Publications by authors named "Anil Arat"

69 Publications

Dual Stenting with New Generation Stents for Aneurysm Embolization in Acute Subarachnoid Hemorrhage.

World Neurosurg 2021 Jul 3. Epub 2021 Jul 3.

Ankara Hacettepe University, Department of Interventional Radiology Ankara, Turkey. Electronic address:

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.wneu.2021.06.135DOI Listing
July 2021

Stroke Mechanism in COVID-19 Infection: A Prospective Case-Control Study.

J Stroke Cerebrovasc Dis 2021 Aug 1;30(8):105919. Epub 2021 Jun 1.

Department of Neurology, Hacettepe University Hospitals Turkey.

Background: The characteristics and pathophysiological mechanisms involved in acute ischemic stroke in patients with COVID-19 infection have not been fully clarified. We prospectively studied the phenotypic and etiological features of acute stroke occurring in COVID-19 infection.

Patients & Methods: Within nine months starting from April-2020, the presence of COVID-19 infection was determined by thoracic CT and SARS-CoV-2 PCR in all acute stroke cases managed in a single tertiary center. Consecutive and prospective data on vascular risk factors/comorbidities, in-hospital quality metrics, discharge outcomes, etiological subclassification and blood markers of thrombosis / inflammation were compared in 44 COVID-19 positive cases (37 acute ischemic stroke, 5 TIA, 2 intracerebral hematoma) and 509 COVID-19 negative patients (355 ischemic, 105 TIA, 44 hematoma and 5 stroke mimic).

Results: COVID-19 positive patients had more severe strokes, delayed hospital admission, longer hospital stay, higher mortality rates, but had similar vascular risk factors/comorbidities frequency, thrombolysis/thrombectomy utilization rates, metrics, and stroke etiological subtype. They had significantly higher CRP, fibrinogen, ferritin, leukocyte count and lower lymphocyte count. No difference was detected in aPTT, INR, D-dimer, platelet, hemoglobin, homocysteine levels and ANA, anti-dsDNA antibody and ENA panel positivity rates. Anti-phospholipid antibodies have been studied in 70% of COVID-19 positive and all cryptogenic patients, but were never found positive. Tests for coagulation factor levels and hereditary thrombophilia did not show major thrombophilia in any of the stroke patients with COVID-19.

Conclusion: We documented that there is no significant difference in etiological spectrum in acute stroke patients with COVID-19 infection. In addition, cryptogenic stroke and antiphospholipid antibody positivity rates did not increase.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2021.105919DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8166511PMC
August 2021

The implications of magnetic resonance angiography artifacts caused by different types of intracranial flow diverters.

J Cardiovasc Magn Reson 2021 Jun 7;23(1):69. Epub 2021 Jun 7.

Department of Radiology, Hacettepe University Hospitals, Ankara, Turkey.

Background: Serial cerebral angiographic imaging is necessary to ensure cerebral aneurysm occlusion after flow diverter placement. Time-of-flight (TOF)-magnetic resonance angiography (MRA) is used for this purpose due to its lack of radiation, contrast media and complications. The comparative diagnostic yield of TOF-MRA for different flow diverters has not been previously analyzed.

Purpose: To evaluate the diagnostic accuracy of TOF-MRA in cerebral aneurysms treated w divertersith different flow diverters.

Materials And Methods: Flow-diverted patients whose cerebral follow-up MRA and digital subtraction angiograms (DSA) were obtained within 6 weeks were retrospectively identified. The DSA (as gold standard) and MRA images of these patients were compared by two readers (blinded to both patient data and endovascular procedure data) for residual aneurysms and the status of the parent artery for each type of flow diverter. In a second group of patients, magnetic susceptibility artifacts were manually measured and compared for different FDs.

Results: Seventy-six patients (85 aneurysms) were included in group one, and 86 patients (95 aneurysms) were included in group 2. TOF-MRA and DSA showed almost perfect agreement for residual aneurysms (κ = 0.88, p < 0.001) (positive predictive value (PPV) = 1.00, specificity = 1.00, negative predictive value (NPV) = 0.89, sensitivity = 0.89). Intermodality agreement (κ = 0.97 vs. κ = 0.74, p < 0.005) and sensitivity (0.97 vs. 0.77, NPV: 0.96 vs. 0.77) were highest with nitinol stents. MRA and DSA showed no agreement for occluded or stenotic parent vessels (κ = 0.13, p = 0.015, specificity = 0.44, NPV = 1.00, sensitivity = 1.00). Specificity was lower in chromium-cobalt based FDs than in nitinol devices (specificity = 0.08 vs. 0.60). Chromium-cobalt stents generated the largest artifacts (p < 0.005). The size of the device-related artifact, in millimeters, increased in respective order, for the Silk, Derivo, Pipeline and Surpass devices.

Conclusion: Unlike DSA, TOF-MRA is susceptible to dissimilarities between flow diverters. MRA is not well-suited for research studies comparing different flow diverters. Nitinol FDs appear to be advantageous for TOF-MRA follow-up so as not to miss small aneurysm remnants or clinically relevant parent artery stenosis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12968-021-00753-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8182930PMC
June 2021

Lateralized Periodic Discharges in a Patient With Dural Arteriovenous Fistula: SPECT and DWI Studies Suggest They are Ictal.

Clin EEG Neurosci 2021 Apr 26:15500594211012352. Epub 2021 Apr 26.

64005Hacettepe University Faculty of Medicine, Ankara, Turkey.

