Publications by authors named "Bernd Turowski"

128 Publications

Consequences of COVID-19 pandemic lockdown on emergency and stroke care in a German tertiary stroke center.

Neurol Res Pract 2021 Mar 31;3(1):21. Epub 2021 Mar 31.

Department of Neurology, Medical Faculty, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany.

Background: COVID-19 pandemic caused a decline in stroke care in several countries. The objective was to describe lockdown stroke care in a tertiary stroke center in Düsseldorf, Germany near Heinsberg, a German hot spot for COVID-19 in spring 2020.

Methods: In a retrospective, observational, single-center study, we compared all patients treated in our emergency department (ED), patients seen by a neurologist in the ED, ED patients suffering from ischemic and hemorrhagic strokes and transient ischemic attacks (TIAs) as well as stroke patients admitted to our stroke unit during lockdown in spring 2020 (16 March 2020-12 April 2020) to those cared for during the same period in 2019 and lockdown light in fall 2020 (2 November - 29 November 2020).

Results: In spring 2020 lockdown the mean number of patients admitted to our ED dropped by 37.4%, seen by a neurologist by 35.6%, ED stroke patients by 19.2% and number of patients admitted to our stroke unit by 10% compared to the same period in 2019. In fall lockdown light 2020 effects were comparable but less pronounced. Thrombolysis rate was stable during spring and fall lockdown, however, endovascular treatment (EVT) rate declined by 58% in spring lockdown and by 51% in fall lockdown compared to the period in 2019.

Conclusions: Our study indicates a profound reduction of overall ED patients, neurological ED patients and EVT during COVID-19 pandemic caused lockdowns. Planning for pandemic scenarios should include access to effective emergency therapies.
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http://dx.doi.org/10.1186/s42466-021-00118-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8011045PMC
March 2021

Clinical Diffusion Mismatch to Select Pediatric Patients for Embolectomy 6 to 24 Hours After Stroke: An Analysis of the Save ChildS Study.

Neurology 2021 01 3;96(3):e343-e351. Epub 2020 Nov 3.

From the Department of Neuroradiology (P.B.S., M.-N.P., A.B.), Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Switzerland; Department of Diagnostic and Interventional Neuroradiology (P.B.S., U.H., G.B., J.F.), University Medical Center Hamburg-Eppendorf, Hamburg; Departments of Pediatrics (R.S.), and Neurology (J.M.), University Hospital of Muenster; Department of Neuroradiology (R.C.), Alfried-Krupp Hospital, Essen; Department of Neuroradiology (H.H., E.H.), Klinikum Stuttgart, Germany; Department of Neuroradiology (A.G.), Medical University of Innsbruck, Austria; Department for Diagnostic and Interventional Neuroradiology (F.D.), University of Munich (LMU), Campus Grosshadern; Department of Neuroradiology (O.N., M.W.), RWTH Aachen University; Diagnostic and Interventional Neuroradiology (G.B.), Eberhard Karls University Tuebingen; Department of Radiology and Neuroradiology (A.W.), University Hospital Knappschaftskrankenhaus Bochum Langendreer; Department of Neuroradiology (D.K.), University Hospital Carl Gustav Carus, Dresden7; Department of Neuroradiology (U.Y.), Saarland University Hospital, Homburg, Germany; ASST Valcamonica (A.M.), Ospedale di Esine, UOSD Neurologia, Esine, Italy; Division of Neuroradiology and Musculoskeletal Radiology (W.M.), Department of Biomedical Imaging and Image-Guided Therapy, and Department of Biomedical Imaging and Image-Guided Therapy (R.N.), Division of Cardiovascular and Interventional Radiology, Medical University of Vienna, Austria; Department of Radiology and Neuroradiology (U.J.-K.), University Hospital of Schleswig-Holstein, Kiel; Section of Neuroradiology (M.B.), University of Ulm, Guenzburg; Department for Neuroradiology (S.S.), University Hospital Leipzig; Department of Neuroradiology (O.B.), University Hospital of Magdeburg; Department of Diagnostic and Interventional Neuroradiology (F.G.), Hannover Medical School, Germany; Institute of Neuroradiology (J.T.), Kepler University Hospital, Johannes Kepler University Linz, Austria; Institute of Neuroradiology (B.T.), University Hospital Duesseldorf; Department of Neuroradiology at Heidelberg University Hospital (M.M.); Department of Radiology (C.W.), University Hospital Regensburg; Department of Neuroradiology (P.S., A. Kemmling), University Hospital of Luebeck, Germany; Department of Neurology (P.L.M.), Massachusetts General Hospital, Harvard Medical School, Boston; Division of Child Neurology (S.L.), Department of Neurology, Stanford University, CA; Department of Neuroradiology (M.S.), University Hospital of Cologne; Department of Diagnostic and Interventional Radiology and Neuroradiology (A.R.), University Hospital Essen, University of Duisburg-Essen; Institute of Epidemiology and Social Medicine (A. Karch, N.R.), University of Muenster; and Department of Radiology, University of Munich (LMU) (M.W.), Campus Grosshadern, Germany.

Objective: To determine whether thrombectomy is safe in children up to 24 hours after onset of symptoms when selected by mismatch between clinical deficit and infarct.

Methods: A secondary analysis of the Save ChildS Study (January 2000-December 2018) was performed, including all pediatric patients (<18 years) diagnosed with arterial ischemic stroke who underwent endovascular recanalization at 27 European and United States stroke centers. Patients were included if they had a relevant mismatch between clinical deficit and infarct.

Results: Twenty children with a median age of 10.5 (interquartile range [IQR] 7-14.6) years were included. Of those, 7 were male (35%), and median time from onset to thrombectomy was 9.8 (IQR 7.8-16.2) hours. Neurologic outcome improved from a median Pediatric NIH Stroke Scale score of 12.0 (IQR 8.8-20.3) at admission to 2.0 (IQR 1.2-6.8) at day 7. Median modified Rankin Scale (mRS) score was 1.0 (IQR 0-1.6) at 3 months and 0.0 (IQR 0-1.0) at 24 months. One patient developed transient peri-interventional vasospasm; no other complications were observed. A comparison of the mRS score to the mRS score in the DAWN and DEFUSE 3 trials revealed a higher proportion of good outcomes in the pediatric compared to the adult study population.

Conclusions: Thrombectomy in pediatric ischemic stroke in an extended time window of up to 24 hours after onset of symptoms seems safe and neurologic outcomes are generally good if patients are selected by a mismatch between clinical deficit and infarct.

Classification Of Evidence: This study provides Class IV evidence that for children with acute ischemic stroke with a mismatch between clinical deficit and infarct size, thrombectomy is safe.
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http://dx.doi.org/10.1212/WNL.0000000000011107DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7884981PMC
January 2021

Comparative Analysis of the Pipeline and the Derivo Flow Diverters for the Treatment of Unruptured Intracranial Aneurysms-A Multicentric Study.

World Neurosurg 2021 Jan 17;145:e326-e331. Epub 2020 Oct 17.

Institute for Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Cologne, Cologne, Germany.

Objective: Flow diversion represents a safe and efficient technique for the endovascular treatment of complex intracranial aneurysms. This study compares 2 competing flow diverters, the Pipeline embolization device (PED) and the Derivo Embolization Device (DED) regarding technical aspects, clinical outcome, and angiographic results.

Methods: A total of 111 patients with unruptured aneurysms were treated with the PED (n = 62) or the DED (n = 49) between 2011 and 2019. Procedural specifics, complication rates, functional outcome, and aneurysm occlusion were evaluated retrospectively.

Results: Flow-diverter implantation was technically successful in all patients. There were no significant differences regarding baseline characteristics, adjunctive coiling, and fluoroscopy time. Multiple devices were more often used in the PED group (35.6%) than in the DED group (4.1%, P < 0.001). Procedural adverse events occurred in 4 cases of each group (PED: 5.5%, DED: 8.2%, P = 0.713), including 3 thromboembolic events and 1 hemorrhagic event per group. Morbidity rates were similar between the 2 groups (PED: 2.7%, DED: 4.1%, P = 1.0). There was no procedural mortality. At 6-month follow-up, complete or near-complete occlusion (O'Kelly-Marotta scale C+D) was achieved in 79.0% (49/62) after PED implantation and 80.0% (32/40) after DED implantation (P = 0.354).

