Publications by authors named "Christian Herweh"

45 Publications

Predictors for Failure of Early Neurological Improvement After Successful Thrombectomy in the Anterior Circulation.

Stroke 2021 Feb 25:STROKEAHA120030519. Epub 2021 Feb 25.

Department of Neurology, Heidelberg University Hospital, Germany. (Y.M., S.S., P.A.R.).

Background And Purpose: Failure of early neurological improvement (fENI) despite successful mechanical thrombectomy in the anterior circulation is a clinically frequent occurrence. Purpose of this analysis was to define independent clinical, radiological, laboratory, or procedural predictors for fENI.

Methods: Retrospective single-center analysis of patients treated for acute ischemic stroke in the anterior circulation ensuing successful mechanical thrombectomy between January 2014 and April 2019. Patients were compared according to fENI (equal or higher National Institutes of Health Stroke Scale) and ENI (lower National Institutes of Health Stroke Scale at discharge). Thirty-eight variables were examined in multivariable analysis for association with fENI.

Results: Five hundred forty-nine out of 1146 patients experienced successful recanalization (modified Treatment in Cerebral Ischemia 2c-3). fENI occurred in 115/549 (20.9%) patients. Independent predictors of fENI were premorbid modified Rankin Scale (odds ratio [OR] per point [IC], 1.21 [1.00-1.46], 0.049), end-stage renal failure (OR [IC], 12.18 [2.01-73.63], 0.007), admission glucose (OR [IC], 1.018 [1.004-1.013] per mg/dL, 0.001), bridging IV lysis (OR [IC], 0.57 [0.35-0.93], : 0.024), time from groin puncture to final recanalization (OR [IC], 1.004 [1.001-1.007] per minute, 0.015), general anesthesia during mechanical thrombectomy (OR, 2.41 [1.43-4.08], <0.001), symptomatic intracranial hemorrhage (OR [CI], 6.81 [1.84-25.16], 0.004), and follow-up Alberta Stroke Program Early Computed Tomography Score (OR [IC], 0.76 [0.69-0.84] per point, <0.001). In a secondary analysis, involvement of the regions internal capsule, M4 and M5 (motor cortex) were further independent predictors for fENI. Patients with ENI were more likely to experience a good outcome (modified Rankin Scale on day 90, 0-2: n=229/435 [52.8%] versus n=13/115 [11.3%]; <0.001).

Conclusions: The extent of infarction and the involvement of motor cortex and internal capsule as well as higher premorbid modified Rankin Scale, end-stage renal failure, high glucose level on admission, absence of bridging IV lysis, general anesthesia, and a longer therapy interval are presumably independent predictors for fENI in patients with successful mechanical thrombectomy.
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http://dx.doi.org/10.1161/STROKEAHA.120.030519DOI Listing
February 2021

Diagnostic accuracy of automated occlusion detection in CT angiography using e-CTA.

Int J Stroke 2021 Feb 11:1747493021992592. Epub 2021 Feb 11.

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

Background And Aim: The aim of this study was to assess the diagnostic accuracy of e-CTA (product name) (Brainomix) in the automatic detection of large vessel occlusions in anterior circulation stroke.

Methods: Of 487 CT angiographies from patients with large vessel occlusions stroke, 327 were used to train the algorithm while the remaining cases together with 140 negative CT angiographies were used to validate its performance against ground truth. Of these 301 cases, 144 were randomly selected and used for an additional comparative analysis against 4 raters. Sensitivity, specificity, positive and negative predictive value (PPV and NPV), accuracy and level of agreement with ground truth (Cohen's Kappa) were determined and compared to the performance of a neuroradiologist, a radiology resident, and two neurology residents.

Results: e-CTA had a sensitivity and specificity of 0.84 (0.77-0.89) and 0.96 (0.91-0.98) respectively for the detection of any large vessel occlusions on the correct side in the whole validation cohort. This performance was identical in the comparative analysis subgroup and was within the range of physicians at different levels of expertise: 0.86-0.97 and 0.91-1.00, respectively. For the detection of proximal occlusions, it was 0.92 (0.84-0.96) and 0.98 (0.94-1.00) for the whole cohort and 0.93 (0.80-0.98) and 1.00 (0.95-1.00) for the comparative analysis, respectively for e-CTA. The range was 0.8-0.97 for sensitivity and 0.97-1.00 for specificity for the four physicians.

Conclusions: The performance of e-CTA in detecting any large vessel occlusions is comparable to less experienced physicians but is similar to experienced physicians for detecting proximal large vessel occlusions.
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http://dx.doi.org/10.1177/1747493021992592DOI Listing
February 2021

Multimodal Predictive Modeling of Endovascular Treatment Outcome for Acute Ischemic Stroke Using Machine-Learning.

Stroke 2020 12 12;51(12):3541-3551. Epub 2020 Oct 12.

Department of Neuroradiology (G.B., U.N., M.A.M., M.F., Ch.H., S.H., C.U., M.B., M.A.M., J.A.R.P., P.V.), Heidelberg University Hospital, Germany.

Background And Purpose: This study assessed the predictive performance and relative importance of clinical, multimodal imaging, and angiographic characteristics for predicting the clinical outcome of endovascular treatment for acute ischemic stroke.

