatment failure for PTA±BMS versus DES (P=0.041). The observed major amputation rate remained lower in the DES group until 2 years post-treatment, with a trend toward significance (P=0.066). Less minor amputations occurred after DES until 6 months post-treatment (P=0.03).

Conclusions—

In patients with critical limb ischemia caused by infrapopliteal lesions, DES provide better 6-month patency rates and less amputations after 6 and 12 months compared with PTA±BMS.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00471289.

Comparison of CTA- and DSA-Based Collateral Flow Assessment in Patients with Anterior Circulation Stroke

BACKGROUND AND PURPOSE

Collateral flow is associated with clinical outcome after acute ischemic stroke and may serve as a parameter for patient selection for intra-arterial therapy. In clinical trials, DSA and CTA are 2 imaging modalities commonly used to assess collateral flow. We aimed to determine the agreement between collateral flow assessment on CTA and DSA and their respective associations with clinical outcome.

MATERIALS AND METHODS

Patients randomized in MR CLEAN with middle cerebral artery occlusion and both baseline CTA images and complete DSA runs were included. Collateral flow on CTA and DSA was graded 0 (absent) to 3 (good). Quadratic weighted κ statistics determined agreement between both methods. The association of both modalities with mRS at 90 days was assessed. Also, association between the dichotomized collateral score and mRS 0-2 (functional independence) was ascertained.

RESULTS

Of 45 patients with evaluable imaging data, collateral flow was graded on CTA as 0, 1, 2, 3 for 3, 10, 20, and 12 patients, respectively, and on DSA for 12, 17, 10, and 6 patients, respectively. The κ-value was 0.24 (95% CI, 0.16-0.32). The overall proportion of agreement was 24% (95% CI, 0.12-0.38). The adjusted odds ratio for favorable outcome on mRS was 2.27 and 1.29 for CTA and DSA, respectively. The relationship between the dichotomized collateral score and mRS 0-2 was significant for CTA (P = .01), but not for DSA (P = .77).

CONCLUSIONS

Commonly applied collateral flow assessment on CTA and DSA showed large differences, indicating that these techniques are not interchangeable. CTA was significantly associated with mRS at 90 days, whereas DSA was not.

Collateral Status on Baseline Computed Tomographic Angiography and Intra-Arterial Treatment Effect in Patients With Proximal Anterior Circulation Stroke

Background and Purpose—

Recent randomized trials have proven the benefit of intra-arterial treatment (IAT) with retrievable stents in acute ischemic stroke. Patients with poor or absent collaterals (preexistent anastomoses to maintain blood flow in case of a primary vessel occlusion) may gain less clinical benefit from IAT. In this post hoc analysis, we aimed to assess whether the effect of IAT was modified by collateral status on baseline computed tomographic angiography in the Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands (MR CLEAN).

Methods—

MR CLEAN was a multicenter, randomized trial of IAT versus no IAT. Primary outcome was the modified Rankin Scale at 90 days. The primary effect parameter was the adjusted common odds ratio for a shift in direction of a better outcome on the modified Rankin Scale. Collaterals were graded from 0 (absent) to 3 (good). We used multivariable ordinal logistic regression analysis with interaction terms to estimate treatment effect modification by collateral status.

Results—

We found a significant modification of treatment effect by collaterals ( P =0.038). The strongest benefit (adjusted common odds ratio 3.2 [95% confidence intervals 1.7–6.2]) was found in patients with good collaterals (grade 3). The adjusted common odds ratio was 1.6 [95% confidence intervals 1.0–2.7] for moderate collaterals (grade 2), 1.2 [95% confidence intervals 0.7–2.3] for poor collaterals (grade 1), and 1.0 [95% confidence intervals 0.1–8.7] for patients with absent collaterals (grade 0).

Conclusions—

In MR CLEAN, baseline computed tomographic angiography collateral status modified the treatment effect. The benefit of IAT was greatest in patients with good collaterals on baseline computed tomographic angiography. Treatment benefit appeared less and may be absent in patients with absent or poor collaterals.

Clinical Trial Registration—

URL: http://www.trialregister.nl and http://www.controlled-trials.com . Unique identifier: (NTR)1804 and ISRCTN10888758, respectively.

Catheter-directed thrombolysis for acute upper extremity ischemia

AIM

Acute nontraumatic upper extremity ischemia has significant chronic disability when not treated adequately and timely. As surgical treatment can be challenging, this study evaluates catheter-directed thrombolysis as first-line treatment for acute upper extremity ischemia.