Conclusions: In regard to complication rates, functional outcome, and aneurysm occlusion, no significant differences were found between the PED and DED collective.
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http://dx.doi.org/10.1016/j.wneu.2020.10.062DOI Listing
January 2021

The impact of preoperative MRI-based apparent diffusion coefficients on local recurrence and outcome in patients with cerebral metastases.

Br J Neurosurg 2020 Sep 29:1-8. Epub 2020 Sep 29.

Klinik für Neurochirurgie, Heinrich-Heine-Universität, Düsseldorf, Germany.

Background: Surgery of single cerebral metastases is standard but frequently fails to achieve local tumour control. Reliable predictors for local tumour progression and overall survival are unknown. MRI-based apparent diffusion coefficients (ADC) correlate with tumour cellularity and invasion. The present study analysed a potential relation between the MRI based apparent diffusion coefficients local recurrence and outcome in patients with brain metastases.

Methods: A retrospective analysis was performed for patients with cerebral metastases and complete surgical resection evaluated by an early postoperative MRI < 72h. Minimal ADC and mean ADC were assessed in preoperative 1,5T-MRI scans by placing regions of interests in the tumour and the peritumoural tissue.

Results: Analysis of the relation between ADC values, local progression and outcome was performed in 86 patients with a mean age of 59 years (range 33-83 years). Primary site was NSCLC in 37.2% of all cases. Despite complete resection 33.7% of all patients suffered from local in-brain-progression. There were no significant differences in ADC values in groups based on histology. In the present cohort, the mean ADCmin and the mean ADCmean within the metastasis did not differ significantly between patients with and without a later local in-brain progression (634 × 10 vs. 661 × 10 mm/s and 1324 × 10 vs. 1361 × 10 mm/s; 1100 × 10 vs. 1054 × 10 mm/s; each  > 0.05). Mean ADC values did not correlate significantly with PFS and OAS.

Conclusion: In the present study analysed ADC values had no significant impact on local in brain progression and survival parameters.
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http://dx.doi.org/10.1080/02688697.2020.1817856DOI Listing
September 2020

Case Report: A Case of Severe Clinical Deterioration in a Patient With Multiple Sclerosis.

Front Neurol 2020 18;11:782. Epub 2020 Aug 18.

Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany.

Tumefactive multiple sclerosis (MS) is a rare variant of MS that may lead to a rapidly progressive clinical deterioration requiring a multidisciplinary diagnostic workup. Our report describes the diagnostic and therapeutic approach of a rare and extremely severe course of MS. A 51-year-old man with an 8-year history of relapsing-remitting MS (RRMS) was admitted with a subacute progressive left lower limb weakness and deterioration of walking ability. After extensive investigations including repeated MRI, microbiological, serological, cerebrospinal fluid (CSF) studies, and finally brain biopsy, the diagnosis of a tumefactive MS lesion was confirmed. Despite repeated intravenous (IV) steroids as well as plasma exchanges and IV foscarnet and ganciclovir owing to low copy numbers of human herpesvirus 6 (HHV-6) DNA in polymerase chain reaction (PCR) analysis, the patient did not recover. The clinical presentation of tumefactive MS is rare and variable. Brain biopsy for histopathological workup should be considered in immunocompromised patients with rapidly progressive clinical deterioration with brain lesions of uncertain cause.
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http://dx.doi.org/10.3389/fneur.2020.00782DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7461937PMC
August 2020

Serum neurofilament light chain: No clear relation to cognition and neuropsychiatric symptoms in stable MS.

Neurol Neuroimmunol Neuroinflamm 2020 11 24;7(6). Epub 2020 Sep 24.

From the Department of Neurology (O.A., M.G., K.L., N.G., J.G., H.-P.H., P.A., I.-K.P.), Medical Faculty, University Düsseldorf, Germany; Cogito Center for Applied Neurocognition and Neuropsychological Research (A.R., M.F., S.B., N.S., I.-K.P.), Düsseldorf, Germany; Department of Neurology (A.H., M.S., M.O., H.T.), University Hospital Ulm, Germany; Department of Neurology (C.E., D.P.), Research Unit for Neuronal Plasticity and Repair, Medical University of Graz, Austria; Division of Neuroradiology, Vascular and Interventional Radiology (C.E.), Department of Radiology, Medical University of Graz, Austria; Department of Diagnostic and Interventional Radiology (G.A., B.T.), Medical Faculty, University Düsseldorf, Germany; and Department of Neurology (H.T.), Dietenbronn, Germany.

Objective: To explore the hypothesis that serum neurofilament light chain (sNfL) indicative of neuroaxonal damage may improve precise disease profiling with regard to cognition and neuropsychiatric symptoms, we analyzed potential associations of sNfL levels with cognitive test scores, fatigue, depression, and anxiety.

Methods: Patients with relapsing-remitting and secondary progressive MS (SPMS) underwent an elaborated assessment including MRI, various cognitive tests, and patient-reported outcomes. We determined sNfL levels by single molecule array (Simoa) assay. Relationships between sNfL, cognition, neuropsychiatric symptoms, and demographical data were analyzed using correlations, group comparisons, and regressions.

Results: In 45 clinically stable patients with MS (Expanded Disability Status Scale = 2.73 ± 1.12, disease duration = 10.03 ± 7.49 years), 40.0% were cognitively impaired. Mean sNfL levels were 16.02 ± 10.39 pg/mL, with higher levels in the SPMS subgroup ( = 0.038). sNfL levels did reliably link neither with the investigated cognitive and affective parameters nor with fatigue levels. The only relationship found in a small subgroup of patients with SPMS (n = 7) with visuospatial learning ( = -0.950, = 0.001) and memory ( = -0.813; = 0.026) disappeared when further controlling for age, educational level, and sex.

Conclusions: In patients with stable MS at less advanced disease stages, sNfL did not convincingly relate to cognitive performance, fatigue, depression, or anxiety and thus may not serve as a surrogate biomarker for neuropsychological status in such populations.
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http://dx.doi.org/10.1212/NXI.0000000000000885DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7673283PMC
November 2020

Derivo embolization device in the treatment of unruptured intracranial aneurysms: a prospective multicenter study.

J Neurointerv Surg 2021 Jun 8;13(6):541-546. Epub 2020 Sep 8.

Department of Intracranial Endovascular Therapy, Alfried Krupp Krankenhaus Essen, Essen, Germany.

Background: Flow diverters (FD) are used regularly for the endovascular treatment of unruptured intracranial aneurysms. We aimed to assess the safety and effectiveness of the Derivo embolization device (DED) with respect to long-term clinical and angiographic outcomes.

Methods: A prospective multicenter trial was conducted at 12 centers. Patients presenting with modified Rankin Score (mRS) of 0-1, treated for unruptured intracranial aneurysms with DED were eligible. Primary endpoint was the mRS assessed at 18 months with major morbidity defined as mRS 3-5. Satisfactory angiographic occlusion was defined as 3+4 on the Kamran scale.

Results: Between July 2014 and February 2018, 119 patients were enrolled. Twenty-three patients were excluded. Ninety-six patients, 71 (74%) female, mean age 54±12.0 years, were included in the analysis. Mean aneurysm size was 14.2±16.9 mm. The mean number of devices implanted per patient was 1.2 (range 1-3). Clinical follow-up at 18 months was available in 90 (94%) patients, resulting in a mean follow-up period of 14.8±5.2 months. At last available follow-up of 96 enrolled patients, 91 (95%) remained mRS 0-1. The major morbidity rate (mRS 3-5) was 3.1% (3/96), major stroke rate was 4.2% (4/96), and mortality was 0%. Follow-up angiographies were available in 89 (93%) patients at a median of 12.4±5.84 months with a core laboratory adjudicated satisfactory aneurysm occlusion in 89% (79/89).

Conclusion: Our results suggest that DED is a safe and effective treatment for unruptured aneurysms with high rates of satisfactory occlusion and comparably low rates of permanent neurological morbidity and mortality.