Methods: A consecutive series of 246 patients with acute ischemic stroke and large vessel occlusion in the anterior circulation who underwent endovascular treatment between April 2014 and January 2018 was analyzed. Clinical, conventional imaging (electronic Alberta Stroke Program Early CT Score, acute ischemic volume, site of vessel occlusion, and collateral score), and advanced imaging characteristics (CT-perfusion with quantification of ischemic penumbra and infarct core volumes) before treatment as well as angiographic (interval groin puncture-recanalization, modified Thrombolysis in Cerebral Infarction score) and postinterventional clinical (National Institutes of Health Stroke Scale score after 24 hours) and imaging characteristics (electronic Alberta Stroke Program Early CT Score, final infarction volume after 18-36 hours) were assessed. The modified Rankin Scale (mRS) score at 90 days (mRS-90) was used to measure patient outcome (favorable outcome: mRS-90 ≤2 versus unfavorable outcome: mRS-90 >2). Machine-learning with gradient boosting classifiers was used to assess the performance and relative importance of the extracted characteristics for predicting mRS-90.

Results: Baseline clinical and conventional imaging characteristics predicted mRS-90 with an area under the receiver operating characteristics curve of 0.740 (95% CI, 0.733-0.747) and an accuracy of 0.711 (95% CI, 0.705-0.717). Advanced imaging with CT-perfusion did not improved the predictive performance (area under the receiver operating characteristics curve, 0.747 [95% CI, 0.740-0.755]; accuracy, 0.720 [95% CI, 0.714-0.727]; =0.150). Further inclusion of angiographic and postinterventional characteristics significantly improved the predictive performance (area under the receiver operating characteristics curve, 0.856 [95% CI, 0.850-0.861]; accuracy, 0.804 [95% CI, 0.799-0.810]; <0.001). The most important parameters for predicting mRS 90 were National Institutes of Health Stroke Scale score after 24 hours (importance =100%), premorbid mRS score (importance =44%) and final infarction volume on postinterventional CT after 18 to 36 hours (importance =32%).

Conclusions: Integrative assessment of clinical, multimodal imaging, and angiographic characteristics with machine-learning allowed to accurately predict the clinical outcome following endovascular treatment for acute ischemic stroke. Thereby, premorbid mRS was the most important clinical predictor for mRS-90, and the final infarction volume was the most important imaging predictor, while the extent of hemodynamic impairment on CT-perfusion before treatment had limited importance.
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http://dx.doi.org/10.1161/STROKEAHA.120.030287DOI Listing
December 2020

Direct Transfer to Angio-Suite Versus Computed Tomography-Transit in Patients Receiving Mechanical Thrombectomy: A Randomized Trial.

Stroke 2020 09 10;51(9):2630-2638. Epub 2020 Aug 10.

Department of Neuroradiology (J.A.R.P., C.H., C.U., M.B., M.A.M.), Heidelberg University Hospital, Germany.

Background And Purpose: To quantify workflow metrics in patients receiving stroke imaging (noncontrast-enhanced computed tomography [CT] and CT-angiography) in either a computed-tomography scanner suite (CT-Transit [CTT]) or an angio-suite (direct transfer to angio-suite-[DTAS]-using flat-panel CT) before undergoing mechanical thrombectomy.

Methods: Prospective, single-center investigator initiated randomized controlled trial in a comprehensive stroke center focusing on time from imaging to groin puncture (primary end point) and time from hospital admission to final angiographic result (secondary end point) in patients receiving mechanical thrombectomy for anterior circulation large vessel occlusion after randomization to the CTT or DTAS pathway.

Results: The trial was stopped early after the enrollment of n=60 patients (CTT: n=34/60 [56.7 %]; DTAS: n=26/60 [43.3%]) of n=110 planned patients because of a preplanned interim analysis. Time from imaging to groin puncture was shorter in DTAS-patients (in minutes, median [interquartile range]: CTT: 26 [23-32]; DTAS: 19 [15-23]; value: 0.001). Time from hospital admission to stroke imaging was shorter in patients randomized to DTAS (CTT: 12 (7-18); DTAS: 21 (15-25), value: 0.007). Time from hospital admission to final angiographic reperfusion was comparable between patient groups (CTT: 78 [58-92], DTAS: 80 [66-118]; value: 0.067).

Conclusions: This trial showed a reduction in time from imaging to groin-puncture when patients are transferred directly to the angiosuite for advanced stroke-imaging compared with imaging in a CT scanner suite. This time saving was outweighed by a longer admission to imaging time and could not translate into a shorter time to final angiographic reperfusion in this trial.
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http://dx.doi.org/10.1161/STROKEAHA.120.029905DOI Listing
September 2020

Distal arterial occlusions in patients with mild strokes - is endovascular therapy superior to thrombolysis alone?

J Stroke Cerebrovasc Dis 2020 Jul 13;29(7):104868. Epub 2020 May 13.

Department of Neurology, University Hospital Heidelberg, Germany. Electronic address:

Background And Purpose: Safety and efficacy of endovascular thrombectomy (EVT) in patients with mild stroke syndromes is unclear, especially in distal vessel occlusions.

Methods: We analysed in our stroke database (HeiReKa) between 2002 and April 2019 safety and efficacy of EVT compared to intravenous thrombolysis (IVT) in patients with occlusions distal to the M1 segment of the middle cerebral artery and the top of the basilar artery who presented with a National Institute of Health Stroke Scale (NIHSS) below 6. Excellent (good) outcome was defined as modified rankin scale (mRS) 0-1 (0-2) or return to baseline mRS (good) after 3 months. Safety endpoints were mortality after 3 months and intracranial hemorrhage according to the Heidelberg Bleeding Classification (HBC).

Results: Of 4167 patients 94 met the inclusion criteria. Sixty-four patients were allocated to the IVT group and 30 to the EVT group of which 15 also received IVT; three patients (4.6%) in the IVT group received rescue EVT. Baseline characteristics did not differ but more M2 occlusions were found in the EVT group (93.3% vs. 64.1%, p = 0.02). Intracranial bleeding occurred more often in EVT patients (HBC class 2: 13.3% vs. 1.6%, p = 0.01). Excellent and good outcome were not significantly different (75% vs. 70%, p = 0.65 and 87.5% vs. 73.3%, p = 0.14). Mortality was significantly lower in IVT patients (1.6% vs. 13.3%, p = 0.04).