METHODS

Between January 2006 and December 2010, 28 patients (22 women; mean age, 63±16 years) underwent catheter-directed thrombolysis for acute upper extremity ischemia, Rutherford class I or IIa. Proximal extent of the occlusion was in the subclavian (32%), axillary (7%), brachial (25%) and forearm arteries (36%). Median occlusion length was 18 cm (range, 12-43). Causes were embolus (14%), thrombus (39%), thoracic outlet syndrome (14%), paraneoplastic (4%), or unknown (29%).

RESULTS

Technical success was 96%, radiologic success (>95% clot lysis) 61%, and clinical success 68%. Median duration of thrombolysis was 24 hours (range, 18-96). Of the 11 radiologically unsuccessful patients (39%), five were treated conservatively and six underwent surgical intervention. In-hospital amputation-rate was 7%. Four complications occurred: embolization to the lower extremity, a transient ischemic attack, a subcapsular splenic hematoma and a pseudoaneurysm. Cumulative amputation-free survival at six months was 93%, standard error (SE) 4.87 and at one year 88%, SE 6.50.

CONCLUSION

These results show that catheter-directed thrombolysis is effective in over 60% of patients as first-line treatment of extensive acute upper extremity ischemia and can prevent surgical intervention in these patients.

Experience with new techniques for the treatment of type II endoleaks post-EVAR

Endovascular aneurysm management (EVAR) is hampered by persistent arterial blood flow in the aneurysm sac after treatment, known as endoleak (EL). Type II EL consist of blood flow from one or more aortic branch vessels; they only require treatment when the aneurysm sac fails to shrink. Post-EVAR follow up is mostly done with contrast enhanced computed tomography. If a type II EL requiring treatment is found, a variety of options exist, depending on the source of EL and the anatomy. Inferior mesenteric artery EL is best treated by endovascular embolization through the superior mesenteric artery and Riolans' arc. In hypogastric to lumbar artery EL success of endovascular treatment is limited. In these cases a successful embolization of the EL can often be performed by a direct percutaneous approach to the EL inside the aneurysmal sac. CT guidance provides a good way to exactly puncture the EL percutaneously in most cases, but limited workspace and lack of fluoroscopy availability for the ensuing catheter manipulation hampers this technique. A novel way to puncture the EL and subsequently treat it is performed on flat panel detector angiography units. By a rotation around the patients these units provide the possibility to create a cone-beam CT (CBCT) in the angio suite. Using the 3-dimensional dataset thus acquired, a needle path can be planned and the EL nidus can be punctured with great confidence and without danger of inadvertently perforating vital structures. After the EL has been punctured, microcatheters can be inserted to embolize the origins of branch vessels and/or the aneurysm sac can be filled with thrombogenic agents or glue. CBCT guided procedures incur lower radiation dose and have higher accuracy compared to conventional CT guided procedures. Details of CBCT guided procedures; the materials and technique used are detailed in this manuscript.

Direct haemodynamic effects of pulmonary arteriovenous malformation embolisation

BACKGROUND

Transcatheter embolisation is widely used to close pulmonary arteriovenous malformations (PAVMs) in patients with hereditary haemorrhagic telangiectasia (HHT). Data on the direct cardiovascular haemodynamic changes induced by this treatment are scarce.

OBJECTIVES

We investigated the direct haemodynamic effects of transcatheter embolisation of PAVMs, using non-invasive finger pressure measurements.

METHODS

During the procedure, blood pressure, heart rate (HR), stroke volume (SV), cardiac output (CO), total peripheral resistance (TPR) and delta pressure/delta time (dP/dt) were continuously monitored using a Finometer®. Potential changes in these haemodynamic parameters were calculated from the pressure registrations using Modelflow® methodology. Absolute and relative changes were calculated and compared using the paired sample t-test.

RESULTS

The present study includes 29 HHT patients (mean age 39 ± 15 years, 11 men) who underwent transcatheter embolotherapy of PAVMs. The total number of embolisations was 72 (mean per patient 2.5). Directly after PAVM closure, SV and CO decreased significantly by -11.9 % (p = 0.01) and -9.5 % (p = 0.01) respectively, without a significant change in HR (1.8 %). Mean arterial blood pressure increased by 4.1 % (p = 0.02), while the TPR and dP/dt did not increase significantly (5.8 % and 0.2 %, respectively).

CONCLUSIONS

Significant haemodynamic changes occur directly after transcatheter embolisation of PAVMs, amongst which a decrease in stroke volume and cardiac output are most important.