Lateralized periodic discharges (LPDs) are unilateral electroencephalography (EEG) waveforms, recurring at regular intervals. There has been a long-lasting debate about whether they represent ictal or interictal phenomena. Very few patients in the literature have been investigated with multimodal functional imaging techniques. Here, we present a 58-year-old male patient with symptomatic epilepsy who had cerebral venous sinus thrombosis in the right temporo-parietal area and dural arteriovenous fistula (dAVF) over the left fronto-parietal region. He developed acute speech disturbances and altered mental status after a generalized tonic-clonic seizure. Video-EEG monitoring (VEEGM) demonstrated LPDs over the left fronto-central area, overlapping in part with the dAVF. Diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) sequences revealed restricted diffusion compatible with cytotoxic edema, whereas single-photon emission computed tomography (SPECT) indicated hyperperfusion in the same region, leading to the conclusion that he was having possible nonconvulsive status epilepticus (NCSE). An increase in antiseizure medications led to gradual improvement in clinical status and the disappearance of LPDs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/15500594211012352DOI Listing
April 2021

Dual Testing to Achieve Low On-treatment Platelet Reactivity for Aneurysm Embolization.

Clin Neuroradiol 2021 Apr 12. Epub 2021 Apr 12.

Department of Radiology, Hacettepe University Hospitals, Ankara, Turkey.

Background And Purpose: Although point-of-care tests are used extensively to test platelet function before endovascular aneurysm treatment, their use and validity are still debated. We compared the results of two point-of-care tests (VerifyNow® and Multiplate®) for assessing patients treated with stents and flow diverters and determined their relation to periprocedural complications.

Methods: All patients undergoing treatment of intracranial aneurysms were tested using both methods and were retrospectively evaluated. Patients with acute subarachnoid hemorrhage and those who had to be maintained on anticoagulants for unrelated diseases were excluded. An acceptable level of platelet inhibition was required on both tests to commence with treatment, otherwise antiplatelet medication was adjusted to reach this level.

Results: Mean PRU (platelet reactivity units) and ADP AUC (adenosine diphosphate area under the aggregation curve) were 68 ± 66 and 23 ± 15, respectively, in 295 patients. Both tests showed a good correlation (r = 0.45). Both tests were able to predict hemorrhagic events but not ischemic events. When patients with very low reactivity (PRU < 60) were compared to the rest of the group, there were more hemorrhagic events in the first group but the overall rate of complications were similar (p = 0.27).

Conclusion: In this largest study comparing two widely used commercial platelet function tests, the correlation between the tests were less than ideal; however, the very low platelet reactivity attained by the help of dual platelet testing did not result in an increased overall complication rate.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00062-021-01011-7DOI Listing
April 2021

Flow diverter stents in the treatment of recanalized intracranial aneurysms.

Interv Neuroradiol 2021 Jan 28:1591019921990507. Epub 2021 Jan 28.

Radiology Department, School of Medicine, Hacettepe University, Ankara, Turkey.

Background: We assessed the safety and efficacy of flow diverter stents (FDSs) in the treatment of recanalized or residual intracranial aneurysms treated endovascularly.

Materials & Methods: Patients whose recanalized or residual aneurysms were treated with FDSs in five tertiary hospitals were reviewed retrospectively. The patients' demographic data, aneurysm characteristics, types of previous treatment, and clinical complications, or serious adverse events associated with FDSs, as well as the results of neurological and angiographic follow-up assessments, were recorded.

Results: Eighty-six patients (37 males) with 87 aneurysms were included in this study. Eighty (91.9%) aneurysms were in the anterior and seven (8.1%) in the posterior circulation. The initial treatment methods were the primary coiling or balloon remodeling technique in 69 (79.3%) and stent-assisted coiling in 18 (20.7%) aneurysms. The endovascular procedure was successful in all patients. Complications occurred in four patients, for a total complication rate of 4.6%. A technical complication developed in one patient (1.2%). An in-stent thrombosis treated with tirofiban was seen in two cases. Late in-stent stenosis exceeding 50% was treated with balloon angioplasty in one patient. The mean length of follow-up was 21.0 months. The first angiographic follow-up (3-6 months) revealed the complete occlusion of 74 aneurysms (85.1%). While 76 aneurysms (87.4%) were occluded at the last angiographic follow-up (mean: 26.0 months), 11 aneurysms (12.6%) were still filling. Morbimortality was zero.

Conclusion: The drawback of endovascular treatment is aneurysmal remnants or recurrences, which is safely and durably amenable to flow diversion.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1591019921990507DOI Listing
January 2021

Response to "Some observations over the article "Evaluation of the anastomoses between the ophthalmic artery and the middle meningeal artery by superselective angiography"".

Surg Radiol Anat 2021 Mar 3;43(3):429-431. Epub 2021 Jan 3.

Department of Preventive Oncology, Faculty of Medicine, Hacettepe University, 06100, Ankara, Turkey.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00276-020-02624-2DOI Listing
March 2021

The Exchange-Free Technique: A Novel Technique for Enhancing Surpass Flow Diverter Placement.

Asian J Neurosurg 2020 Jul-Sep;15(3):620-626. Epub 2020 Aug 28.

Department of Radiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey.

Background: Following flow diverter placement, approximately 20% of intracranial aneurysms remain as residual aneurysms at 1 year. Device malapposition is a cause of residual aneurysms after flow diversion. We present a new and straightforward technique (exchange-free technique [EFT]) to enhance apposition of the surpass flow diverter (SFD), the only over-the-wire flow diverter currently available.

Materials And Methods: We deployed laser-cut mini stents through the inner deployment catheter of the SFD. This maneuver was performed simply by withdrawing the micro-guidewire from its lumen and replacing it with a mini-stent (stents deliverable through microcatheters with inner diameter of 0.0165 inches), without a need to re-cross the deployed SFD or an exchange maneuver. All aneurysms in which this technique was utilized were retrospectively reviewed.

Results: Twenty-eight patients (20 females) with 30 treated aneurysms were identified. The mean aneurysm diameter was 10.2 ± 6.6 mm. Technical success rate was 96.6% (29/30 aneurysms). There was no mortality or permanent morbidity related to the procedures. Except for the patient treated for an iatrogenic, surgery-related internal carotid artery pseudoaneurysm who died secondary to consequences of multiple surgeries, no cases of mortality or permanent morbidity were noted. Complete aneurysm occlusion rates were 78.2%, 82.1%, and 95.2% at 0-3, 3-6, and 9-12 months, respectively. None of the patients were re-treated.