Conclusion: Rates of excellent and good outcome after IVT or EVT were almost similar, but safety parameters were increased after EVT. EVT may be considered in selected patients after careful risk/benefit analysis.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2020.104868DOI Listing
July 2020

Impact of slice thickness on clinical utility of automated Alberta Stroke Program Early Computed Tomography Scores.

Eur Radiol 2020 Jun 21;30(6):3137-3145. Epub 2020 Feb 21.

Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.

Objectives: The clinical utility of electronically derived ASPECTS (e-ASPECTS) to quantify signs of acute ischemic infarction could be demonstrated in multiple studies. Here, we aim to clinically validate the impact of CT slice thickness (ST) on the performance of e-ASPECTS software.

Methods: A consecutive series of n = 258 patients (06/2016 and 01/2019) with middle cerebral artery occlusion and subsequent treatment with mechanical thrombectomy was analyzed. The e-ASPECTS score and acute infarct volumes were calculated from baseline non-contrast CT with a software using 1-mm slice thickness (ST) (defined as ground truth) and axial reconstructions with 2-10-mm ST and correlated with baseline stroke severity (NIHSS) as well as clinical outcome (mRS) using logistic regressions.

Results: In comparison with the ground truth, significant differences were seen in e-ASPECTS scores with ST > 6 mm (p ≤ 0.031) and infarct volumes with ST > 4 mm (p ≤ 0.001). There was a significant correlation of lower e-ASPECTS and higher acute infarct volumes with increasing baseline NIHSS values for all ST (p ≤ 0.001, respectively), with values derived from 1 mm yielding the highest correlation for both parameters (rho, - 0.38 and 0.31, respectively). Similarly, lower e-ASPECTS and higher acute infarct volumes from all ST were significantly associated with poor outcome after 90 days (p ≤ 0.05, respectively) with values derived from 1-mm ST yielding the highest effects for both parameters (OR, 0.69 [95% CI 0.50-0.88] and 1.27 [95% CI 1.10-1.50], respectively).

Conclusions: The e-ASPECTS software generates robust values for e-ASPECTS and acute infarct volumes when using ST ≤ 4 mm with ST = 1 mm yielding the best performance for predicting baseline stroke severity and clinical outcome after 90 days.

Key Points: • Clinical utility of automatically derived ASPECTS from computed tomography scans was shown in patients with acute ischemic stroke and treatment with mechanical thrombectomy. • Thin slices (= 1 mm) had the highest clinical utility in comparison with thicker slices (2-10 mm) by having the strongest correlation with baseline stroke severity and independent effects on clinical outcome after 90 days. • Automatically calculated acute infarct volumes possess clinical utility beyond ASPECTS and should be considered in future studies.
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http://dx.doi.org/10.1007/s00330-019-06616-8DOI Listing
June 2020

Cerebrospinal fluid proteomic profiling in nusinersen-treated patients with spinal muscular atrophy.

J Neurochem 2020 06 19;153(5):650-661. Epub 2020 Feb 19.

Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany.

Promising results from recent clinical trials on the approved antisense oligonucleotide nusinersen in pediatric patients with 5q-linked spinal muscular atrophy (SMA) still have to be confirmed in adult patients but are hindered by a lack of sensitive biomarkers that indicate an early therapeutic response. Changes in the overall neurochemical composition of cerebrospinal fluid (CSF) under therapy may yield additive diagnostic and predictive information. With this prospective proof-of-concept and feasibility study, we evaluated non-targeted CSF proteomic profiles by mass spectrometry along with basic CSF parameters of 10 adult patients with SMA types 2 or 3 before and after 10 months of nusinersen therapy, in comparison with 10 age- and gender-matched controls. These data were analyzed by bioinformatics and correlated with clinical outcomes assessed by the Hammersmith Functional Rating Scale Expanded (HFMSE). CSF proteomic profiles of SMA patients differed from controls. Two groups of SMA patients were identified based on unsupervised clustering. These groups differed in age and expression of proteins related to neurodegeneration and neuroregeneration. Intraindividual CSF differences in response to nusinersen treatment varied between patients who clinically improved and those who did not. Data are available via ProteomeXchange with identifier PXD016757. Comparative CSF proteomic analysis in adult SMA patients before and after treatment with nusinersen-identified subgroups and treatment-related changes and may therefore be suitable for diagnostic and predictive analyses.
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http://dx.doi.org/10.1111/jnc.14953DOI Listing
June 2020

e-ASPECTS derived acute ischemic volumes on non-contrast-enhanced computed tomography images.

Int J Stroke 2020 Dec 30;15(9):995-1001. Epub 2019 Sep 30.

Brainomix Ltd, Oxford, UK.

Background And Purpose: Validation of automatically derived acute ischemic volumes (AAIV) from e-ASPECTS on non-contrast computed tomography (NCCT).

Materials And Methods: Data from three studies were reanalyzed with e-ASPECTS Version 7. AAIV was calculated in milliliters (ml) in all scored ASPECTS regions of the hemisphere detected by e-ASPECTS. The National Institute of Health Stroke Scale (NIHSS) determined stroke severity at baseline and clinical outcome was measured with the modified Rankin Scale (mRS) between 45 and 120 days. Spearman ranked correlation coefficients (R) of AAIV and e-ASPECTS scores with NIHSS and mRS as well as Pearson correlation of AAIV with diffusion-weighted imaging and CT perfusion-estimated ischemic "core" volumes were calculated. Multivariate regression analysis (odds ratio, OR with 95% confidence intervals, CI) and Bland-Altman plots were performed.