Trapped cerebral thrombectomy device: A case report of a rare complication

Intravenous thrombolysis with recombinant tissue plasminogen activator is currently the standard therapy for acute ischaemic stroke when started within 4.5 h of symptom onset. Systemic thrombolytic therapy can, however, lead to potentially lethal bleeding complications and is contra-indicated in several circumstances. Intra-arterial thrombolysis and/or intra-arterial thrombectomy can overcome these drawbacks and even increase the rate of recanalization. While intravenous thrombolysis is a relatively non-complex treatment, intra-arterial therapy in acute ischaemic stroke patients requires a dedicated intervention team which has to be available at all times. In this case report, we describe the multidisciplinary approach of a rare complication of a trapped mechanical thrombectomy device.

High versus standard clopidogrel loading in patients undergoing carotid artery stenting prior to cardiac surgery to assess the number of microemboli detected with transcranial Doppler: results of the randomized IMPACT trial

AIM

The aim of this study was to compare the effects of 300 mg or 600 mg clopidogrel loading dose, prior to carotid artery stenting (CAS) on the number of transcranial Doppler (TCD)-detected microembolic signals (MES) and to investigate the relationship between the magnitude of platelet reactivity and MES.

METHODS

In this prospective randomized, double-blind study, 35 consecutive asymptomatic patients (17.1% females), scheduled for CAS and cardiac surgery were included. The primary endpoint was the number of TCD-detected MES. The secondary endpoints were the absolute magnitude of on-treatment platelet reactivity and the adverse cerebral events. Negative binomial regression to find predictors for sum of single emboli, the student's t-test to assess the association between platelet function tests and randomized dose of 300 mg or 600 mg clopidogrel, and the R2 calculation for the assessment of the association between platelet function tests and embolic load, were used.

RESULTS

No statistically significant difference in the number of TCD-detected MES, in the sum of all the single emboli or showers and platelet aggregation measurements between the two groups was observed (aggregometry: 21.7±18.3 versus 23±18%, P=0.8499 and 45.8±17.5 versus 46.5±14.5%, P=0.9003) (verifyNow P2Y12 assay: 231±93 PRU versus 222±86 PRU, P=0.7704). In one patient a transient ischemic attack occurred.

CONCLUSION

A loading dose of 300 mg of clopidogrel in combination with aspirin is as effective as 600 mg of clopidogrel in achieving adequate platelet inhibition and preventing periprocedural events in asymptomatic patients undergoing CAS prior to cardiac surgery.

The use of endoanchors in repair EVAR cases to improve proximal endograft fixation

AIM

The aim of this paper was to evaluate short-term outcome of the use of endoanchors to secure the primary migrated endograft and additional extender cuffs to the aortic wall in patients with previous failed endovascular aortic aneurysm repair.

METHODS

Consecutive patients who needed proximal repair of a primary failed endograft due to migration (with or without type IA endoleaks) were treated with endoanchors, with or without additional extender cuffs. Data of this group were prospectively gathered in vascular referral centers that were early adopters of the endoanchor technique. Preprocedural and periprocedural data were prospectively gathered and retrospectively analyzed. Follow-up after endoanchor placement consisted of regular hospital visits, with computed tomography or duplex scanning at 1, 6, and 12 months.

RESULTS

From July 2010 to May 2011, 11 patients (8 men), mean age 77 years (range, 59-88 years), were treated with endoanchors for a failed primary endograft (2 Excluder endografts, 1 AneuRx endograft, and 8 Talent endografts) due to distal migration of the main body, with or without type IA endoleak. Revision consisted of using endoanchors to secure the body of the primary endograft to the aortic wall to avoid persistent migration. Most patients had additional proximal extender cuffs with suprarenal fixation, which were secured with endoanchors to the aortic wall and in some patients also to the primary endograft. A median of 6 endoanchors were implanted. All endoanchors were positioned correctly but one. One endoanchor dislodged but was successfully retrieved using an endovascular snare. During a mean follow-up of 10 months (range, 3-18 months) no endoanchor-related complications or renewed migration of the endografts occurred. Two patients underwent repeat intervention due to persistent type IA endoleak during follow-up.

CONCLUSION

The use of endoanchors to secure migrated endografts to the aortic wall is safe and feasible and might help to overcome persistent migration of primary failed endografts. In combination with the use of sole extender cuffs the majority of proximal EVAR failures can be solved.

Outcome of carotid artery stenting for radiation-induced stenosis

PURPOSE

Patients who have been irradiated at the neck have an increased risk of symptomatic stenosis of the carotid artery during follow-up. Carotid angioplasty and stenting (CAS) can be a preferable alternative treatment to carotid endarterectomy, which is associated with increased operative risks in these patients.

METHODS AND MATERIALS

We performed a prospective cohort study of 24 previously irradiated patients who underwent CAS for symptomatic carotid stenosis. We assessed periprocedural and nonprocedural events including transient ischemic attack (TIA), nondisabling stroke, disabling stoke, and death. Patency rates were evaluated on duplex ultrasound scans. Restenosis was defined as a stenosis of >50% at the stent location.