Trial Registration: DRKS00006103.
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http://dx.doi.org/10.1136/neurintsurg-2020-016303DOI Listing
June 2021

Automated age- and sex-specific volumetric estimation of regional brain atrophy: workflow and feasibility.

Eur Radiol 2021 Feb 27;31(2):1043-1048. Epub 2020 Aug 27.

Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstr. 5, D-40225, Düsseldorf, Germany.

Objectives: An automated workflow for age- and sex-specific estimation of regional brain volume changes from structural MRI relative to a standard population is presented and evaluated for feasibility.

Methods: T1w MRI scans are preprocessed in a standardized way comprising gray matter (GM) segmentation, normalization, modulation, and spatial smoothing. Resulting GM images are then compared to precomputed age- and sex-specific GM templates derived from the population-based Nathan Kline Institute Rockland Sample, and voxel-wise z-maps are compiled. z-maps are color-coded and fused with the subject's T1w images. The rate of technical success of the proposed workflow was evaluated in 1330 subjects of the Alzheimer's Disease Neuroimaging Initiative (ADNI). Furthermore, medial temporal atrophy (MTA) was assessed using the color-coded maps and with the MTA visual rating scale in these subjects. Sensitivities and specificity of color-coded maps and MTA scale were compared using McNemar's test.

Results: One test dataset was excluded due to severe motion artifacts. Out of the remaining 1329 datasets, atrophy map generation was successful in 1323 ADNI subjects (99.5%). Sensitivity for AD diagnosis (71.4 % vs. 53.3%, p < 0.0001 for left; 70.4% vs. 55.3%, p < 0.0001 for right hemisphere) and for MCI (45.4% vs. 17.4, p < 0.0001 for left; 43.5% vs. 14.6%, p < 0.0001 for right hemisphere) based on medial temporal atrophy assessment in color-coded maps was significantly higher than for MTA visual rating scale, while specificity was lower (78.4% vs. 93.8%, p < 0.0001 for left; 79.4% vs. 95.8%, p < 0.0001 for right hemisphere). The workflow is named veganbagel and is published as open-source software with an integrated PACS interface.

Conclusions: Automated brain volume change estimation with the proposed workflow is feasible and technically dependable. It provides high potential for radiologic assessment of brain volume changes and neurodegenerative diseases.

Key Points: • A workflow combining techniques from voxel-based morphometry and population-based neuroimaging data is feasible and technically highly dependable. • The workflow is provided as open-source software, named veganbagel. • Sensitivity of medial temporal atrophy assessment in atrophy maps from veganbagel exceeds the sensitivity of MTA visual rating scale for the diagnosis of Alzheimer's disease.
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http://dx.doi.org/10.1007/s00330-020-07196-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7813701PMC
February 2021

eCLIPs bifurcation remodeling system for treatment of wide neck bifurcation aneurysms with extremely low dome-to-neck and aspect ratios: a multicenter experience.

J Neurointerv Surg 2021 May 11;13(5):438-442. Epub 2020 Aug 11.

Diagnostic and Therapeutic Neuroradiology, St Michael's Hospital, Toronto, Ontario, Canada

Background: Wide necked bifurcation aneurysms (WNBA) are among the most difficult aneurysms to treat. Very low dome-to-neck (DTN) and aspect ratios provide an even greater challenge in the management of WNBAs. We present the safety and efficacy profile for endovascular clip system (eCLIPs) device in the treatment of this subset of WNBAs with very unfavorable morphologies.

Methods: In our case series, 24 patients treated at 12 international centers were taken from a larger prospective voluntary post-marketing registry of 65 patients treated with the eCLIPs device and coiling. Those who had WNBAs at either the carotid or basilar terminus with a DTN ratio <1.6 and aspect ratio <1.2 were included. Radiologic and clinical outcomes were assessed immediately after the procedure and at the latest follow-up.

Results: The eCLIPs device was successfully deployed in 23 cases (96%). One patient (4.2%) died due to guidewire perforation distal to the implant site. No other complications were documented. After a mean follow-up of 15.8 months (range 3-40 months), good radiologic outcomes (modified Raymond-Roy classification (MRRC) scores of 1 or 2) were documented in 20 of 21 patients (95%) with follow-up data. The lone patient with an MRRC score of 3 showed coiled compaction after incomplete neck coverage with the device.

Conclusion: Our series of patients with aneurysms having adverse DTN and aspect ratios demonstrated that the eCLIPs device has a safety and efficacy profile comparable with currently available devices in the treatment of WNBAs.
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http://dx.doi.org/10.1136/neurintsurg-2020-016354DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8053345PMC
May 2021

Age-stratified clinical performance and survival of patients with IDH-wildtype glioblastoma homogeneously treated by radiotherapy with concomitant and maintenance temozolomide.

J Cancer Res Clin Oncol 2021 Jan 3;147(1):253-262. Epub 2020 Aug 3.

Department of Neurosurgery, Medical Faculty, Heinrich Heine University, Moorenstraße 5, 40225, Düsseldorf, Germany.

Objective: Isocitrate dehydrogenase (IDH)-wildtype glioblastomas are the most malignant glial tumours. Median survival is only 14-16 months after diagnosis, with patients aged ≥ 65 years reportedly showing worse outcome. This study aimed to further evaluate the prognostic role of age in a homogenously treated patient cohort.

Methods: The study includes 132 IDH-wildtype glioblastoma patients treated between 2013 and 2017 with open resection followed by radiotherapy with concomitant and maintenance temozolomide. Patients were dichotomized into a non-elderly (< 65 years) and an elderly (≥ 65 years) group. Extent of resection and the O6-methylguanine-DNA methyltransferase (MGMT) promoter methylation status were determined for each tumour. Clinical and radiological follow-up data were obtained at 6 weeks after the end of radiation therapy and thereafter in 3-month intervals. Progression-free survival (PFS) and overall survival (OS) were evaluated in univariate and multivariate cox regression analyses.

Results: The elderly group consisted of 58 patients (median age: 70.5 years) and the non-elderly group of 74 patients (median age: 55 years). Median pre- and postoperative operative Karnofsky Performance Scale (KPS), Eastern Cooperative Oncology Group (ECOG) score and National Institutes of Stroke Scale (NIHSS) were not significantly different between the groups, but KPS and ECOG scores became significantly worse in the elderly group at 6 weeks after termination of radiation therapy. Neither PFS nor OS differed significantly between the age groups. Patients with MGMT promoter-methylated tumours survived longer.

Conclusion: Elderly patients in good pre- and postoperative clinical conditions may show similar outcome as younger patients when treated according to standard of care. However, elderly patients may suffer more frequently from clinical deterioration following chemoradiotherapy. In both age groups, MGMT promoter methylation was linked to longer PFS and OS.
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http://dx.doi.org/10.1007/s00432-020-03334-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7810639PMC
January 2021

Automatic Alignment of Cranial CT Examinations to the Anterior Commissure/Posterior Commissure (ACPC) Reference Plane for Reliable Interpretation and Quality Assurance.

Rofo 2021 Jan 9;193(1):61-67. Epub 2020 Jun 9.

University Dusseldorf, Medical Faculty, Department of Diagnostic and Interventional Radiology, D-40225 Dusseldorf, Germany.