Results: We included 388 patients. Mean AAIV was 11.6 ± 18.9 ml and e-ASPECTS was 9 (8-10: median and interquartile range). AAIV, respectively e-ASPECTS correlated with NIHSS at baseline (R = 0.35,  < 0.001; R = -0.36,  < 0.001) and follow-up mRS (R = 0.29,  < 0.001; R = -0.3,  < 0.001). In subsets of patients, AAIV correlated strongly with diffusion-weighted imaging ( = 37, R = 0.68,  < 0.001) and computed tomography perfusion-derived ischemic "core" ( = 41, R = 0.76,  < 0.001) lesion volume and Bland-Altman plots showed a bias close to zero (-2.65 ml for diffusion-weighted imaging and 0.45 ml forcomputed tomography perfusion "core"). Within the whole cohort, the AAIV (OR 0.98 per ml, 95% CI 0.96-0.99) and e-ASPECTS scores (OR 1.3, 95%CI 1.07-1.57) were independent predictors of good outcome.

Conclusion: AAIV on NCCT correlated moderately with clinical severity but strongly with diffusion-weighted imaging lesion and computed tomography perfusion ischemic "core" volumes and predicted clinical outcome.
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http://dx.doi.org/10.1177/1747493019879661DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7739116PMC
December 2020

Computer-aided imaging analysis in acute ischemic stroke - background and clinical applications.

Neurol Res Pract 2019 15;1:23. Epub 2019 Aug 15.

Department of Neurology, University Hospital Heidelberg, INF 400, 69120 Heidelberg, Germany.

Tools for medical image analysis have been developed to reduce the time needed to detect abnormalities and to provide more accurate results. Particularly, tools based on artificial intelligence and machine learning techniques have led to significant improvements in medical imaging interpretation in the last decade. Automatic evaluation of acute ischemic stroke in medical imaging is one of the fields that witnessed a major development. Commercially available products so far aim to identify (and quantify) the ischemic core, the ischemic penumbra, the site of arterial occlusion and the collateral flow but they are not (yet) intended as standalone diagnostic tools. Their use can be complementary; they are intended to support physicians' interpretation of medical images and hence standardise selection of patients for acute treatment. This review provides an introduction into the field of computer-aided diagnosis and focuses on the automatic analysis of non-contrast-enhanced computed tomography, computed tomography angiography and perfusion imaging. Future studies are necessary that allow the evaluation and comparison of different imaging strategies and post-processing algorithms during the diagnosis process in patients with suspected acute ischemic stroke; which may further facilitate the standardisation of treatment and stroke management.
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http://dx.doi.org/10.1186/s42466-019-0028-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7650084PMC
August 2019

Electronic Alberta Stroke Program Early CT score change and functional outcome in a drip-and-ship stroke service.

J Neurointerv Surg 2020 Mar 27;12(3):252-255. Epub 2019 Jul 27.

Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany.

Background: Debate continues as to whether patients with acute ischemic stroke with (suspected) large vessel occlusion benefit from direct referral versus secondary transportation.

Aims: To analyze the change in early infarct signs, collaterals, and acute ischemia volume and their association with transfer time and functional outcome.

Methods: We retrospectively analyzed consecutive transfers between 2013 and 2016 for patients with anterior circulation stroke transported from referring hospitals to our center as potential candidates for thrombectomy. Alberta Stroke Programme Early CT Scores (ASPECTS) were automatically calculated on external and in-house CT using the Brainomix e-ASPECTS software, and collaterals were assessed using the e-CTA tool. Functional status after stroke using the modified Rankin scale (mRS) was obtained.

Results: 102 patients with CT scans both at the referring hospital and our center were identified. During patient transfer, e-ASPECTS declined by a median of 1 point (0-2). Functional outcome correlated with the change in e-ASPECTS (decline, n=54) (Spearman =0.322, 95% CI 0.131 to 0.482, p=0.001). The median image-to-image time was 149 min (IQR 113-190), but did not correlate with change in e-ASPECTS (p=0.754) and mRS score at 3 months (p=0.25). Preserved good collateral status assessed at the comprehensive stroke center was associated with better functional outcome ( =-0.271, 95% CI -0.485 to -0.037, p=0.02).

Conclusions: Patient transfer in a drip-and-ship network was associated with declines in e-ASPECTS associated with worse functional outcome. Image-to-image time did not influence this association, but worsening collateral status did.
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http://dx.doi.org/10.1136/neurintsurg-2019-015134DOI Listing
March 2020

A search for cortical correlates of trait impulsivity in Parkinson´s disease.

Behav Brain Res 2019 09 13;369:111911. Epub 2019 Apr 13.

Center for Psychosocial Medicine, Department of General Psychiatry, University of Heidelberg, Germany.

Background: Impulsivity is an enduring personality trait that is highly relevant for the development of neuropsychiatric disorders. Although impulse control disorders (ICD) are well-characterized non-motor features in Parkinson's disease (PD), mainly related to medication, little is known about neural correlates reflecting trait aspects of impulsivity in PD patients. Here, we address the question whether motor, attentional and non-planning components, measured by the Barratt Impulsiveness Scale (BIS-11), are distinctly related to cortical thickness and cortical folding abnormalities in PD when compared to age-matched healthy controls (HC).

Method: We investigated cortical thickness (CT) and complexity of cortical folding (CCF) in 22 PD patients with moderately advanced disease stages without ICD and 18 HC using high-resolution structural magnetic resonance imaging (MRI) data. Surface-based data analysis was driven by CAT12 toolbox.

Results: PD patients showed widespread CT loss in frontal, cingulate, temporo-parietal and occipital regions (FDR corrected at p < 0.05 using threshold-free cluster enhancement). Significant differences in CCF between groups were not found. Using a multiple regression model, CT in inferior and superior frontal, anterior cingulate and precentral regions significantly predicted BIS attentional subscores (p = 0.041).