Conclusion: EFT is a simple and fast technique which was not associated with adverse effects in our series. The higher aneurysm obliteration rate obtained with EFT is probably the result of better wall apposition of the SFD.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4103/ajns.AJNS_374_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7591168PMC
August 2020

Characteristic imaging features of neurovascular involvement in primary Sneddon's syndrome: an analysis of 12 cases.

Neurol Sci 2021 Jun 13;42(6):2363-2369. Epub 2020 Oct 13.

Neurology Department, Hacettepe University Hospitals, 06100, Sıhhiye, Ankara, Turkey.

Objective: Sneddon's syndrome is a cerebrocutaneous non-inflammatory progressive distal arteriopathy, characterized by livedo racemosa, stroke, and neuropsychiatric symptoms. Our aim was to highlight the characteristic neuroimaging features of Sneddon's syndrome that might be helpful to clinicians in timely diagnosis of this entity.

Methods: Twelve patients (median age 49 years, 11 female) with primary Sneddon's syndrome, diagnosed in last 10 years, were analyzed from the perspective of magnetic resonance imaging (MRI) features. In addition, a novel pseudoangiomatosis score was defined for grading angiographic abnormalities (range: 0 to 6).

Results: Median interval from the onset of neurological symptoms to diagnosis was 6 years. Presentation was with acute stroke in 5, seizures in 3, dementia/speech problems in 2, seizures plus cognitive dysfunction in 1, and chronic progressive hemiparesis in 1. All patients had a typical lesion pattern on MRI. This included multiple (median 3) cortical-subcortical supratentorial and cerebellar non-territorial infarcts, accompanied by multifocal cerebral atrophy. Of note, large territorial infarcts due to cerebral parent artery occlusion, an embolic pattern with multi-territorial involvement on diffusion-weighted imaging, small vessel disease features like severe white matter involvement or lacunar infarcts, and cerebral hemorrhage in the absence of anticoagulation were not observed. MRI lesion severity was not correlated with angiographic arteriopathy severity, clinical stage, or presentation symptoms.

Conclusion: Sneddon's syndrome is characterized by highly typical clinico-radiological features. Brain MRI has diagnostic value. By knowing the characteristics of the syndrome, misdiagnosis and potentially harmful treatment can be prevented in this entity that might pose a diagnostic challenge.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s10072-020-04621-0DOI Listing
June 2021

Review of current intracranial aneurysm flow diversion technology and clinical use.

J Neurointerv Surg 2021 Jan 25;13(1):54-62. Epub 2020 Sep 25.

Department of Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA

Endovascular treatment of intracranial aneurysms (IAs) has evolved considerably over the past decades. The technological advances have been driven by the experience that coils fail to completely exclude all IAs from the blood circulation, the need to treat the diseased parent vessel segment leading to the aneurysm formation, and expansion of endovascular therapy to treat more complex IAs. Stents were initially developed to support the placement of coils inside wide neck aneurysms. However, early work on stent-like tubular braided structure led to a more sophisticated construct that then later was coined as a flow diverter (FD) and found its way into clinical application. Although FDs were initially used to treat wide-neck large and giant internal carotid artery aneurysms only amenable to surgical trap with or without a bypass or endovascular vessel sacrifice, its use in other types of IAs and cerebrovascular pathology promptly followed. Lately, we have witnessed an explosion in the application of FDs and subsequently their modifications leading to their ubiquitous use in endovascular therapy. In this review we aim to compile the available FD technology, evaluate the devices' peculiarities from the authors' perspective, and analyze the current literature to support initial and expanded indications, recognizing that this may be outdated soon.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/neurintsurg-2020-015877DOI Listing
January 2021

Clinical challenges associated with the endovascular treatment of acute stroke in a patient with infective endocarditis.

J Cerebrovasc Endovasc Neurosurg 2020 09 21;22(3):176-181. Epub 2020 Sep 21.

Department of Radiology, Hacettepe University Faculty of Medicine, Ankara, Turkey.

Although stroke is common in infective endocarditis (IE), only 26 cases of thrombectomy have been reported to date for IE-related acute stroke. We report a 40-year-old man who presented with left middle cerebral artery occlusion of unknown cause. Multiple attempts of mechanical aspiration thrombectomy and stentrievers failed to recanalize the artery. Effective revascularization was eventually achieved by placing a self-expanding intracranial stent. Post-procedurally the patient was diagnosed with IE with mitral valve insufficiency, mandating emergent valvular replacement while the patient was still on tirofiban infusion. On follow-up, the patient had a modified Rankin's score of 0, had no recurrent stroke, and the intracranial stent remained patent yet stenosed. Based on the use of a self-expanding intracranial stent in the setting of IE, we discuss the consequences of the fibrotic and inflammatory content of the embolus and the associated high risk of intracranial hemorrhage which complicates clinical decision making.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.7461/jcen.2020.22.3.176DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7522393PMC
September 2020

Evaluation of the anastomoses between the ophthalmic artery and the middle meningeal artery by superselective angiography.

Surg Radiol Anat 2020 Nov 16;42(11):1355-1361. Epub 2020 Aug 16.

Department of Preventive Oncology, Faculty of Medicine, Hacettepe University, 06100, Ankara, Turkey.

Purpose: There are three anastomoses between the ophthalmic artery (OA) and the middle meningeal artery (MMA): the anastomotic branch with MMA, the recurrent meningeal branch and the anterior falx artery. We aimed to evaluate the anastomotic branches between the OA and the MMA on superselective angiograms of pediatric patients with retinoblastoma.

Materials And Methods: We evaluated 126 angiographies performed on children with retinoblastoma. The mean diameter and angiographic visibility percentage of the anastomotic branches between the OA and the MMA were examined according to age group and sex.