RESULTS

Periprocedural TIA rate was 8%, and periprocedural stroke (nondisabling) occurred in 4% of patients. After a mean follow-up of 3.3 years (range, 0.3-11.0 years), only one ipsilateral incident event (TIA) had occurred (4%). In 12% of patients, a contralateral incident event was present: one TIA (4%) and two strokes (12%, two disabling strokes). Restenosis was apparent in 17%, 33%, and 42% at 3, 12, and 24 months, respectively, although none of the patients with restenosed vessels became symptomatic. The length of the irradiation to CAS interval proved the only significant risk factor for restenosis.

CONCLUSIONS

The results of CAS for radiation-induced carotid stenosis are favorable in terms of recurrence of cerebrovascular events at the CAS site.

VAST: Vertebral Artery Stenting Trial. Protocol for a randomised safety and feasibility trial

Background

Twenty to 30 percent of all transient ischaemic attacks and ischaemic strokes involve tissue supplied by the vertebrobasilar circulation. Atherosclerotic stenosis ≥ 50% in the vertebral artery accounts for vertebrobasilar stroke in at least one third of the patients. The risk of recurrent vascular events in patients with vertebral stenosis is uncertain and revascularisation of vertebral stenosis is rarely performed. Observational studies have suggested that the risk of subsequent stroke or death in patients with vertebrobasilar ischaemic events is comparable with that in patients with carotid territory events. Treatment of vertebral stenosis by percutaneous transluminal angioplasty has been introduced as an attractive treatment option. The safety and benefit of stenting of symptomatic vertebral stenosis as compared with best medical therapy alone remains to be elucidated in a randomised clinical trial.

Study objectives

The primary aim of the Vertebral Artery Stenting Trial (VAST) is to assess whether stenting for symptomatic vertebral artery stenosis ≥ 50% is feasible and safe. A secondary aim is to assess the rate of new vascular events in the territory of the vertebrobasilar arteries in patients with symptomatic vertebral stenosis ≥ 50% on best medical therapy with or without stenting.

Design

This is a randomised, open clinical trial, comparing best medical treatment with or without vertebral artery stenting in patients with recently symptomatic vertebral artery stenosis ≥ 50%. The trial will include a total of 180 patients with transient ischaemic attack or non-disabling ischaemic stroke attributed to vertebral artery stenosis ≥ 50%. The primary outcome is any stroke, vascular death, or non-fatal myocardial infarction within 30 days after start of treatment. Secondary outcome measures include any stroke or vascular death during follow-up and the degree of (re)stenosis after one year.

Discussion

Improvements both in imaging of the vertebral artery and in endovascular techniques have created new opportunities for the treatment of symptomatic vertebral artery stenosis. This trial will assess the feasibility and safety of stenting for symptomatic vertebral artery stenosis and will provide sufficient data to inform a conclusive randomised trial testing the benefit of this treatment strategy. The VAST is supported by the Netherlands Heart Foundation (2007B045; ISRCTN29597900).

The Fate of the External Carotid Artery after Carotid Artery Stenting. A Follow-up Study with Duplex Ultrasonography

OBJECTIVE

To evaluate the long-term effect of carotid angioplasty and stenting (CAS) of the internal carotid artery (ICA) on the ipsilateral external carotid artery (ECA).

SUBJECTS AND METHODS

We prospectively registered the pre- and post-interventional duplex scans obtained from 312 patients (mean age 70 years) who underwent CAS. Duplex scans were scheduled the day before CAS, 3 and 12 months post-procedurally and yearly thereafter, to study progression of obstructive disease in the ipsilateral ECA compared to the contralateral ECA. The duplex ultrasound criteria used to identify ECA stenosis >or=50% were Peak Systolic Velocities of >or=125 cm/s.

RESULTS

Preprocedural evaluation of the ipsilateral ECA demonstrated >or=50% stenosis in 32.7% of cases vs 30% contralateral. Both ipsilateral and contralateral 3 (1%) ECA occlusions were noted. After stenting 5 (1.8%) occlusions were seen vs 1% contralateral. No additional ipsilateral occlusions and 2 additional contralateral occlusions were noted at extended follow-up. The prevalence of >or=50% stenosis of the ipsilateral ECA (Kaplan-Meier estimates) progressed from 49.1% at 3, to 56.4%, 64.7%, 78.2%, 72.3%, and 74% at 12, 24, 36, 48, and 60 months respectively. Contralateral prevalences were 31.3%, 37.7%, 41.7%, 43.1%, 46.0%, and 47.2% respectively (p<0.001). Progression of stenosis was more pronounced in 234 patients (75%) with overstenting of the carotid bifurcation (p=0.004).