Conclusion: These data suggest a specific cortical trajectory associated with impulsivity in moderately advanced staged PD patients. The attentional dimension of trait impulsivity appears to be specifically related to CT, in contrast to alterations of early neurodevelopmental markers, i. e. CCF. Our results shed light on structural correlates of trait impulsivity in PD patients and establish a baseline for future research into neural risk factors potentially predisposing to ICD development.
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http://dx.doi.org/10.1016/j.bbr.2019.111911DOI Listing
September 2019

Simplified selection criteria for patients with longer or unknown time to treatment predict good outcome after mechanical thrombectomy.

J Neurointerv Surg 2019 Jun 27;11(6):559-562. Epub 2018 Oct 27.

Department of Neurology, University of Heidelberg, Heidelberg, Germany.

Objective: To identify simplified selection criteria for mechanical thrombectomy (MT) in longer and unknown time windows.

Methods: Patients with large vessel occlusion (LVO) in the anterior circulation who underwent MT between January 2014 and November 2017 were identified from the local registry. Patients were selected for analysis if they met the current guideline recommendation for MT treatment except for time window (HERMES-like) and were divided according to time they were last seen well (LSW): LSW <6 hours or LSW >6 hours before MT. The primary endpoint, good outcome, was modified Rankin scale score 0-2 on day 90. Safety outcomes were mortality on day 90 and symptomatic intracranial hemorrhage (sICH). Univariate and multivariate analysis were performed for good outcome in HERMES-like patients.

Results: In total, 752 patients were identified and 390 patients (51.9%) fulfilled the HERMES-like criteria. Despite differences in baseline parameters, more diffusion-weighted imaging (DWI) (43.9% vs 11.3%, p<0.001) and fewer cases of thrombolysis (32.7% vs 77%, p<0.001), patients LSW >6 hours (n=107) did not differ in the primary and secondary endpoints: good outcome (44.9% vs 44.9%, p=1.0), mortality (14% vs 15.2%, p=0.87), and sICH (5.6% vs 6%, p=1.0). After multivariate regression analysis, independent predictors of good outcome remained: age, OR=0.96 (95% CI 0.95 to 0.98); National Institutes of Health Stroke Scale score, OR=0.92 (95% CI 0.89 to 0.96); Alberta Stroke Programme Early CT Score (ASPECTS), OR=1.26 (95% CI 1.06 to 1.49); general anesthesia, OR=0.2 (95% CI 0.04 to 0.99), and successful recanalization, OR=12 (95% CI 4.7 to 30.5); but not treatment time and DWI or CT perfusion at baseline.

Conclusion: Patients with proven LVO in unknown and longer time windows may be selected for MT based on ASPECTS and clinical criteria.
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http://dx.doi.org/10.1136/neurintsurg-2018-014347DOI Listing
June 2019

CT Reconstruction Levels Affect Automated and Reader-Based ASPECTS Ratings in Acute Ischemic Stroke.

J Neuroimaging 2019 01 19;29(1):62-64. Epub 2018 Sep 19.

Department of Neuroradiology at Heidelberg University Hospital, Heidelberg, Germany.

Background And Purpose: We investigated whether automated and reader-based ASPECTS in acute stroke patients are affected by different CT image reconstruction algorithms.

Methods: ASPECTS were assessed by commercial software and four independent blinded readers (two residents and two consultants) from different CT reconstructions (filtered back projection and two different iterative reconstruction [IR] levels) in 43 acute stroke patients with proximal middle cerebral artery occlusion. Ground truth was provided by an expert with unrestricted data access.

Results: The residents showed significant variations between IR levels and had a significantly lower internal consistency across different reconstructions compared to the software, which performed similarly to the consultants. The consultant as well as the software also showed different deviations from ground truth with different IR levels, which were least at IR strength level 2.

Conclusions: CT image postprocessing affects either automated or human ASPECTS in acute stroke patients. This effect was most pronounced in the less experienced readers, while the software had the most robust performance.
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http://dx.doi.org/10.1111/jon.12562DOI Listing
January 2019

Interdisciplinary treatment algorithm for facial high-flow arteriovenous malformations, and review of the literature.

J Craniomaxillofac Surg 2018 May 9;46(5):765-772. Epub 2018 Mar 9.

Department of Oral and Maxillofacial Surgery, Heidelberg University Hospital, Heidelberg, Germany.

Introduction: High-flow arteriovenous malformations (HF-AVMs) are congenital vascular malformations. Typical localizations include the face, oral cavity, and extremities. Due to the high recurrence rate of AVM after incomplete resection or embolization, a combination of both therapeutic modalities has become the preferred choice of treatment. Therefore, we have developed an interdisciplinary therapeutic treatment algorithm for facial HF-AVM and performed a systematic review of the literature.

Patients And Methods: In a retrospective analysis, all patients who were treated using the interdisciplinary therapeutic treatment algorithm for facial HF-AVM between 10/2010 and 09/2014 were included in the study. Small HF-AVMs (n = 2) without prior therapy and with clearly detectable arterial blood supply were treated by surgical monotherapy. Larger, previously unsuccessfully treated HF-AVMs and lesions with complex arterial blood supply were treated using a combined therapy (n = 6). Combined therapy consisted of a preoperative embolization and a subsequent surgical resection 1-2 days later. If an extensive surgical reconstruction became necessary due to the size of the malformation, or the risk of recurrence was high due to the complex vascular anatomical situation, a second postoperative angiogram was performed to safely exclude a residual nidus, using a 'second look' prior to definitive wound closure (n = 3). HF-AVMs that did not allow for curative therapeutic intervention due to their size and localization were treated by interventional monotherapy (n = 1). Patients with suspicion of a primarily hormone-dependent growth during pregnancy were closely followed up clinically, following a 'wait and see' strategy (n = 1). In addition, a systematic literature review was performed to analyze treatment outcomes and current standards.