Results: The mean diameter of anastomotic branch with MMA was measured 0.58 ± 0.13 mm and we found this branch in 15 of 126 angiographic images (11.9%). We detected the recurrent meningeal branch in 47 of total images (37.3%). The recurrent meningeal branch arose 85.1% from the lacrimal artery, 8.5% from the anastomotic branch with MMA and 6.4% directly from the OA. The mean diameter of this artery was measured 0.21 ± 0.06 mm. Anterior falx artery was found in 86 of 126 angiographic peocedures (68.3%) and the mean diameter was measured 0.22 ± 0.06 mm.

Conclusion: Knowledge of the anastomoses between the OA and the MMA system are all necessary to perform safe and successful endovascular and surgical procedures involving the orbital region.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00276-020-02546-zDOI Listing
November 2020

Y-Stent-Assisted Coiling With Low-Profile Neuroform Atlas Stents for Endovascular Treatment of Wide-Necked Complex Intracranial Bifurcation Aneurysms.

Neurosurgery 2020 09;87(4):744-753

Department of Radiology, Hacettepe University Hospital, Ankara, Turkey.

Background: Y-stent-assisted coiling is one of the eligible techniques for the treatment of complex bifurcation aneurysms. In majority of previous literature, Y-stenting has been performed using stents that could be delivered through large profile microcatheters that are often difficult to manipulate during navigation through sharply angled side branches. Attempts to navigate with these large profile catheters might cause serious complications during Y-stenting procedure.

Objective: To investigate the safety, feasibility, and efficacy of Y-stent-assisted coiling procedure with Neuroform Atlas stents for the treatment of complex bifurcation aneurysms; Neuroform Atlas is a recently introduced open-cell stent that can be delivered though low-profile microcatheters.

Methods: We identified the patients with intracranial bifurcation aneurysms treated by Y-stent-assisted coiling procedure with Neuroform Atlas stents. We assessed the immediate postoperative and follow-up clinical and angiographic outcomes. We also investigated the periprocedural and delayed complications.

Results: A total of 30 aneurysms in 30 patients were included in the study. Y-stenting was successfully performed without any technical complications in all cases (100%). Immediate postprocedural angiography revealed total aneurysm occlusion in 83.3% of patients. The mean angiographic follow-up time was 11.8 mo. The last follow-ups showed complete occlusion in 93.3% of patients. There was no mortality in this study. A procedure-related complication developed in 6.7% and resulted in permanent morbidity in 3.3% of patients.

Conclusion: Neuroform Atlas stent combines the advantages of low-profile deployment microcatheters with an open-cell structure to achieve a successful Y-stenting procedure. Y-stent-assisted coiling with Neuroform Atlas stents provides a safe and effective endovascular treatment for wide-necked complex bifurcation aneurysms.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/neuros/nyz516DOI Listing
September 2020

Floating Aortic Thrombus: A Rare Cause of Acute Ischemic Stroke Necessitating Modification of Access Route for Thrombectomy.

J Stroke Cerebrovasc Dis 2019 Nov 21;28(11):104291. Epub 2019 Aug 21.

Department of Radiology, Hacettepe University Faculty of Medicine, Ankara, Turkey. Electronic address:

We report 2 patients with acute occlusion of middle cerebral artery successfully treated by mechanical thrombectomy performed via transbrachial access. Both patients had floating aortic arch thrombi precluding safe transfemoral access due to risk of further iatrogenic embolization. Moreover both patients were diagnosed with hypercoagulopathy secondary to lung malignancy (paraneoplastic etiology, Trousseau's syndrome) as the cause of both aortic thrombi and acute ischemic stroke. Mechanical thrombectomy in the setting of a floating aortic thrombus has been mentioned only once as part of general management of floating aortic thrombi in the whole body. To the best of our knowledge, it has never been described previously in the literature in the context of cerebral mechanical thrombectomy technique. However, the diagnosis of this entity bears clinical importance for it can modify the treatment approach. A modified transbrachial approach allowed us to treat both patients without neurologic complications and resulted in modified Rankin scores of 1 on follow-up. We advise that the cross-sectional imaging of acute stroke patients should include an evaluation of the aortic arch and should be scrutinized in detail especially in patients with possible hypercoagulable state. Flat panel computed tomography technology allowed us to obtain such an imaging study in the angiography suite.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2019.07.007DOI Listing
November 2019

Retinal and Choroidal Optical Coherence Tomography Findings of Carotid Cavernous Fistula.

Am J Ophthalmol 2019 10 19;206:264-273. Epub 2019 Jun 19.

Division of Interventional Neuroradiology, Department of Radiology, Hacettepe University, Ankara, Turkey.

Purpose: To define the retinal and choroidal imaging findings of carotid cavernous fistula (CCF) including central foveal thickness, subfoveal choroidal thickness, choroidal vascularity index (CVI) parameters, and tortuosity indexes (TIs) as compared to a control group (CG).

Design: Cross-sectional study.

Materials And Methods: The spectral domain enhanced-depth imaging optical coherence tomography images of 19 eyes of 19 consecutive patients with angiographically proven CCF and 19 eyes of 19 age- and sex-matched healthy control subjects were included. The patient group was divided according to CCF venous drainage pattern as anterior (A-CCF: draining into ophthalmic veins) and posterior (P-CCF: not draining into ophthalmic veins). The clinically affected eyes of the patient group, ipsilateral to the fistula, were included in the analysis.

Results: There were 15 A-CCFs (78.9%) and 4 P-CCFs (21.1%). The mean SFCT of the A-CCF group (395.21 ± 111.69 μm) was significantly higher than those of the P-CCF (246.84 ± 94.12 μm) and CG groups (280.79 ± 111.36 μm) (P = .039 and P = .006, respectively). The mean CVI of the A-CCF group was significantly higher than that of the CG (68.97 ± 4.81 and 65.66 ± 3.37, respectively, P = .033). The A-CCF group had significantly higher inferior, superior, and total venous TI than the CG group (P = .001, P = .001, and P < .001, respectively).