Alignment of cranial CT scans (cCTs) to a common reference plane simplifies anatomical-landmark-based orientation and eases follow-up assessment of intracranial findings. We developed and open sourced a fully automated system, which aligns cCTs to the Anterior Commissure/Posterior Commissure (ACPC) line and exports the results to the PACS. FMRIB's Linear Image Registration Tool (FLIRT) with an ACPC-aligned atlas is used in the alignment step. Five mm mean slabs are generated with the top non-air slice as the starting point. For evaluation, 301 trauma cCTs from the CQ500 dataset were processed. In visual comparison with the respective ACPC-aligned atlas, all were successfully aligned. Image quality (IQ) and ease of identification of the central sulcus (CS) were rated on a Likert scale (5 = excellent IQ/immediate CS identification). The median IQ was 4 (range: 2-4) in the original series and 5 (range: 4-5) in the ACPC-aligned series (p < 0.0001). The CS was more easily identified after fatbACPC (original scans: 4 (range: 2-5); ACPC-aligned: 5 (range: 4-5); p < 0.0001). The mean rotation to achieve alignment was |X| = 6.4 ± 5.2° ([-X,+X] = -26.8°-24.2°), |Y| = 2.1 ± 1.7° ([-Y,+Y] = -8.7°-9.8°), and |Z| = 3.1 ± 2.4° ([-Z,+Z] = -14.3°-12.5°). The developed system can robustly and automatically align cCTs to the ACPC line. Degrees of deviation from the ideal alignment could be used for quality assurance. KEY POINTS:: · fatbACPC automatically aligns cranial CT scans to the Anterior Commissure/Posterior Commissure plane.. · ACPC-aligned images simplify anatomical-landmark-based orientation.. · fatbACPC does not impact image quality.. · fatbACPC is robust, fully PACS-integrated, and Open Source: https://github.com/BrainImAccs. CITATION FORMAT: · Rubbert C, Turowski B, Caspers J. Automatic Alignment of Cranial CT Examinations to the Anterior Commissure/Posterior Commissure (ACPC) Reference Plane for Reliable Interpretation and Quality Assurance. Fortschr Röntgenstr 2021; 193: 61 - 67.
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http://dx.doi.org/10.1055/a-1167-8368DOI Listing
January 2021

The New Fully Radiopaque Aperio Hybrid Stent Retriever: Efficient and Safe? An Early Multicenter Experience.

World Neurosurg 2020 09 17;141:e278-e288. Epub 2020 May 17.

Institute for Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany. Electronic address:

Objective: To investigate the visibility, safety, and efficacy of the full-length radiopaque Aperio Hybrid stent retriever (APH) in mechanical thrombectomy of large vessel occlusions.

Methods: Multicentric retrospective analysis of patients with stroke, treated with the APH due to an acute ischemic stroke by large vessel occlusions in the anterior or posterior circulation, was performed. We focused on technical and angiographic parameters including device visibility, perfusion results (modified thrombolysis in cerebral infarction scale [mTICI]), procedural times, periprocedural complications, and favorable clinical outcome (modified Rankin Scale, 0-2) at discharge and after 90 days.

Results: A total of 48 patients (male: n = 22, 45.8%, mean age 73 years [standard deviation (SD), ±15], median baseline National Institutes of Health Stroke Scale: 15 [2-36], n = 25, 52.1% received additional intravenous thrombolytics) were treated with the APH with a mean number of 2 device passes (SD, +3) in APH-only cases (n = 41). The median time from groin puncture to the final mTICI was 54 minutes (SD, +33). In 46 patients (95.8%), mTICI 2b-3 was achieved (mTICI 2c, 12.5%; mTICI 3, 47.9%). Favorable outcome (modified Rankin Scale <2) was achieved in 15 (32.6%) patients at discharge and in 11 of the 30 (36.7%) patients available for 90-day follow-up. Symptomatic intracranial hemorrhage was recorded in 3 of 48 cases (6.3%). Difficulties during device delivery and/or deployment occurred in 6.3% (3 of 48). APH-related adverse events did not occur. APH radiopacity was rated as good and very good in 97.9% (47 of 48).

Conclusions: Mechanical thrombectomy with the APH appeared feasible, efficient, and safe. Full-length device radiopacity may facilitate thrombectomy or support to adapt the course of action during retrieval, if required.
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http://dx.doi.org/10.1016/j.wneu.2020.05.104DOI Listing
September 2020

Mechanical thrombectomy in acute middle cerebral artery M2 segment occlusion with regard to vessel involvement.

Neurol Sci 2020 Nov 30;41(11):3165-3173. Epub 2020 Apr 30.

Department of Diagnostic and Interventional Radiology, University Dusseldorf, Medical Faculty, D-40225, Dusseldorf, Germany.

Background: Endovascular treatment (EVT) is an established procedure in patients with acute ischemic stroke due to occlusion of the proximal M1-segment of middle cerebral artery. The assessment of distal thrombectomy in daily clinical routine has not yet been sufficiently evaluated.

Methods: Patients with M2-segment-occlusions treated by EVT in the local department (January 2012-December 2017) were included (n = 57, mean National-Institutes-of-Health-Stroke-Scale of 11, range 0-20). Patients were grouped according to localization of M2-occlusion (Cohort A (n = 14): central region only, B (n = 24): central region and involvement of frontal vessels, C (n = 19): parietal, occipital, and/or temporal vessels). Differences in proximal (M2-trunk, n = 34) and distal (M2-branches, n = 23) occlusions were also examined. Reperfusion (Thrombolysis-In-Cerebral-Infarction (TICI)), early clinical outcome at discharge (modified Rankin Scale (mRS)), and complications (hemorrhage, new emboli) were noted.

Result: Successful reperfusion (TICI2b-3) was found in 49 patients (86.0%). Favorable early clinical outcome (mRS0-2) was achieved in n = 19 (37.7%). Compared to admission, mRS at discharge improved significantly (median (admission) 5 vs. median (discharge) 4, p < 0.001). Early clinical outcome was more favorable in patients with better reperfusion (TICI2b-3: mean mRS 3 ± 1.7 vs. TICI0-2a: mean mRS 4.4 ± 1.4, p = 0.037). Six (10.5%) patients suffered from symptomatic intracranial hemorrhage during treatment or hospitalization. Four patients died (7.0%). No significant differences in favorable clinical outcome (mRS ≤ 2: Cohort A 42.9%, B 50.0%, C 16.7%, p = 0.4; χ-test) or periinterventional complications were found with regard to vessel involvement.

Conclusion: EVT in patients with acute M2-occlusion is safe and leads to a significant clinical improvement at discharge. No significant differences in clinical outcome or complications were found with regard to the localization of the M2-occlusion.
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http://dx.doi.org/10.1007/s10072-020-04430-5DOI Listing
November 2020

Does Device Selection Impact Recanalization Rate and Neurological Outcome?: An Analysis of the Save ChildS Study.

Stroke 2020 04 2;51(4):1182-1189. Epub 2020 Mar 2.

Institute of Neuroradiology, University Hospital Duesseldorf, Germany (B.T.).

Background and Purpose- The recent Save ChildS study provides multicenter evidence for the use of mechanical thrombectomy in children with large vessel occlusion arterial ischemic stroke. However, device selection for thrombectomy may influence rates of recanalization, complications, and neurological outcomes, especially in pediatric patients of different ages. We, therefore, performed additional analyses of the Save ChildS data to investigate a possible association of different thrombectomy techniques and devices with angiographic and clinical outcome parameters. Methods- The Save ChildS cohort study (January 2000-December 2018) analyzed data from 27 European and United States stroke centers and included all pediatric patients (<18 years), diagnosed with arterial ischemic stroke who underwent endovascular recanalization. Patients were grouped into first-line contact aspiration (A Direct Aspiration First Pass Technique [ADAPT]) and non-ADAPT groups as well as different stent retriever size groups. Associations with baseline characteristics, recanalization rates (modified Treatment in Cerebral Infarction), complication rates, and neurological outcome parameters (Pediatric National Institutes of Health Stroke Scale after 24 hours and 7 days; modified Rankin Scale and Pediatric Stroke Outcome Measure at discharge, after 6 and 24 months) were investigated. Results- Seventy-three patients with a median age of 11.3 years were included. Currently available stent retrievers were used in 59 patients (80.8%), of which 4×20 mm (width×length) was the most frequently chosen size (36 patients =61%). A first-line ADAPT approach was used in 7 patients (9.6%), and 7 patients (9.6%) were treated with first-generation thrombectomy devices. In this study, a first-line ADAPT approach was neither associated with the rate of successful recanalization (ADAPT 85.7% versus 87.5% No ADAPT) nor with the complication rate or the neurological outcome. Moreover, there were no associations of stent retriever sizes with rates of recanalization, complication rates, or outcome parameters. Conclusions- Our study suggests that neurological outcomes are generally good regardless of any specific device selection and suggests that it is important to offer thrombectomy in eligible children regardless of technique or device selection. Registration- URL: https://www.drks.de/; Unique identifier: DRKS00016528.
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http://dx.doi.org/10.1161/STROKEAHA.119.028221DOI Listing
April 2020

Low-Profile Laser-Cut Stents for Endovascular Treatment of Intracranial Aneurysms : Incidence, Clinical Presentation and Risk Factors of Thromboembolic Events.