Results: 13 patients with a mean age of 39 years were included in the analysis. Patients were followed up for a mean of 26.8 months (range 12-60 months). Combined treatment (n = 9) was free of recurrence in all cases (100%) after a mean follow up of 30.3 months (range 12-60 months). Surgical monotherapy (n = 2) was also successful in both cases. Non-curative, interventional monotherapy lead to significant decrease in symptoms and did not have to be repeated. A postpartum decrease of the tumor could be observed in the 'wait and see' group. However, at the end of the observational period, a hormone-independent growth occurred. Results were supported by findings of the review.

Conclusion: The treatment of HF-AVMs of the head and neck remains challenging due to high recurrence rates. In our cohort, following the Heidelberg treatment algorithm both surgical monotherapy and combined surgical and interventional therapy had very high success rates. For non-curative, symptomatic therapy, interventional treatment should be discussed in terms of the risk of growth induction of HF-AVMs. Findings from the literature concerning therapeutic strategies and success rates are in line with the developed Heidelberg treatment algorithm. However, a larger sample of patients will be necessary to prove the validity of this algorithm.
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http://dx.doi.org/10.1016/j.jcms.2018.03.002DOI Listing
May 2018

Clinical results of a new concept of neurothrombectomy coverage at a remote hospital-"drive the doctor".

Int J Stroke 2018 10 13;13(7):696-699. Epub 2018 Mar 13.

1 Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany.

Background Many tertiary care hospitals cannot provide a continuous thrombectomy service due to the lack of a neurointerventionalist. Aims In this study, we present procedural and clinical results of a new concept in which neuroradiologists of a university hospital provide neurointerventional stroke service to a remote hospital ("drive the doctor"). Methods All consecutive patients with acute ischemic stroke due to large vessel occlusion of the anterior circulation treated with mechanical thrombectomy after hours at a remote hospital (distance of about 100 km) between 2012 and 2016 were analyzed retrospectively. These patients were compared to a group of patients referred to the above mentioned university hospital for MT over a comparable distance ("drip and ship"). Results A total of 60 patients were treated by "drive the doctor" and 66 patients were treated by "drip and ship." Time from onset to imaging was similar in both groups (77 vs. 70 min, P = 0.6847). However, time from imaging to groin puncture was significantly lower in the "drive the doctor" model (112 vs. 232 min, P < 0.0001). Nonetheless, recanalization rate and clinical outcome were similar in both cohorts. Conclusions "Drive the doctor" is a feasible concept of neurothrombectomy coverage at remote hospitals. The presented data suggest that "drive the doctor" is not inferior compared to established stroke concepts such as "drip and ship" regarding recanalization rate and outcome. However, larger and prospective studies are necessary to confirm this finding.
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http://dx.doi.org/10.1177/1747493018765267DOI Listing
October 2018

Climatic and Seasonal Circumstances of Hypertensive Intracerebral Hemorrhage in a Worldwide Cohort.

Stroke 2017 12 3;48(12):3384-3386. Epub 2017 Nov 3.

From the Departments of Neuroradiology (C.H., S.N., M.B.), Medical Biometry and Informatics (L.U.), and Neurology (M.S., T.S.), University of Heidelberg, Germany; Department of Neurology, Frankfurt Hoechst Hospital, Frankfurt am Main, Germany (T.S.); and Department of Neurology, St. John's Hospital Vienna, Austria (M.S.).

Background And Purpose: Numerous studies have investigated the influence of meteorologic factors and seasons on the incidence of spontaneous intracerebral hemorrhage (ICH) with ambiguous results. In the present study, data from a large, international multicenter trial in patients with ICH were used to identify seasonal and meteorologic determinants for hypertensive-ICH with greater applicability.

Methods: Patients were grouped according to the presumptive ICH cause, that is, hypertensive when located in the basal ganglia brain stem as well as cerebellum and nonhypertensive when located lobar. Both groups were compared with regard to air temperature and air pressure and their occurrence during the year. A regression analysis was performed to identify independent predictors of hypertensive-ICH.

Results: Only hypertensive-ICH showed a seasonal pattern and occurred with higher air pressure values and at younger age. Independent predictors of hypertensive-ICH were increased air pressure on the actual day of the event and younger age as well as higher temperature.

Conclusions: In the present study with an international cohort, besides age air pressure, more than temperature, had an influence on the occurrence of hypertensive-ICH, only.
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http://dx.doi.org/10.1161/STROKEAHA.117.018779DOI Listing
December 2017

Classification of Bleeding Events: Comparison of ECASS III (European Cooperative Acute Stroke Study) and the New Heidelberg Bleeding Classification.

Stroke 2017 07 28;48(7):1983-1985. Epub 2017 Apr 28.

From the Department of Neuroradiology, Heidelberg University Hospital, Germany.

Background And Purpose: Intracranial hemorrhage (ICH) after acute ischemic stroke treatments represents a feared complication with possible prognostic implications. In recent years, ICHs were commonly classified according to the ECASS (European Cooperative Acute Stroke Study). To improve the clinical applicability and relevance, the new Heidelberg Bleeding Classification (HBC) has been proposed in 2015. Here, we compared the ECASS and HBC classification with regard to observed events and prognostic relevance.

Methods: A retrospective analysis of a prospectively compiled database of patients with acute ischemic stroke in the anterior circulation who received mechanical thrombectomy between February 2011 and March 2016 was performed. Presence of ICH after mechanical thrombectomy was evaluated on postinterventional computed tomographic imaging. ICHs were specified according to both ECASS III and HBC classification and analyzed with regard to their symptoms and outcome.