Conclusion: In this first study investigating the CVI and TI in CCF patients, we demonstrated that SFCT, CVI, and TI could potentially be used to aid in the diagnosis of A-CCF.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ajo.2019.06.010DOI Listing
October 2019

Unusual ophthalmic artery origin: Implications for intraarterial chemotherapy of retinoblastoma.

Interv Neuroradiol 2019 Dec 3;25(6):638-643. Epub 2019 Jun 3.

Department of Radiology, Hacettepe University Faculty of Medicine, Sıhhiye, Ankara, Turkey.

We report two pediatric retinoblastoma patients with unusual ophthalmic artery (OA) origins who were referred to our interventional neuroradiology department for intraarterial chemotherapy. The first patient had double OAs arising from the ipsilateral internal carotid artery and a central retinal artery (CRA) arising from the more cranially located artery, whereas the second patient had an OA originating from the A1 segment of the ipsilateral anterior cerebral artery. In both cases the CRA arose from the artery entering the orbit through the optic foramen. Both patients tolerated the procedures well. To the best of our knowledge, our retinoblastoma patients with unusual OA origins are the first in the literature in which detailed knowledge of the orbital vasculature and especially CRA origin carried immediate clinical implications, altering access strategies. These variations were proved both by flat-panel detector computed tomography findings and superselective injections of OAs with unusual origins. Our results show that in patients with retinoblastoma, a detailed angiographic work-up may be necessary to evaluate the orbital vasculature and possible abnormal origin of the OA. Recognition of possible variations of OA origin and its branching patterns is of the utmost importance for successful treatment and avoidance of adverse events among retinoblastoma patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1591019919852737DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6838853PMC
December 2019

Intra-aneurysmal air after flow diversion treatment in intracranial aneurysms: incidence, characteristics and clinical significance.

Jpn J Radiol 2019 Jul 6;37(7):549-554. Epub 2019 May 6.

Department of Radiology, Faculty of Medicine, School of Medicine, Hacettepe University, Ankara, Turkey.

Objective: To describe the rate and characteristics of air bubble retention (ABR) within cerebral aneurysms treated by flow diversion.

Methods: Procedural flat detector CT (FDCT) studies were scrutinized for the presence of air bubbles (density < - 200 HU) in patients treated by flow diversion. Patients with intrasaccular treatment or previous clipping were excluded. Clinical outcomes, procedural angiograms, aneurysm characteristics and imaging features of air within the aneurysm were evaluated.

Results: Bubbles were noted in 17.1% of 105 aneurysms in 85 FDCTs. Aneurysms with ABR were significantly larger (mean diameter: 18.9 versus 7.5 mm, P < 0.0001). There was a trend for the use of multiple devices during the treatment of these aneurysms (72.2% vs 49.4%, P = 0.071). All of the bubbles were located rostrally in the aneurysm sac and were smaller than 6 mm (mean diameter: 2.1 ± 1.3 mm). None of the patients had post-procedural neurological deterioration. The air had spontaneously disappeared on follow-up CT images (available in 12 patients) obtained at a mean follow-up duration of 48 h.

Conclusions: ABR is not infrequent in cerebral flow diversion procedures. It is a clinically silent and self-limited technical complication. We propose air entrapment or filtration through the flow diverter as causative factors.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11604-019-00842-2DOI Listing
July 2019

The Experience of the Derivo® Embolisation Device in Intracranial Aneurysms.

Turk Neurosurg 2020 ;30(1):30-37

Ankara Numune Training and Research Hospital, Department of Neurosurgery, Ankara, Turkey.

Aim: To investigate the safety and efficacy of Derivo® embolisation device (DED), a new-generation flow diverter designed to treat cerebrovascular aneurysms, and its long-term clinical outcomes.

Material And Methods: In total, 146 patients with 182 aneurysms were treated with DED. The mean age of the participants was 51.5 years; among them, 46 (31.5%) presented with acute subarachnoid haemorrhage. The mean aneurysm size was 8.3 mm, and 12 aneurysms were involved the vertebrobasilar system. Ophthalmic aneurysms account for most internal carotid artery (ICA) aneurysms.

Results: The Glasgow Coma Scale (GCS) score of 12 patients was < 15. DED was associated with a mortality rate of 2.7% and permanent morbidity rate of 3.4%, and a complete aneurysm occlusion rate was achieved in 78.7% of cases after 7.02 months.

Conclusion: The DED device is a new-generation flow diverter with excellent opening behaviour and navigational benefits. Our results indicated a safe aneurysm occlusion with optimum morbidity and mortality values despite the fact that almost one-third of the patients presented with subarachnoid haemorrhage.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5137/1019-5149.JTN.25776-19.2DOI Listing
July 2020

The effect of carotid artery stenting on capillary transit time heterogeneity in patients with carotid artery stenosis.

Eur Stroke J 2018 Sep 26;3(3):263-271. Epub 2018 Apr 26.

Department of Neurology, Faculty of Medicine, Hacettepe University, Turkey.

Introduction: Carotid revascularisation improves haemodynamic compromise in cerebral circulation as an additional benefit to the primary goal of reducing future thromboembolic risk. We determined the effect of carotid artery stenting on cerebral perfusion and oxygenation using a perfusion-weighted MRI algorithm that is based on assessment of capillary transit-time heterogeneity together with other perfusion and metabolism-related metrics.

Patients And Methods: A consecutive series of 33 patients were evaluated by dynamic susceptibility contrast perfusion-weighted MRI prior to and within 24 h of the endovascular procedure. The level of relative change induced by stenting, and relationship of these changes with respect to baseline stenosis degree were analysed.