Clin Neuroradiol 2021 Mar 22;31(1):107-115. Epub 2020 Jan 22.

Department of Neuroradiology, University Hospital of Cologne, Kerpener Str. 67, 50937, Cologne, Germany.

Purpose: Low-profile intracranial stents are characterized by a miniaturized design that enables deployment via a 0.0165″ or 0.017″ internal diameter microcatheter, which is typically intended for coil delivery. This study analyzed the incidence, clinical relevance and risk factors of thromboembolic events (TEE) occurring during low-profile stent-assisted coiling of intracranial aneurysms.

Methods: This was a retrospective, multicenter analysis of consecutive patients who underwent stent-assisted aneurysm coiling (SAC) with the laser-cut Acandis Acclino and Neuroform Atlas stents. The study evaluated the incidence of symptomatic and asymptomatic TEEs and the impact on functional outcome. Risk factors for TEEs were determined by univariate and bivariate logistic regression analyses.

Results: Among 131 procedures (mean patient age 56.5 ± 12.8 years, mean aneurysm size: 6.7 ± 3.9 mm) TEEs occurred in 14 cases (10.7%) of which 2 patients (1.5%) developed ischemic stroke, while the remaining TEEs remained asymptomatic. Multivariate analysis revealed Y‑stenting as potential risk factor for TEEs (odds ratio: 3.9, 95% confidence interval: 1.0-16.5; p = 0.08).

Conclusion: The use of SAC with low-profile intracranial stents is associated with a favorable safety profile; however, Y‑stenting may carry an increased risk of TEEs, which needs to be considered during treatment planning.
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http://dx.doi.org/10.1007/s00062-019-00874-1DOI Listing
March 2021

Association between aneurysm hemodynamics and wall enhancement on 3D vessel wall MRI.

J Neurosurg 2020 Jan 10:1-11. Epub 2020 Jan 10.

5Department of Neurosurgery and.

Objective: Aneurysm wall enhancement (AWE) on 3D vessel wall MRI (VWMRI) has been suggested as an imaging biomarker for intracranial aneurysms (IAs) at higher risk of rupture. While computational fluid dynamics (CFD) studies have been used to investigate the association between hemodynamic forces and rupture status of IAs, the role of hemodynamic forces in unruptured IAs with AWE is poorly understood. The authors investigated the role and implications of abnormal hemodynamics related to aneurysm pathophysiology in patients with AWE in unruptured IAs.

Methods: Twenty-five patients who had undergone digital subtraction angiography (DSA) and VWMRI studies from September 2016 to September 2017 were included, resulting in 22 patients with 25 IAs, 9 with and 16 without AWE. High-resolution CFD models of hemodynamics were created from DSA images. Univariate and multivariate analyses were performed to investigate the association between AWE and conventional morphological and hemodynamic parameters. Normalized MRI signal intensity was quantified and quantitatively associated with wall shear stresses (WSSs) for the entire aneurysm sac, and in regions of low, intermediate, and high WSS.

Results: The AWE group had lower WSS (p < 0.01) and sac-averaged velocity (p < 0.01) and larger aneurysm size (p < 0.001) and size ratio (p = 0.0251) than the non-AWE group. From multivariate analysis of both hemodynamic and morphological factors, only low WSS was found to be independently associated with AWE. Sac-averaged normalized MRI signal intensity correlated with WSS and was significantly different in regions of low WSS compared to regions of intermediate (p = 0.018) and high (p < 0.001) WSS.

Conclusions: The presence of AWE was associated with morphological and hemodynamic factors related to rupture risk. Low WSS was found to be an independent predictor of AWE. Our findings support the hypothesis that low WSS in IAs with AWE may indicate a growth and remodeling process that may predispose such aneurysms to rupture; however, a causality between the two cannot be established.
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http://dx.doi.org/10.3171/2019.10.JNS191251DOI Listing
January 2020

Long-term Angiographic Results of the Low-profile Acandis Acclino Stent for Treatment of Intracranial Aneurysms : A Multicenter Study.

Clin Neuroradiol 2020 Dec 15;30(4):827-834. Epub 2019 Nov 15.

Department of Neuroradiology, University Hospital of Cologne, Kerpener Straße 67, 50937, Cologne, Germany.

Purpose: The low-profile Acandis Acclino is a self-expandable nitinol microstent for stent-assisted coiling of intracranial aneurysms. This article reports long-term clinical and angiographic outcome in a multicenter setting.

Methods: In this study 98 consecutive patients (mean age 55.4 ± 13.5 years) were treated with the Acclino for 98 aneurysms (28 unruptured, 20 recurrent, 50 ruptured) at 3 German tertiary care centers within a 6-year period. The technical success, complications, clinical outcome and angiographic results were retrospectively analyzed.

Results: The technical success rate was 100% with immediate complete occlusion achieved in 89.8% of the patients. Among 65 patients (66.3%) available for a 6‑month follow-up, complete and near-complete occlusion rates were 92.3% and 98.5%, respectively. In 38 patients (38.8%) with long-term follow-up (mean: 21 months), complete and near-complete occlusion were achieved in 81.2% and 89.5%, respectively. Aneurysm recurrence between mid-term and long-term follow-up was observed in 14.3%. The retreatment rate was 11.3%. There were three thromboembolic events (3.1%), of which one resulted in ischemic stroke (1.0%). For unruptured aneurysms, the procedural and device-related morbidity rates were 2.1% and 0%, respectively.

Conclusion: In the present study, the Acclino was associated with a low risk of thromboembolic complications and high aneurysm occlusion rates at long-term follow-up. Due to incomplete angiographic follow-up in this series, prospective studies will be necessary to confirm the results.
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http://dx.doi.org/10.1007/s00062-019-00847-4DOI Listing
December 2020

Feasibility, Safety, and Outcome of Endovascular Recanalization in Childhood Stroke: The Save ChildS Study.

JAMA Neurol 2020 01;77(1):25-34

Institute of Neuroradiology, University Hospital Duesseldorf, Duesseldorf, Germany.

Importance: Randomized clinical trials have shown the efficacy of thrombectomy of large intracranial vessel occlusions in adults; however, any association of therapy with clinical outcomes in children is unknown.

Objective: To evaluate the use of endovascular recanalization in pediatric patients with arterial ischemic stroke.

Design, Setting, And Participants: This retrospective, multicenter cohort study, conducted from January 1, 2000, to December 31, 2018, analyzed the databases from 27 stroke centers in Europe and the United States. Included were all pediatric patients (<18 years) with ischemic stroke who underwent endovascular recanalization. Median follow-up time was 16 months.

Exposures: Endovascular recanalization.

Main Outcomes And Measures: The decrease of the Pediatric National Institutes of Health Stroke Scale (PedNIHSS) score from admission to day 7 was the primary outcome (score range: 0 [no deficit] to 34 [maximum deficit]). Secondary clinical outcomes included the modified Rankin scale (mRS) (score range: 0 [no deficit] to 6 [death]) at 6 and 24 months and rate of complications.

Results: Seventy-three children from 27 participating stroke centers were included. Median age was 11.3 years (interquartile range [IQR], 7.0-15.0); 37 patients (51%) were boys, and 36 patients (49%) were girls. Sixty-three children (86%) received treatment for anterior circulation occlusion and 10 patients (14%) received treatment for posterior circulation occlusion; 16 patients (22%) received concomitant intravenous thrombolysis. Neurologic outcome improved from a median PedNIHSS score of 14.0 (IQR, 9.2-20.0) at admission to 4.0 (IQR, 2.0-7.3) at day 7. Median mRS score was 1.0 (IQR, 0-1.6) at 6 months and 1.0 (IQR, 0-1.0) at 24 months. One patient (1%) developed a postinterventional bleeding complication and 4 patients (5%) developed transient peri-interventional vasospasm. The proportion of symptomatic intracerebral hemorrhage events in the HERMES meta-analysis of trials with adults was 2.79 (95% CI, 0.42-6.66) and in Save ChildS was 1.37 (95% CI, 0.03-7.40).