Results: ICHs were observed in 156 of 768 patients (20.3%). Using ECASS III classification, 101 ICHs could be unambiguously assigned, of which 28 (27.7%; 3.6% of all treated patients) were symptomatic ICHs. Using HBC, 55 additional ICHs could be categorized. Of these total 156 ICHs, 29 (18.6%; 3.8% of all treated patients) were classified as symptomatic according to HBC.

Conclusions: Classification of ICH by ECASS III and HBC criteria show distinct differences. These differences warrant special attention during interpretation and comparison of scientific publications.
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http://dx.doi.org/10.1161/STROKEAHA.117.016735DOI Listing
July 2017

The Association Between Leukoaraiosis and Poor Outcome in Intracerebral Hemorrhage Is Not Mediated by Hematoma Growth.

J Stroke Cerebrovasc Dis 2017 Jun 23;26(6):1328-1333. Epub 2017 Feb 23.

Department of Neurocritical Care, Sigmund Freud Privatuniversität, Vienna, Austria; Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany.

Background: The significance of white matter lesions (WMLs) in intracerebral hemorrhage (ICH) remains unclear. We investigated the effects of WML on initial hematoma volume, hematoma growth, intraventricular extension, and clinical outcome in patients with spontaneous ICH.

Methods: Computed tomography scans of 262 patients included in a placebo arm of a prospective, multicenter trial were used for a semi-quantitative analysis of white matter changes. A logistic regression analysis was used to explore the effects on hematoma volume, volume changes, intraventricular hemorrhage, and clinical outcome after 90 days.

Results: The degree of WML was not associated with initial hematoma volume, absolute and relative hematoma growth, hematoma growth >33% or >6 mL, or with intraventricular extension. WML significantly increased the odds for poor outcome after 90 days (adjusted OR 1.4, 95% CI 1.1-1.8, P = .02).

Conclusions: WMLs were not associated with initial hematoma volume, hematoma growth, or intraventricular extension. WMLs were associated with poor outcome independently.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2017.02.003DOI Listing
June 2017

Influence of a combined CT/C-arm system on periprocedural workflow and procedure times in mechanical thrombectomy.

Eur Radiol 2017 Sep 17;27(9):3966-3972. Epub 2017 Feb 17.

Department of Neuroradiology, University of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.

Objective: To achieve the fastest possible workflow in ischaemic stroke, we developed a CT/C-arm system, which allows imaging and endovascular treatment on the same patient table.

Methods: This prospective, monocentric trial was conducted between October 2014 and August 2016. Patients received stroke imaging and mechanical thrombectomy under general anaesthesia (GA) or conscious sedation (CS) using our combined setup comprising a CT-scanner and a mobile C-arm X-ray device. Primary endpoint was time between stroke imaging and groin puncture. We compared periprocedural workflow and procedure times with the literature and a matched patient cohort treated with a biplane angiographic system before installation of the CT/C-arm system.

Results: In 50 patients with acute ischaemic stroke due to large-vessel occlusion in the anterior circulation, comparable recanalization rates were achieved by using the CT/C-arm setup (TICI2b-3:CT/C-arm-GA: 85.7%; CT/C-arm-CS: 90.9%; Angiosuite: 78.6%; p = 0.269) without increasing periprocedural complications. Elimination of patient transport resulted in a significant reduction of the time between stroke imaging and groin puncture: median, min (IQR): CT/C-arm-GA: 43 (35-52); CT/C-arm-CS: 39 (28-49); Angiosuite: 64 (48-74); p < 0.0001.

Conclusion: The combined CT/C-arm system allows comparable recanalization rates as a biplane angiographic system and accelerates the start of the endovascular stroke treatment.

Key Points: • The CT/C-arm setup reduces median time from stroke imaging to groin puncture. • Mechanical thrombectomy using a C-arm device is feasible without increasing peri-interventional complications. • The CT/C-arm setup might be a valuable fallback solution for emergency procedures. • The CT/C-arm setup allows immediate control CT images during and after treatment.
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http://dx.doi.org/10.1007/s00330-017-4762-7DOI Listing
September 2017

Impact of thrombus length on recanalization and clinical outcome following mechanical thrombectomy in acute ischemic stroke.

J Neurointerv Surg 2017 Oct 15;9(10):937-939. Epub 2016 Sep 15.

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

Purpose: The impact of thrombus length on recanalization in IV thrombolysis for acute intracranial artery occlusion has been well studied. Here we analyzed the influence of thrombus length on the number of thrombectomy maneuvers needed for recanalization, intraprocedural complications, recanalization success, and clinical outcome after mechanical thrombectomy.

Methods: We retrospectively analyzed angiographic and clinical data from 72 consecutive patients with acute occlusion of the M1 segment of the middle cerebral artery who were treated with mechanical thrombectomy using stent retrievers. Successful recanalization was defined as a Thrombolysis in Cerebral Infarction score of 2b or 3. Good neurological outcome was defined as a modified Rankin Scale score of ≤2 at 90 days after stroke onset.

Results: Mean thrombus length was 13.4±5.2 mm. Univariate binary logistic regression did not show an association of thrombus length with the probability of a good clinical outcome (OR 0.95, 95% CI 0.84 to 1.03, p=0.176) or successful recanalization (OR 0.92, 95% CI 0.81 to 1.05, p=0.225). There was no significant correlation between thrombus length and the number of thrombectomy maneuvers needed for recanalization (p=0.112). Furthermore, thrombus length was not correlated with the probability of intraprocedural complications (p=0.813), including embolization in a new territory (n=3).