Results: Stenting led to significant increase in cerebral blood flow ( < 0.001), and decrease in cerebral blood volume ( = 0.001) and mean transit time ( < 0.001); this was accompanied by reduction in oxygen extraction fraction ( < 0.001) and capillary transit-time heterogeneity ( < 0.001), but an overall increase in relative capillary transit-time heterogeneity (RTH: CTH divided by MTT;  = 0.008). No significant change was observed with respect to cerebral metabolic rate of oxygen. The median volume of tissue with MTT > 2s decreased from 24 ml to 12 ml ( = 0.009), with CTH > 2s from 29 ml to 19 ml ( = 0.041), and with RTH < 0.9 from 61 ml to 39 ml ( = 0.037) following stenting. These changes were correlated with the baseline degree of stenosis. Stenting improved the moderate stage of haemodynamic compromise at baseline in our cohort. The decreased relative transit-time heterogeneity, which increases following stenting, is probably a reflection of decreased functional capillary density secondary to chronic hypoperfusion induced by the proximal stenosis. Carotid artery stenting, is not only important for prophylaxis of future vascular events, but also is critical for restoration of microvascular function in the cerebral tissue.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/2396987318772686DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6453199PMC
September 2018

Endovascular Treatment of Superior Cerebellar Artery Aneurysms.

Turk Neurosurg 2019 ;29(4):564-569

Adana City Training and Research Hospital, Department of Neurosurgery, Adana, Turkey.

Aim: To present our experience on superior cerebellar artery (SCA) aneurysms treated with embolization by using current endovascular techniques.

Material And Methods: All SCA aneurysms treated by our endovascular team since 2013 were retrospectively evaluated. Clinical information and angiographic findings on presentation, during treatment and on follow-up were noted.

Results: Endovascular treatment was the primary treatment method for SCA aneurysms during the study period. Twenty three patients (15 female, 8 male) with a mean age of 50.6 years, 12 of whom with subarachnoid hemorrhage were treated. Treatments included coiling (56%), stent assisted coiling, stentriever assisted coiling, Y stent assisted coiling and flow diversion with either flow diverter placement or telescopic stenting. Two patients died secondary to consequences of subarachnoid hemorrhage. The outcome of 1 patient was Modified Rankin Scale (mRS) 3 and the outcome of remaining 20 patients was mRS 0. The rates of aneurysm occlusion according to Raymond-Roy classification were: class 1 in 11 patients, class 2 in 6 patients and class 3 in 2 patients on a mean follow-up of 15.3 months. Only one patient required retreatment.

Conclusion: Current endovascular techniques are able to address the high rate of recanalization and retreatment of SCA aneurysms which are currently the major drawbacks associated with primary coiling when compared with surgical treatment. It remains to be shown if use of these latest techniques are associated with increased risk of thromboembolic events.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5137/1019-5149.JTN.24640-18.3DOI Listing
October 2019

Can Convexity Subarachnoid Hemorrhage be Caused by Rupture of a Saccular Aneurysm?

J Vasc Interv Neurol 2018 Nov;10(2):1-3

Department of Neurology and Neurological Intensive Care Unit, Hacettepe University Hospitals, Sihhiye, Ankara, Turkey.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6350862PMC
November 2018

Transvenous Treatment of Carotid Aneurysms Through Transseptal Access.

World Neurosurg 2019 Jan 17. Epub 2019 Jan 17.

Department of Neurology, Hacettepe University Hospitals, HUTF Noroloji ABD, Ankara, Turkey.

Background: Transseptal puncture has been widely used by cardiologists to reach the left side of the heart through a transvenous access. Rarely, it also can be used to pass into the supra-aortic arteries from the venous side when conventional transarterial access pathways (transfemoral, transradial/brachial routes, or direct carotid puncture) are likely to fail.

Case Description: We report 2 cases of transvenous femoral access followed by transseptal access to aorta to treat dissecting carotid artery aneurysms at the level of the skull base with flow diverters. In one case, multiple cervical arterial bypass operations and in the other a rare anomaly of the aortic arch precluded endovascular treatment through conventional routes.

Conclusions: Transvenous-transseptal access enabled treatment of both cases easily and without complications. On follow-up computed tomography angiograms, both flow diverters were patent, there were no residual aneurysms, and no neurologic or cardiac adverse events in either patient.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.wneu.2018.12.207DOI Listing
January 2019

Endovascular treatment of true renal artery aneurysms: a single center experience.

Diagn Interv Radiol 2019 Jan;25(1):62-70

Department of Radiology, Hacettepe University School of Medicine, Ankara, Turkey.

Purpose: We aimed to report a single center's experience on endovascular treatment of true renal artery aneurysms (TRAAs), including treatment techniques and outcomes.

Methods: This retrospective study was designed to evaluate the treatment and follow-up of TRAAs treated by a variety of endovascular interventional techniques over a period of 6 years. Six patients with nine TRAAs were identified; seven of the TRAAs were treated using different combinations of coil embolization and flow diverter stents. The clinical findings, aneurysm characteristics, endovascular methods and treatment outcomes were reported.

Results: Seven TRAAs of six patients were treated, with a median aneurysm size of 20 mm. Three TRAAs were treated with primary sac occlusion (one with primary coil embolization, one with balloon and stent assisted coil and glue embolization, and one with amplatzer vascular occlusion device and coil embolization). The remaining four TRAAs of three patients were treated with flow diverter stents (Cardiatis, Silk, Pipeline, and Surpass). Immediate clinical success was achieved in patients treated with primary sac embolization (95% CI, 29.2%-100%). Among patients treated with flow diverter stents, one patient required an additional flow diverter at 6-month follow-up. The occlusion time in flow diverters ranged from 1 month to 12 months (median, 3.5 months) taking the repeat procedure into account. In patients treated with flow diverters, the clinical success rate was 100% (95% CI, 29.2%-100%) at one-year follow-up. Long-term follow-up ranged from 3 to 52 months. One intraprocedural complication was encountered with a flow diverter during deployment, which required additional stenting and tirofiban infusion. No other major complication was seen.