Conclusions And Relevance: The results of this study suggest that the safety profile of thrombectomy in childhood stroke does not differ from the safety profile in randomized clinical trials for adults; most of the treated children had favorable neurologic outcomes. This study may support clinicians' practice of off-label thrombectomy in childhood stroke in the absence of high-level evidence.
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http://dx.doi.org/10.1001/jamaneurol.2019.3403DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6802048PMC
January 2020

Endovascular treatment of intracranial 'blister' and dissecting aneurysms.

Neuroradiol J 2019 Oct 4;32(5):353-365. Epub 2019 Jul 4.

1 Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstraße 5, 40225 Düsseldorf, Germany.

Introduction: Blister and dissecting aneurysms may have a different pathological background but they are commonly defined by instability of the vessel wall and bear a high risk of fatal rupture and rerupture. Lack of aneurysm sack makes treatment challenging.

Purpose: The purpose of this study was to assess the safety and feasibility of endovascular treatment of intracranial blister and dissecting aneurysms.

Methods: We retrospectively analysed all patients with ruptured and unruptured blister and dissecting aneurysms treated endovascularly between 2004-2018. Procedural details, complications, morbidity/mortality, clinical favourable outcome (modified Rankin Scale ≤2) and aneurysm occlusion rates were assessed.

Results: Thirty-four patients with endovascular treatment of 35 aneurysms (26 dissecting aneurysms and 9 blister aneurysms) were included. Five aneurysms were treated by parent vessel occlusion, and 30 aneurysms were treated by vessel reconstruction using stent monotherapy ( = 9), stent-assisted coiling ( = 7), flow diverting stents ( = 13) and coiling + Onyx embolization ( = 1). No aneurysm rebleeding and no procedure-related major complications or deaths occurred. There were five deaths in consequence of initial subarachnoid haemorrhage. Complete occlusion (79.2%) was detected in 19/24 aneurysms available for angiographic follow-up, and aneurysm recurrence in 2/24 (8.3%). The modified Rankin Scale ≤2 rate at mean follow-up of 15.1 months was 64.7%.

Conclusion: Treatment of blister and dissecting aneurysms developed from coil embolization to flow diversion with multiple stents to the usage of flow diverting stents. Results using modern flow diverting stents encourage us to effectively treat this aneurysm entity endovascularly by vessel reconstruction. Therefore, we recommend preference of vessel reconstructive techniques to parent vessel occlusion.
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http://dx.doi.org/10.1177/1971400919861406DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6728703PMC
October 2019

Single-center experience with the new generation Derivo Embolization Device in ruptured dissecting and blister aneurysms.

Acta Radiol 2020 Jan 5;61(1):37-46. Epub 2019 Jun 5.

University Düsseldorf, Medical Faculty, Department of Diagnostic and Interventional Radiology, Germany.

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http://dx.doi.org/10.1177/0284185119852731DOI Listing
January 2020

Systematic evaluation of computed tomography angiography collateral scores for estimation of long-term outcome after mechanical thrombectomy in acute ischaemic stroke.

Neuroradiol J 2019 Aug 20;32(4):277-286. Epub 2019 May 20.

1 Medical Faculty, Department of Diagnostic and Interventional Radiology, University Duesseldorf, Moorenstr. 5, 40225 Duesseldorf, Germany.

Purpose: This study compares computed tomography angiography-based collateral scoring systems in regard to their inter-rater reliability and potential to predict functional outcome after endovascular thrombectomy, and relates them to parenchymal perfusion as measured by computed tomography perfusion.

Methods: Eighty-four patients undergoing endovascular thrombectomy in anterior circulation ischaemic stroke were enrolled. Modified Tan Score, Miteff Score, Maas Score and Opercular Index Score ratio were assessed in pre-interventional computed tomography angiographies independently by two readers. Collateral scores were tested for inter-rater reliability by weighted-kappa, for correlations with three-months modified Rankin Scale, and their potential to differentiate between patients with favourable (modified Rankin Scale ≤2) and poor outcome (modified Rankin Scale ≥3). Correlations with relative cerebral blood volume and relative cerebral blood flow were tested in patients with available computed tomography perfusion.

Results: Very good inter-rater reliability was found for Modified Tan, Miteff and Opercular Index Score ratio, and substantial reliability for Maas. There were no significant correlations between collateral scores and three-months modified Rankin Scale, but significant group differences between patients with favourable and poor outcome for Maas, Miteff and Opercular Index Score ratio. Miteff and Maas were significant predictors of favourable outcome in binary logistic regression analysis. Miteff best differentiated between both outcome groups in receiver-operating characteristics, and Maas reached highest sensitivity for favourable outcome prediction of 96%. All collateral scores significantly correlated with mean relative cerebral blood volume and relative cerebral blood flow.

Conclusions: Computed tomography angiography scores are valuable in estimating functional outcome after mechanical thrombectomy and reliable across readers. The more complex scores, Maas and Miteff, show the best performances in predicting favourable outcome.
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http://dx.doi.org/10.1177/1971400919847182DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6639643PMC
August 2019

Risk factors for in-brain local progression in elderly patients after resection of cerebral metastases.

Sci Rep 2019 05 15;9(1):7431. Epub 2019 May 15.

Department of Neurosurgery, Heinrich Heine University Hospital, Dusseldorf, Germany.

Intracranial metastases are the most frequent brain tumor with recurrence rates after treatment of around 40-60%. Age is still considered a determinant of treatment and prognosis in this pathology. Recent studies analyzing the impact of metastasectomy in elderly patients focused on reporting perioperative mortality and morbidity rates but not on the evaluation of oncological outcome parameters. Aim of this study is to determine risk factors for in-brain local recurrence after brain surgery in this sub-population. From October 2009 until September 2016 all patients aged 65 years and above with histopathologically confirmed metastasis after surgical resection were retrospectively studied. Clinical, radiological and perioperative information was collected and statistically analysed. Follow-up consisted of clinical and radiological assessment every 3-months following surgery. 78 patients were included, of these 50% were female (39 patients). Median age was 71 years (66-83). Early postoperative-MRI verified a complete surgical resection in 41 patients (52.6%) and showed a tumor-remnant in 15 patients (19.2%). In 22 patients the MRI result was inconclusive (28.2%). None of the patients experienced severe complications due to surgery. The median postoperative NIHSS was adequate 1 ± 1.4 (0-6), nonetheless, insignificantly improved in comparison to the preoperative NIHSS (p = 0.16). A total of 20 patients (25.6%) presented local recurrence. The only statistically significant factor for development of local in-brain recurrence after resection of cerebral metastases in patients above 65 years of age was a tumor-remnant in the early postoperative MRI (p = 0.00005). Median overall survival was 13 months. Local in-brain recurrence after surgical resection of a cerebral metastasis in patients above 65 years of age was 25.6%. In our analysis, tumor-remnant in early postoperative MRI is the only risk factor for local in-brain recurrence. Oncological parameters in the present cohort do not seem to differ from recent phase III studies with non-geriatric patients. Nevertheless, controlled studies on the impact of metastasectomy in elderly patients delivering high quality reliable data are required.
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http://dx.doi.org/10.1038/s41598-019-43942-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6520351PMC
May 2019

Single-center experience with the new-generation Derivo embolization device for ruptured and unruptured intracranial aneurysms.

J Neurosurg Sci 2020 Aug 6;64(4):353-363. Epub 2019 May 6.

Department of Diagnostic and Interventional Radiology, Medical Faculty, University of Duesseldorf, Duesseldorf, Germany.

Background: The aim of this study is to evaluate safety and efficacy of the new-generation Derivo embolization device in complex ruptured (RIA) and unruptured (UIA) intracranial aneurysms.

Methods: Retrospective analysis of 32 patients with complex RIAs and UIAs treated with Derivo at our hospital from November 2015 to December 2018. Clinical safety was defined as absence of death, transient attack, absence of minor and major stroke, and Derivo associated hemorrhage. Treatment efficacy was assessed angiographically (DSA) immediately after treatment and at 6-month follow-up according to the O'Kelly-Marotta (OKM) Grading Scale (from A=total filling to D=no filling; prolongation of stasis 1=arterial to 3=venous phase).