CONCLUSION

Our results show that significant progression of >or=50% stenosis in the ipsilateral ECA occurs after CAS. There was greater progression of disease in the ipsilateral compared with the contralateral ECA. Progression of disease in the ECA did not lead to the occurrence of occlusion during follow up.

Long-term Results of Percutaneous Transluminal Angioplasty for Symptomatic Iliac In-stent Stenosis

OBJECTIVE

This study describes the long-term results of endoluminal therapy for iliac in-stent obstructions.

DESIGN

This is a retrospective study.

MATERIALS AND METHODS

From 1992 to 2005, 68 patients (22 women), with a mean age of 61+/- 13 years and 16 bi-iliac in-stent obstructions, underwent 84 endovascular interventions for focal iliac in-stent stenoses (n = 61) or occlusions (n = 23). Primarily, only uncovered stents were placed. All patients were symptomatic: 70% had disabling intermittent claudication, 23% had resting pain, and 7% had trophic changes. All had in-stent diameter reduction exceeding 50% that was confirmed by duplex scanning and angiography. Procedures were performed under local anesthesia via the femoral route.

RESULTS

All interventions were initially technically successful, with a minor complication of pneumonia in one patient (2%). Initial clinical success was achieved in 86% of patients. PTA alone was used to treat 72 (86%) in-stent obstructions, the other 12 (14%) had PTA and renewed stent placement. The 30-day mortality rate was 0%. Mean follow-up was 35 months (range, 3 months to 10 years) and included duplex scanning. Primary clinical patency was 88% at 1 year, 62% at 3 years, and 38% at 5 years follow-up. During follow-up, 28 (33%) of 84 extremities required secondary reinterventions because of symptomatic renewed in-stent stenosis, and 11 were treated successfully with repeated endovascular interventions. Secondary patency at 1 year was 94%, 78% at 3 years, and 63% at 5 years. Surgical intervention was eventually needed in 17 (20%) of the 84 extremities.

CONCLUSIONS

Endoluminal therapy for iliac focal in-stent obstructive disease seems to be a safe technique with acceptable long-term outcome and therefore a true alternative to primary surgical reconstruction.

Early transection of a central venous catheter in a sedated ICU patient

We report transection and embolization to the heart of a subclavian venous catheter in an immobilized and mechanical ventilated patient. The catheter tip was retrieved using a percutaneous method via the left femoral vein. Mechanical compression of the subclavian venous catheter at the costoclavicular area is termed pinch-off syndrome. It can be recognized by intermittent difficulties with drug injection, and chest wall swelling at the insertion site. The diagnosis can be confirmed by chest radiography with or without contrast administration. A more lateral approach of the subclavian vein is advocated to prevent compression.

Thoracic Stent Grafting for Acute Aortic Pathology

BACKGROUND

Elective endovascular repair of the thoracic aorta has shown reduced morbidity and mortality when compared with open surgery. The number of studies describing the use of thoracic endovascular stent grafts for acute pathology is limited, however. The purpose of this study was to describe our increasing experience with stent grafting for acute thoracic aortic pathology.

METHODS

Since January 2002, 28 patients underwent endovascular stent graft treatment for various types of acute thoracic aorta diseases, including complicated Stanford type B dissection (n = 12), ruptured descending aorta aneurysms (n = 7), intramural hematoma (n = 4), traumatic rupture of the thoracic aorta (n = 2), aortopulmonary fistula (n = 2), and penetrating aortic ulcer (n = 1). These acute thoracic aortic syndromes were predominantly localized in the proximal descending thoracic aorta (75%). Talent stent grafts were used in 26 patients and Excluder stent grafts in 2 patients.

RESULTS

Stent graft deployment at the intended position was successful in all patients. There was 1 intraoperative death (3.6%), due to acute myocardial infarction, after successful exclusion of the lesion with a stent graft. Hospital mortality was 21.4% (n = 6). Four of 6 hospital deaths, however, were directly related to the severely compromised clinical status preoperatively, including extensive bowel ischemia and irreversible cerebral damage after resuscitation. New neurologic symptoms were seen in 4 patients. The majority of the neurologic symptoms improved and faded away during hospital stay. Mean follow-up was 11 months (range, 1 to 31), and all the hospital survivors (n = 22) were alive. There was 1 nonrelated stroke 4 months postoperatively. During follow-up, 2 patients required transposition of the left subclavian artery for malperfusion, and 2 patients required a second stent graft procedure for endoleak. Additionally, 2 patients with early type II endoleaks were treated conservatively, and 1 of them sealed spontaneously at 6 months.