Conclusion: Endovascular treatment is an effective and safe method offering high success rates and low morbidity in the treatment of TRAAs and may supplant surgery as the primary therapy. Current experience in the use of flow diverter stents in TRAAs is limited to individual case reports with one brand of flow diverter device. Our small numbered series of four TRAAs shows our experience regarding endovascular treatment with different flow diverter brands.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5152/dir.2018.17354DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6339632PMC
January 2019

Usefulness of contrast-enhanced and TOF MR angiography for follow-up after low-profile stent-assisted coil embolization of intracranial aneurysms.

Interv Neuroradiol 2018 Dec 5;24(6):655-661. Epub 2018 Jul 5.

4 Department of Radiology, Artvin State Hospital, Artvin, Turkey.

Background: Low-profile, self-expandable stents are used to treat wide-neck aneurysms located on the smaller distal intracranial arteries. This study aimed to assess the usefulness of time-of-flight (TOF) and contrast-enhanced (CE) magnetic resonance angiography (MRA) for follow-up after LEO Baby stent (LBS)-assisted coil embolization.

Methods: Twenty-four aneurysms treated with LBS-assisted coil embolization were evaluated. Researchers reviewed TOF MRA and CE MRA images in terms of occlusion and stent patency. Aneurysm occlusion was graded according to Raymond-Roy classification as follows: total occlusion (grade 1), residual neck (grade 2), and residual aneurysm (grade 3). Stent patency was scored as follows: occlusion (1), stenosis (2), and normal (3). Interobserver and intermodality agreement values were determined by weighted kappa (κ) statistics.

Results: Intermodality and interobserver values of TOF MRA and CE MRA with digital subtraction angiography (DSA) were perfect (κ = 1.00, p < 0.001) in terms of aneurysm occlusion. Rate of stent occlusion and stenosis in DSA, TOF, and MRA, respectively, were as follows: 0 and 12.5%, 16.6 and 70.8%, and 0 and 62.5%. Intermodality agreement values of TOF MRA and CE MRA with DSA were insignificant in terms of stent patency (κ = 0.065, p = 0.27; κ = 0.158, p = 0.15, respectively). Interobserver agreement was substantial in both TOF MRA (κ = 0.71, p < 0.001) and CE MRA (κ = 0.64, p = 0.001).

Conclusions: Both TOF and CE MRA techniques have strong concordance with DSA for the detection of aneurysm occlusion status. CE MRA can be used as a first-line noninvasive imaging modality due to its superiority to TOF MRA with respect to the visualization of in-stent signals.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1591019918785910DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6259350PMC
December 2018

Hybrid vascular intervention for a giant cervical carotid artery aneurysm in a clopidogrel-hyporesponsive child.

J Neurosurg Pediatr 2018 09 22;22(3):265-269. Epub 2018 Jun 22.

Departments of1Radiology.

Aneurysms of the extracranial internal carotid artery (ICA) in pediatric patients are rare and mostly treated surgically. The authors present the case of a child with a giant extracranial ICA aneurysm presenting with gradual airway compression. A plan was made to explore the aneurysm surgically and straighten the associated carotid artery kinks during the operation to enable further endovascular treatment if primary reconstruction of the carotid artery proved not to be possible. Finally, the aneurysm was successfully treated with staged hybrid intervention, which consisted of surgical correction of parent artery kinks followed by endovascular implantation of stent grafts. The child tolerated the procedure well without adverse events. A craniocervical CT angiogram at 5 months showed patency of the stent construct and relief of airway compression. However, a follow-up CT angiogram at 14 months showed total occlusion of the ipsilateral carotid artery without clinical sequelae and complete cessation of airway compression. The management of this was unique since the patient is the first reported case of clopidogrel hyporesponsiveness in a child undergoing neurovascular intervention with prasugrel monotherapy. Point-of-care testing-based adjustment of prasugrel necessitated education of the patient's family regarding the loss of effect of the prasugrel tablets upon crushing and contact with air.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3171/2018.3.PEDS17669DOI Listing
September 2018

Intermediate catheter placement distal to the cerebral aneurysm during flow diversion embolization with the Surpass device.

J Neurointerv Surg 2018 Dec 25;10(12):e35. Epub 2018 Apr 25.

Department of Radiology, Yeditepe University Hospital, Istanbul, Turkey.

Purpose: We present the preliminary angiographic and clinical results of the combined utilization of an AXS Catalyst 5 (Cat5) distal access catheter and a Surpass flow diverter (SFD) for the endovascular treatment of intracranial aneurysms.

Materials And Methods: Interventional neuroradiology case records were evaluated retrospectively to identify patients treated with an SFD in combination with Cat5. Demographic data, technical success, location of the catheter tip, aneurysm occlusion rate, and procedure-related morbidity and mortality were noted.

Results: The analysis yielded 24 patients with 25 aneurysms with a mean age of 52.3±19.7 years. The mean aneurysm diameter was 15.7±8.8 mm. Twenty-one were anterior circulation (seven supraclinoid, one middle cerebral, one anterior choroidal and 12 petrocavernous) and four were posterior circulation (three basilar tip, one posterior inferior cerebellar) aneurysms. Only two of these aneurysms were re-treatments for recurrences. For SFD deployment, the distal tip of Cat5 was placed intradurally and at, or distal to, M1 segment in 88% and 48% of patients, respectively. Aneurysms were bypassed with Cat5 in 80% of the procedures. In one patient, flow diversion was abandoned totally due to arterial tortuosity. With the exclusion of this patient, the technical success rate was 91.7%. There was no permanent procedure-related morbidity or mortality. Of the 22 aneurysms treated successfully with the Surpass device, 20 had imaging follow-up at 6.3±3.8 months and 95% were totally occluded.