Results: Thirty-two patients with 39 aneurysms were treated with 42 Derivos. In five aneurysms, additional coiling was performed. Deployment was technically successful in all cases. Two patients developed a procedure related minor stroke (one transient). In one patient bleeding due to an inflammatory aneurysmatic wall process occurred 20 days after retreatment and in one patient a stroke due to in-stent thrombosis occurred when dual platelet inhibition (PI) was switched to permanent single PI 12 month after FD treatment. No treatment related deaths were observed. Initial DSA revealed three OKM D, six OKM C, five OKM B, and 25 OKM A. Six-month follow-up for DSA and clinical evaluation was available in 20/32 patients (62.5%), 26 of 39 aneurysms (66.7%) and revealed 73.1% complete and 3.8% subtotal occlusion (OKM D: 19 of 26, OKM C3: one of 26).

Conclusions: Treatment of complex RIAs and UIAs with the new-generation Derivo appeared to be safe and effective in this single-center case series for ruptured and unruptured intracranial aneurysms. Immediate DSA revealed a significant flow modulation; and 6-month follow-up showed a high occlusion rate.
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http://dx.doi.org/10.23736/S0390-5616.19.04678-2DOI Listing
August 2020

Predictors for basal ganglia viability after mechanical thrombectomy in proximal middle cerebral artery occlusion.

Clin Imaging 2019 Sep - Oct;57:1-6. Epub 2019 May 2.

Department of Diagnostic and Interventional Radiology, Heinrich Heine University Duesseldorf, Medical Faculty, Germany.

Background/purpose: In acute proximal middle cerebral artery (MCA) occlusion covering the lenticulostriate arteries (LSA), ischemic tolerance of basal ganglia is limited due to supposed lack of collateral supply. However, in several patients, basal ganglia (BG) infarction was absent after successful mechanical thrombectomy (MTE). Purpose of our study was to evaluate predictors for BG viability in stroke patients despite prolonged MCA mainstem occlusion.

Material/methods: We retrospectively reviewed all stroke patients from our local registry with MCA mainstem occlusion after mechanical thrombectomy between November 2009 and October 2016. All patients underwent non-enhanced post-interventional cranial CT imaging (NCCT) and were classified according to 6 patterns of BG viability: complete: putamen (P) and globus pallidus (GP); partial: P or GP, and combination of complete or partial BG and/or adjacent white matter/cortical (WMC) viability. We compared viability patterns with respect to pre-interventional stroke imaging including NCCT, CT-angiography (CTA), CT perfusion (CTP); demographics, pre- and intra-procedural data and occurrence of post-procedural intracerebral hematoma (ICH). CTP imaging of the affected and contralateral BG-territories were obtained separately and CTA-collateral score (CS) was assessed.

Results: A significant correlation between higher collateral score and viability of GP (OR = 1.949; p = .011), P (OR = 2.039, p = .011), and the combination of GP, P and WMC (OR = 2.767, p = .007) was revealed. Higher relative CBV ratio (rCBVR) was significantly associated with viability of the pattern GP + WMC (univariate: OR = 3.160, p = .014; multivariate: OR = 6.058; p = .021).

Conclusion: CTA collateral score and rCBVR were predictive for BG viability in stroke patients after successful MTE in prolonged complete MCA-mainstem and LSA occlusion.
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http://dx.doi.org/10.1016/j.clinimag.2019.04.013DOI Listing
January 2020

How words get meaning: The neural processing of novel object names after sensorimotor training.

Neuroimage 2019 08 26;197:284-294. Epub 2019 Apr 26.

Institute for Experimental Psychology, Department of Biological Psychology, Heinrich Heine University Düsseldorf, Germany.

The hypothesis that individual experience affects the formation and processing of conceptual representations is controversially debated. Previous training studies with novel tool-like objects have found experience effects on conceptual representations as measured in tasks requiring the processing of object pictures. This study instead explored the neural processing of training-induced word meaning of novel object names. We asked whether the type of experience gained during object concept formation specifically modulates object name processing. In three training sessions with novel tool-like objects, two groups of healthy participants gained either active or observational manipulation experience as well as purely visual experience, while learning pseudowords serving as object names. In an fMRI session after training, participants were presented with the learned novel object names in a lexical decision task. Results revealed that processing novel object names in comparison to meaningless pseudowords elicits a word-like activation pattern in frontal, parietal and temporal regions known to underlie lexical-semantic processing, thus suggesting word meaning formation. Experience-specific modulations did not emerge as regional activation effects. However, a post-hoc analysis revealed that the type of experience (manipulation versus visual) as well as the way, in which the manipulation was learned (active versus observational) led to specific functional connectivity increases between semantic regions and neuronal assemblies in brain areas coding for object manipulation and related visuospatial information. These results suggest that the emergence of conceptual processing for novel object names might be grounded in functional brain networks specifically coding for the experience with their referents.
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http://dx.doi.org/10.1016/j.neuroimage.2019.04.069DOI Listing
August 2019

Machine-learning identifies Parkinson's disease patients based on resting-state between-network functional connectivity.

Br J Radiol 2019 Sep 14;92(1101):20180886. Epub 2019 May 14.

1University Dusseldorf, Medical Faculty, Department of Diagnostic and Interventional Radiology, D-40225 Dusseldorf, Germany.

Objective: Evaluation of a data-driven, model-based classification approach to discriminate idiopathic Parkinson's disease (PD) patients from healthy controls (HC) based on between-network connectivity in whole-brain resting-state functional MRI (rs-fMRI).

Methods: Whole-brain rs-fMRI (EPI, TR = 2.2 s, TE = 30 ms, flip angle = 90°. resolution = 3.1 × 3.1 × 3.1 mm, acquisition time ≈ 11 min) was assessed in 42 PD patients (medical OFF) and 47 HC matched for age and gender. Between-network connectivity based on full and L2-regularized partial correlation measures were computed for each subject based on canonical functional network architectures of two cohorts at different levels of granularity (Human Connectome Project: 15/25/50/100/200 networks; 1000BRAINS: 15/25/50/70 networks). A Boosted Logistic Regression model was trained on the correlation matrices using a nested cross-validation (CV) with 10 outer and 10 inner folds for an unbiased performance estimate, treating the canonical functional network architecture and the type of correlation as hyperparameters. The number of boosting iterations was fixed at 100. The model with the highest mean accuracy over the inner folds was trained using an non-nested 10-fold 20-repeats CV over the whole dataset to determine feature importance.

Results: Over the outer folds the mean accuracy was found to be 76.2% (median 77.8%, SD 18.2, IQR 69.4 - 87.1%). Mean sensitivity was 81% (median 80%, SD 21.1, IQR 75 - 100%) and mean specificity was 72.7% (median 75%, SD 20.4, IQR 66.7 - 80%). The 1000BRAINS 50-network-parcellation, using full correlations, performed best over the inner folds. The top features predominantly included sensorimotor as well as sensory networks.

Conclusion: A rs-fMRI whole-brain-connectivity, data-driven, model-based approach to discriminate PD patients from healthy controls shows a very good accuracy and a high sensitivity. Given the high sensitivity of the approach, it may be of use in a screening setting.

Advances In Knowledge: Resting-state functional MRI could prove to be a valuable, non-invasive neuroimaging biomarker for neurodegenerative diseases. The current model-based, data-driven approach on whole-brain between-network connectivity to discriminate Parkinson's disease patients from healthy controls shows promising results with a very good accuracy and a very high sensitivity.
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http://dx.doi.org/10.1259/bjr.20180886DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6732922PMC
September 2019

Endovascular Thrombectomy as a Means to Improve Survival in Acute Ischemic Stroke: A Meta-analysis.

JAMA Neurol 2019 07;76(7):850-854

Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.

Importance: Although endovascular thrombectomy (EVT) in acute ischemic stroke is recommended by guidelines to improve functional recovery, thus far there are insufficient data on its association with mortality.