CONCLUSIONS

Thoracic stent grafting for acute aortic pathology is feasible in critically ill patients. Postoperative morbidity and mortality is predominantly related to the compromised preoperative clinical status, illustrating its use as salvage strategy.

[The central-venous compression syndrome: rare, but adequately treatable with endovascular stenting]

Two patients, women aged 30 and 29, had severe chronic pain in the left leg, and a woman aged 36 had pain in the left flank. On the grounds of the clinical symptoms, phlebography and venous-duplex ultrasonography, a central-venous compression syndrome was diagnosed: compression of the left common iliac vein between the crossing right common iliac artery and the body of the fifth lumbar vertebra (May-Thurner syndrome). The patient with left flank pain also had haematuria. Angiography, computed tomography and phlebography revealed that these symptoms were due to compression of the left renal vein between the abdominal aorta and the superior mesenteric artery (nutcracker phenomenon). The treatment of all 3 patients consisted of venous endovascular stenting. At follow-up after 12, 30 and 15 months, respectively, the complaints had subsided considerably.

Freedom from secondary interventions to treat stenotic disease after percutaneous transluminal angioplasty of infrarenal aorta: long-term results

PURPOSE

The purpose of this study was to determine the long-term results (1-15 years) of percutaneous transluminal angioplasty (PTA) of localized atherosclerotic lesions of the infrarenal aorta.

METHODS

This was a retrospective study. From January 1987 to January 2002, 69 patients underwent PTA of an isolated stenosis of the lower abdominal aorta under local anesthesia in the department of interventional radiology. All atherosclerotic lesions were hemodynamically significant, defined as a subjective report of walking distance less than one block, resting pain, or trophic changes in combination with diameter reduction of 50% or greater at duplex ultrasound scanning and angiography.

RESULTS

The female-male ratio of study patients was 3.6:1; mean age was 58 years. Endovascular treatment was initially technically and clinically successful in all but one patient (98%), who had a near total occlusion. No major complications were noted. Mean follow-up was 57 months (range, 6 months-15 years). At life table analysis, 5-year primary patency was 75%, and secondary patency was 97%. Twelve patients (17%) required repeat interventions because of hemodynamically significant recurrent stenosis in combination with severe clinical symptoms. Most recurrent stenoses (67%) were successfully treated with repeat endovascular procedures.

CONCLUSIONS

Early and long-term results of PTA (with additional stent placement) of isolated stenosis of the infrarenal aorta are good. This minimally invasive procedure is a true alternative to traditional surgical methods.

TCD-detected cerebral embolism in carotid endarterectomy versus angioplasty and stenting of the carotid bifurcation

PURPOSE

In this article we will review some of the issues surrounding the relationship between TCD-detected emboli and brain function and architecture, both during conventional surgical carotid endarterectomy (CEA) and carotid angioplasty and stenting (CAS).

MATERIAL AND METHODS

In both procedures, the cerebral embolic load was semi quantitatively assessed and associated with clinical outcome during the procedure and after a symptom free interval within 7 days.

RESULTS

In CEA, particulate emboli that occurred during the wound closure stage were associated with intraoperative stroke and stroke related death, odds ratios [OR] 2.3 95% CI 1.2-4.4, p = 0.007. In CAS, showers of microemboli that appeared at postdilatation of the stent (OR 3.2, 95% CI 1.5-6.9, p = 0.002), particulate macroembolism (relative risk [RR] 10.2, 95% CI 5.9-17.3, p < 0.001), and massive air embolism (RR 10.2, 95%CI 5.8-17.7, p < 0.001) were associated with new transient and persistent cerebral deficits.

CONCLUSION

In both CEA and CAS, recording of cerebral emboli by TCD ultrasonography provides insight in the pathogenesis of procedure related adverse cerebral outcome. In several centres TCD monitoring during CEA is now accepted as a clinically relevant tool that helps the surgeon to make the operation safer. In CAS more research is needed, particularly with respect to the impact of cerebral protection devices.

[Diagnostic image (63). Paraganglioma]

A 33-year-old woman was examined for a non-tender mass in the neck. Imaging findings were consistent with paraganglioma. The diagnosis was confirmed at surgery.

Digital chest imaging using a selenium detector. The impact of hard copy size on observer performance: a computed tomography-controlled study

RATIONALE AND OBJECTIVES

The authors compare radiologist detection performance under clinical conditions for assessment of the effect of size reduction on the diagnostic performance of digital chest images obtained with a selenium detector.