Conclusion: The Cat5 catheter, which was manufactured for the navigation of large-bore stent-like devices, is a useful adjunct to the Surpass device and allowed us to deploy the device safely.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/neurintsurg-2017-013662DOI Listing
December 2018

Stent-assisted coiling of cerebral aneurysms with the Neuroform Atlas stent.

Interv Neuroradiol 2018 Jun 19;24(3):263-269. Epub 2018 Jan 19.

Department of Radiology, Hacettepe University Medical School, Ankara, Turkey.

Objectives The Neuroform Atlas stent (AS) is the smallest intracranial stent with an open-cell design. This study reports the first clinical experience with AS. Methods All intracranial aneurysms treated by stent-assisted coiling using a single AS in a single institution were retrospectively evaluated. Patient demographics, aneurysm characteristics, angles between the parent artery and stented branch, technical success, and clinical and angiographic follow-up were analyzed. Results Fifty-five consecutive aneurysms treated with AS-assisted coiling were included. Of these, 69.1% were located distal to the circle of Willis. Technical success rate was 100%. The mean diameters of proximal and distal parent arteries were 2.62 mm (range 1.5-4.4) and 1.8 mm (range 0.8-3.5), respectively. Except for a minor stroke in a patient who completely discontinued antiplatelet therapy on postoperative day 4, there were no clinical events with permanent sequelae, and 94.1% of patients had Raymond-Roy score of 1 or 2 aneurysmal occlusion at a mean follow-up duration of 7.9 months. Although the angle between the parent artery and the stented branch increased significantly ( p < 0.001) with time, the angular change at follow-up was only 16.45 ± 11.03 degrees and was inversely correlated both with preoperative angle and the diameter of the distal parent artery ( r = -0.465 and r = -0.433, respectively, p = 0.004 for both). Conclusion AS-assisted coiling was associated with a favorable early clinical outcome and angiographic results in this series. This stent can be used for distally located aneurysms and results in minimal alteration of the arterial anatomy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1591019917753710DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5967178PMC
June 2018

Percutaneous Treatment of Scalp Arteriovenous Fistulas by Direct Puncture and Polydocanol Sclerotherapy : Report of 2 Cases with Long-term Follow-up.

Clin Neuroradiol 2018 Dec 19;28(4):609-612. Epub 2017 Dec 19.

Department of Plastic and Reconstructive Surgery, Hacettepe University Hospitals, Sihhiye, 06100, Ankara, Turkey.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00062-017-0653-1DOI Listing
December 2018

Septal reduction therapy using nonalcohol agent in hypertrophic obstructive cardiomyopathy: Single center experience.

Catheter Cardiovasc Interv 2018 09 5;92(3):557-565. Epub 2017 Dec 5.

Department of Cardiology, Hacettepe University Faculty of Medicine, Ankara, Turkey.

Aims: Percutaneous septal reduction therapy by either alcohol or nonalcohol agents is an alternative approach to surgery in drug-refractory symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM). Nonalcohol agents have some advantages and disadvantages over alcohol during the procedure. Nowadays, a novel non-alcohol agent, named as Ethylene-vinyl alcohol (EVOH) copolymer (Onyx and Squid ), is used during septal ablation. Thus, in this study, we aimed to evaluate both acute and long-term efficacy and safety profile of EVOH during septal ablation in HOCM.

Methods And Results: A total of 25 patients (52% female; mean age: 55.8 ± 17.1 years) with symptomatic HOCM were enrolled in the study. All subjects underwent clinical and laboratory assessment before and after the procedure. Peak left ventricular outflow tract (LVOT) gradient was significantly reduced just after the procedure (68 vs. 20 mmHg; P < 0.001). Peak serum creatine kinase-myocardial band and troponin I levels were 112 (35-282) ng/ml and 11 (4-93) ng/ml. EVOH embolization to diagonal artery was observed in 1 patient (4%) and the complete atrioventricular block was noted in 2 (8%) patients. During the 12-month follow-up, there was no mortality. There was a significant improvement in New York Heart Association functional class of the subjects P < 0.001). Both interventricular septum thickness and LVOT gradient showed a significant reduction during follow-up (P < 0.05). However, there was no reduction in the LVOT gradient of 3 patients (12%).

Conclusions: In conclusion, our small-sized preliminary study results showed that septal reduction therapy using EVOH is an effective alternative option in reducing symptoms and LVOT gradient in HOCM.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/ccd.27442DOI Listing
September 2018

Dual Mechanical Thrombectomy for Recanalization of a Resistant Acute Posterior Circulation Stroke.

J Cerebrovasc Endovasc Neurosurg 2017 Jun 30;19(2):96-100. Epub 2017 Jun 30.

Department of Radiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey.

A 71-year-old man with acute basilar artery occlusion was referred for endovascular treatment 6 hours after the onset of stroke with a Glasgow Coma Score of 3 and National Institutes of Health Stroke Scale of 27. A cerebral arteriogram revealed occlusion of the left vertebral artery proximally and thromboembolic occlusion of the basilar tip. Direct aspiration and mechanical thrombectomy with various stent retrievers failed to reconstitute arterial flow in the basilar artery. Thrombolysis in cerebral infarction 2b recanalization was achieved only after placement of double Catch Mini stent retrievers through 2 microcatheters, on both side branches of the basilar bifurcation in a kissing fashion and retrieving them simultaneously. It was possible to perform this maneuver through a single distal access catheter without any complications. On follow-up the patient awakened and was able to follow commands on his right side. To our knowledge, dual mechanical thrombectomy with stent retrievers has not been reported in the posterior circulation previously. This technique may be useful in retrieving thrombi located at major intracranial bifurcations of the posterior circulation which do not recanalize with standard mechanical thrombectomy procedures. Although bilateral access to the basilar artery through both vertebral arteries is an advantage in posterior circulation for this technique, dual mechanical thrombectomy can also be performed through a unilateral access.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.7461/jcen.2017.19.2.96DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5678218PMC
June 2017