Objective: To identify guideline-relevant trials of EVT vs medical therapy reporting 90-day mortality and perform a meta-analysis.

Data Sources: All randomized clinical trials cited for recommendations on EVT vs medical therapy in the latest 2018 American Stroke Association/American Heart Association guidelines.

Study Selection: Ten American Stroke Association/American Heart Association guideline-relevant randomized clinical trials of EVT vs medical therapy were selected for inclusion. Two EVT trials were excluded owing to infrequent use of EVT.

Data Extraction And Synthesis: Data were abstracted by 2 independent investigators and double-checked by 4 others. Singular study data were integrated using the Cochran-Mantel-Haenszel method and a random-effects model to compute summary statistics of risk ratios (RR) with 95% CIs.

Main Outcomes And Measures: Risk of 90-day mortality and 90-day intracranial hemorrhage was analyzed; sensitivity analyses were performed in early-window EVT trials (which included patients from the onset of symptoms onward) vs late-window EVT trials (which included patients from 6 hours after onset of symptoms onward).

Results: In 10 trials with 2313 patients, EVT significantly reduced the risk for 90-day mortality by 3.7% compared with medical therapy (15.0% vs 18.7%; RR, 0.81; 95% CI, 0.68-0.98; P = .03). Trends were similar in early-window (RR, 0.83; 95% CI, 0.67-1.01; P = .06) and late-window trials only (RR, 0.76; 95% CI, 0.41-1.40; P = .38). There was no difference in the risk for intracranial hemorrhage in EVT vs medical therapy (4.2% vs 4.0%; RR, 1.11; 95% CI, 0.71-1.72; P = .65). Limitations of the studies include trial protocol heterogeneity and bias originating from prematurely terminated trials.

Conclusions And Relevance: This meta-analysis of all evidence on EVT cited in the 2018 American Stroke Association/American Heart Association guidelines shows significant benefits for survival during the first 90 days after acute ischemic stroke compared with medical therapy alone.
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http://dx.doi.org/10.1001/jamaneurol.2019.0525DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6583698PMC
July 2019

One-year single-center experience with the Aperio thrombectomy device in large vessel occlusion in the anterior circulation: safety, efficacy, and clinical outcome.

Neurol Sci 2019 Jul 4;40(7):1443-1451. Epub 2019 Apr 4.

Medical Faculty, Department of Diagnostic and Interventional Radiology, University Duesseldorf, Moorenstr.5, 40225, Duesseldorf, Germany.

Background And Purpose: The Aperio thrombectomy device (Aperio) is a stent retriever designed to achieve rapid and substantial flow restoration in acute ischemic stroke due to large-vessel occlusions (LVOs). We evaluated the safety and efficacy of the Aperio device and compared it with published data of established stent retrievers.

Methods: We retrospectively analyzed institutional data of consecutive stroke procedures in patients with LVO in the anterior circulation that were treated between January 2017 and December 2017 with the Aperio. Reperfusion rate regarding to the extended thrombolysis in cerebral infarction scale (eTICI), procedural times, early clinical outcome, and complications were documented.

Results: Eighty-two patients were treated by using the Aperio in LVO in the anterior circulation. Median age was 77 (± 12) years (w = 59.8%). Median Baseline National Institutes of Health Stroke Scale (NIHSS) score was 14. Fifty-three (64.6%) patients received intravenous thrombolysis. Successful recanalization (eTICI≥2b) was achieved in 85.3%. Mean time from groin puncture to final recanalization was 52.3 ± 34.8 min. Embolization to new territories occurred in one case. Symptomatic intracranial hemorrhage within 24 h was observed in six patients (7.3%). Twenty-eight (41.2%) out of 68 patients available for assessment of functional outcome at 3 months achieved favorable outcome (mRS 0-2).

Conclusion: The Aperio stent retriever mechanical thrombectomy device demonstrated high rates of successful reperfusion and a good safety profile in patients with acute ischemic stroke due to LVO in the anterior circulation.
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http://dx.doi.org/10.1007/s10072-019-03861-zDOI Listing
July 2019

Improved Occlusion Rate of Intracranial Aneurysms Treated with the Derivo Embolization Device: One-Year Clinical and Angiographic Follow-Up in a Multicenter Study.

World Neurosurg 2019 Jun 23;126:e1503-e1509. Epub 2019 Mar 23.

Department of Neuroradiology, University Hospital of Cologne, Cologne, Germany.

Objective: The Derivo Embolization Device (DED) is a novel flow-diverter stent consisting of a flexible structure and a surface modification that aims to reduce thrombogenicity. Here, we report 1-year clinical and angiographic follow-up results of the second-generation DED for the treatment of intracranial aneurysms.

Methods: This is a retrospective study of 59 consecutive patients (mean age: 53 years, 81% women) treated with the DED for 59 aneurysms (mean size: 8.1 mm) between November 2015 and February 2018 at 3 German tertiary care centers. We evaluated the rate of ischemic stroke, functional outcome, and angiographic results during a 1-year follow-up period.

Results: Deployment of the DED was successful in all cases. Adverse events were observed in 6 procedures (10.2%), of which 2 were symptomatic (3.4%). No delayed ischemic or hemorrhagic events occurred during the 1-year follow-up and there were no deaths. Permanent morbidity due to in-stent thrombosis and consecutive ischemic stroke occurred in 1 patient (1.7%). Complete (O'Kelly-Marotta grading scale D) and favorable (O'Kelly-Marotta grading scale C+D) aneurysm occlusion was obtained in 70.5% (31/44) and 88.7% (39/44) at 6 months and 82.8% (24/29) and 100% (29/29) at 12 months, respectively.

Conclusions: Our results demonstrate that treatment of intracranial aneurysms with the DED is associated with low rates of ischemic complications and adequate aneurysm occlusion at 1-year follow-up.
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http://dx.doi.org/10.1016/j.wneu.2019.03.137DOI Listing
June 2019

A Retrospective Single-Center Case Series of Direct Aspiration Thrombectomy as First-Line Approach in Ischemic Stroke and Review of the Literature.

J Stroke Cerebrovasc Dis 2019 Mar 19;28(3):640-648. Epub 2018 Dec 19.

University Düsseldorf, Medical Faculty, Department of Diagnostic and Interventional Radiology, Moorenstr. 5, D-40225, Düsseldorf, Germany.

Introduction: The benefit of the direct aspiration thrombectomy (ADAPT) technique for the treatment of ischemic stroke due to large vessel occlusion are challenged after publishing of the ASTER trial that failed to show superiority of ADAPT compared to stent retriever. Aim of the present single-center study was a retrospective evaluation of the ADAPT technique comparing our results with literature.

Material/methods: We retrospectively analyzed institutional data of stroke procedures in patients with mainstem occlusion of the middle cerebral artery treated between November 2016 and December 2017 with an initial attempt of manual thrombaspiration. Reperfusion rate (thrombolysis in cerebral infarction), procedural times, early clinical outcome and complications were recorded.

Results: Forty patients were treated by using direct thrombaspiration in middle cerebral artery mainstem occlusion. Median age was 67.5 (±17.8) years (m = 27.5%). Median Baseline National Institutes of Health Stroke Scale score was 12 (IQR 7) preintervention and 3 (IQR 11) postintervention. Twenty-eight (70%) patients received intravenous thrombolysis. Successful recanalization (modified thrombolysis in cerebral infarction ≥ 2b) could be achieved in 85% with direct aspiration alone. Mean time from groin puncture to recanalization was 25.2 ± 14.3 minutes. Embolization to new territories occurred in 1 of 40 (2.5%) cases and symptomatic intracranial hemorrhage in 3 of 40 (7.5%). Nineteen of 40 (47.5%) patients achieved favorable outcome (modified Rankin scale 0-2) at discharge.

Conclusions: The ADAPT technique presented as a safe and efficient first-line recanalization strategy with good clinical outcome for treatment of acute ischemic stroke resulting from large vessel occlusions in this single-center study and review of the literature. However, the concept of ADAPT as an equivalent first-line approach to stent retriever thrombectomy has to be proven by future randomized studies.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2018.11.004DOI Listing
March 2019