METHODS

Sixty-five patients were examined with the digital system. The images were acquired without an antiscatter grid. Sixty-five posteroanterior life-size images (35 x 43 cm) and sixty-five posteroanterior minified images (56% of life size) were analyzed by three observers for detection of pulmonary, mediastinal, and pleural pathology, using computed tomography as the reference standard. The diagnostic value of life-size and minified images for the detection of these chest abnormalities was analyzed with receiver operating characteristic (ROC) methods.

RESULTS

For the detection of the various abnormalities by all radiologists, the areas under the ROC curves with life-size images versus minified images, respectively, were as follows: pulmonary opacities, 0.78 versus 0.78; interstitial disease, 0.74 versus 0.75; mediastinal disease, 0.70 versus 0.72; and pleural abnormalities 0.72 versus 0.67.

CONCLUSIONS

There was no statistically significant difference between the radiologists' performance in detecting pulmonary, mediastinal, and pleural pathology with life-size versus that with minified (56% of life size) digital selenium chest radiography.

Aberrant methylation of the major breakpoint cluster region in chronic myeloid leukemia

Isolated hypomethylated sites exist in the major breakpoint cluster region (M-bcr) where most Philadelphia chromosome (Ph) breakpoints are located. Twenty of 50 (40%) chronic myeloid leukemia (CML) patients were found to have aberrant hypermethylation of these sites on the rearranged M-bcr when compared with control marrows. The aberrancy correlated strongly with M-bcr breakpoint location; 19 of 20 cases had breakpoints located 5' of the M-bcr Sca I site, and 28 of 30 cases with normal M-bcr methylation had breakpoints located 3' of the M-bcr Sca I site. Sequence analysis of the Ph M-bcr breakpoints failed to find an M-bcr nucleotide position that delineated the transition between abnormally and normally methylated cases, indicating that the translocation of a critical M-bcr sequence was not responsible for the methylation abnormality. In 3 of 8 CML patients, cells without the t(9;22) were found to have abnormally methylated, unrearranged M-bcrs. The data indicate that abnormally methylated rearranged M-bcrs are present in CML cases with Ph breakpoints 5' of the M-bcr Sca I site and that the M-bcr in Ph- cells of patients with CML may also be abnormally methylated.

Chest imaging with a selenium detector versus conventional film radiography: a CT-controlled study

PURPOSE

To compare radiologist detection performance under clinical conditions for assessment of conventional radiographs and digital chest images obtained with a selenium detector.

MATERIALS AND METHODS

One hundred four patients were examined with the digital and conventional systems under near identical technical conditions. The digital images were acquired without an antiscatter grid. Two hundred eight images were analyzed by three radiologists for detection of pulmonary, mediastinal, and pleural abnormalities; computed tomography was used as the reference standard. The diagnostic value of both techniques for the detection of these chest abnormalities was analyzed with receiver operating characteristic (ROC) methods.

RESULTS

For detection of the various abnormalities by all radiologists, the areas under the ROC curves with conventional imaging versus digital imaging, respectively, were as follows: pulmonary opacities, 0.81 versus 0.79; interstitial disease, 0.69 versus 0.73; mediastinal disease, 0.79 versus 0.74; and pleural abnormalities, 0.73 versus 0.68.

CONCLUSION

There was no statistically significant difference between the radiologists' performance in detecting pulmonary, mediastinal, and pleural abnormalities with conventional radiography versus that with digital selenium chest radiography.

Nationwide survey on nutritional habits in elite athletes. Part II. Mineral and vitamin intake

The nutritional habits of elite athletes competing at a national and international top level were determined. Groups of endurance strength, and team sport athletes participated. All athletes trained at least 1-2 h daily. The purpose of the study was to quantify the mineral and vitamin intake and to identify the magnitude of the nutrient supplementation use. Information on food intake was obtained by a 4- or 7-day food diary. It was found that calcium and iron intake was positively related to energy intake. In low energy intakes (less than 10 MJ) iron intake might be insufficient. In general, vitamin intake with food was in agreement with the Dutch recommendations. However, if energy intake is high (greater than 20 MJ) the amount of refined carbohydrate is increased. Consequently, the nutrient density for vitamin B1 drops. Therefore, under these conditions, supplementation for vitamin B1 must be considered. The low vitamin intake found in lower energy intakes can be improved by proper nutritional advice. In body building and in professional cycling, high dosages of vitamins are used. The other groups of athletes used only moderate quantities of vitamin supplements. It is concluded that vitamin and mineral intake is sufficient, when energy intake ranges between 10 and 20 MJ/day.

Nationwide survey on nutritional habits in elite athletes. Part I. Energy, carbohydrate, protein, and fat intake

Information about habitual food intake was systematically obtained from elite endurance, strength, and team sport athletes. The athletes (n = 419) trained at least 1-2 h daily and competed on an international level. A 4- or 7-day food diary was kept. For analysis of the data, a computerized food table was used. Mean energy intake varied from 12.1-24.7 MJ per day for male and 6.8-12.9 MJ per day for female athletes. Protein intake was in agreement with or higher than the Dutch recommendations. Contribution of carbohydrate intake to total energy intake varied from 40%-63%. Fat intake tended to meet the criteria for a prudent diet (less than 35%). Snacks contributed about 35% to the total energy intake and the bread/cereals and dairy food groups were the most important energy sources. It is concluded that in general there are two major concerns. In those sports in which body composition plays an important role, energy and thus nutrient intake is often marginal. In all groups of athletes intake of carbohydrate is insufficient.

Deleterious effects of anabolic steroids on serum lipoproteins, blood pressure, and liver function in amateur body builders

The effects of self-administered anabolic steroids (AS) on lipoproteins, liver function, and blood pressure were studied in male amateur body builders. Twenty body builders were studied at the end of a course of AS (group 1) and 42 body builders were studied after discontinuation of the AS for a mean of 5 months (group 2). Sixteen body builders were studied after discontinuation of AS for at least 2 months and at the end of a 9-week course of AS (group 3). A group of 13 body builders who never used AS served as a control group. Both groups 1 and 2 showed higher levels of transaminas and a higher systolic blood pressure than the controls (P less than 0.05). Group 3 showed an increase of the transaminases an a slight but significant increase of systolic blood pressure (+3 mm Hg) and heart rate (+7 bts/min) after one course of AS (P less than 0.05). Group 1 showed a considerably lower high-density lipoprotein cholesterol (HDLC) (P less than 0.001), a higher low-density lipoprotein cholesterol (LDLC) (P less than 0.05), and a lower apoprotein A-l/B ratio (Apo A-l/ApoB) (P less than 0.001) than the controls and group 2. The ratio of LDLC/HDLC in group 1 was fourfold higher than in the controls (P less than 0.01). In group 3 HDLC decreased from 1.18 +/- 0.05 to 0.60 +/- 0.08 mmol/l (P less than 0.001) and LDLC increased from 3.97 +/- 0.39 to 5.74 +/- 0.71 mmol/l (P less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

The force-velocity relationship of arm flexion in untrained males and females and arm-trained athletes

The force-velocity curve (FVC) of arm flexion was established in 123 untrained males and 110 untrained females aged from 15 to 36 years, and 48 arm-trained athletes competing in different sport disciplines. The FVC was described by Hill's equation and defined by the parameters: maximal static moment (M0), maximal angular velocity (omega 0), maximal power (P0) and the concavity of the FVC (H). Within the given age range the level of the curve parameters of both untrained men and women was independent of age. On average, H was the same in all three groups. As compared to M0 of the untrained males, M0 of the athletes was 33% higher and M0 of the females was 38% lower; with regard to P0 these differences were +30% and -43% respectively. omega 0 was the same for trained and untrained males, whereas omega 0 of the women was 10% lower than omega 0 of the men.

Influence of training on the force-velocity relationship of the arm flexors of active sportsmen

The aim of this study was to investigate the influence of specific types of muscle training, performed by previously well-trained competitive athletes, on the force-velocity relationship of the arm flexors. Four rowers, five athletes competing in tug-of-war, and six middle- and long-distance runners were measured at different stages of their training program during the period of 1 training year. The runners performed no special arm training and were included for comparative purposes. A record was made of the type and intensity of training. The force-velocity curve (FVC) was established by measuring the torques (M) and corresponding angular velocities (omega) of maximal arm flexions against different constant torques. Using Hill's equation: (M + a) (omega + b) = constant, a best fitting curve was calculated through the points of measurement. Two-way analysis of variance revealed only few statistically significant (P less than 0.05) changes in the parameters describing the course of the FVC. The results suggest that the force-velocity characteristics of muscle of previously well-trained sportsmen can hardly be influenced.

Influence of static strength training on the force-velocity relationship of the arm flexors

Twenty-nine boys about 16 years old were divided into a training group and a control group. The training group exercised the arm flexors in a static strength training program with 90% of the maximal static strength during 9 weeks, three times a week. Before and after the training period, the force-velocity relationship of the arm flexors was established. For this purpose the maximal speed of flexion against different but constant loads was measured. A best fitting curve was computed according to Hill's equation: (F+a) (v+b) = C. The mean maximal static strength of the training group increased from 238 N to 270 N. No change occurred in the maximal speed at low forces but the speed increased at high forces. This resulted in a more concave course of the F-v curve. Maximal power did not change significantly. No significant changes were observed in the control group.