Conclusions: In this study, thrombus length had no relevant impact on recanalization, neurological outcome, or intraprocedural complications following mechanical thrombectomy of middle cerebral artery occlusions. Therefore, mechanical thrombectomy with stent retrievers can be attempted with large clots.
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http://dx.doi.org/10.1136/neurintsurg-2016-012591DOI Listing
October 2017

One-pass endovascular treatment of intracranial atherosclerotic stenosis with a novel PTA balloon and self-expanding microstent.

Neuroradiology 2016 Sep 16;58(9):893-9. Epub 2016 Jun 16.

Department of Neuroradiology, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany.

Introduction: We present a novel endovascular technique to treat intracranial atherosclerotic stenosis (ICS) with the specific potential to reduce the procedure-related complications which so far limited safety and efficacy of endovascular ICS intervention.

Methods: Six consecutive patients were included in this study with the following criteria of inclusion: (1) failure of dual antiplatelet therapy defined as recurrent TIA or ischemic stroke, (2) presence of ICS of ≥70 %, and (3) endovascular accessibility of the target lesion as judged by CTA or MRA. Technical feasibility, safety, and efficacy were observed for the first-ballon-then-stent (FBTS) technique using the percutaneous transluminal angioplasty (PTA) balloon microcatheter over which a self-expandable microstent can be directly delivered obviating the need to exchange microcatheters.

Results: FBTS was performed in six patients (four female, median age 69, median stenosis 82.5 %) all refractory to best medical treatment: three V4, two M1, and one supraclinoid ICA stenosis. PTA and stent deployment were technically feasible in all patients and immediately effective with a median postprocedural stenosis grade of 10 %. Angiographic and clinical safety measures were met with no occult or clinically evident hemorrhage or ischemic complications (four patients discharged without alteration in mRS, two patients with significant clinical improvement). No occurrence of TIA, stroke, or death was observed during follow-up.

Conclusion: The FBTS method in this series appeared to be safe and effective for the endovascular treatment of ICS. It bears the specific potential to reduce wire perforations, which so far have been linked to major procedure-related adverse events of endovascular ICS treatment.
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http://dx.doi.org/10.1007/s00234-016-1716-8DOI Listing
September 2016

Reduced white matter integrity in amateur boxers.

Neuroradiology 2016 Sep 26;58(9):911-20. Epub 2016 May 26.

Department of Neuroradiology, University of Heidelberg Medical School, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.

Introduction: Professional boxing can lead to chronic traumatic encephalopathy, a variant of traumatic brain injury (TBI). Its occurrence in amateur boxers is a matter of debate since amateur boxing is considered to be less harmful due to more strict regulations. However, several studies using different methodological approaches have revealed subtle signs of TBI even in amateurs. Diffusion tensor imaging (DTI) is sensitive to microscopic white matter changes and has been proven useful in TBI when routine MR imaging often is unrevealing.

Methods: DTI, with tract-based spatial statistics (TBSS) together with neuropsychological examination of executive functions and memory, was used to investigate a collective of 31 male amateur boxers and 31 age-matched controls as well as a subgroup of 19 individuals, respectively, who were additionally matched for intellectual performance (IQ).

Results: All participants had normal findings in neurological examination and conventional MR. Amateur boxers did not show deficits in neuropsychological tests when their IQ was taken into account. Fractional anisotropy was significantly reduced, while diffusivity measures were increased along central white matter tracts in the boxers group. These changes were in part associated with the number of fights.

Conclusions: TBSS revealed widespread white matter disturbance partially related to the individual fighting history in amateur boxers. These findings closely resemble those in patients with accidental TBI and indicate similar histological changes in amateur boxers.
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http://dx.doi.org/10.1007/s00234-016-1705-yDOI Listing
September 2016

Combined proximal balloon occlusion and distal aspiration: a new approach to prevent distal embolization during neurothrombectomy.

J Neurointerv Surg 2017 Apr 7;9(4):346-351. Epub 2016 Apr 7.

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

Background And Purpose: Embolization of thrombus fragments in a new vascular territory is a potential adverse event in neurothrombectomy. This study was performed to evaluate the safety and feasibility of a novel approach combining proximal balloon occlusion and distal aspiration to prevent distal thrombembolic complications.

Methods: Patients with ischemic stroke meeting the following inclusion criteria were eligible: occlusion in the anterior circulation, neurothrombectomy using a balloon catheter for proximal flow arrest, and an intermediate catheter for distal aspiration. Pre- and post-interventional Thrombolysis In Cerebral Infarction (TICI) scores were assessed. Clinical presentation at admission and discharge and after 3 months was also evaluated and complications (particularly new thrombembolic events) were recorded.

Results: We retrospectively identified 31 patients from our prospectively collected stroke database who met the inclusion criteria. In all patients the initial TICI was 0. A TICI score of ≥2b was achieved in 96.8%. No new thrombembolic complications occurred. The median NIH Stroke Scale score was 19 at admission and 4.5 at discharge. After 3 months, 51.6% of the patients had a favorable clinical outcome (modified Rankin Scale score 0-2) and 19.3% had died.

Conclusions: A combination of proximal internal carotid artery occlusion using a balloon catheter and distal aspiration through an intermediate catheter represents a safe and efficient adjunct to mechanical thrombectomy with stent retrievers. In our patient cohort, no new thrombembolic complications were detected.
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http://dx.doi.org/10.1136/neurintsurg-2015-012208DOI Listing
April 2017

Performance of e-ASPECTS software in comparison to that of stroke physicians on assessing CT scans of acute ischemic stroke patients.

Int J Stroke 2016 06 15;11(4):438-45. Epub 2016 Feb 15.

Department of Neurology, University Hospital Heidelberg, Germany

Background: The Alberta Stroke Program Early CT score (ASPECTS) is an established 10-point quantitative topographic computed tomography scan score to assess early ischemic changes. We compared the performance of the e-ASPECTS software with those of stroke physicians at different professional levels.

Methods: The baseline computed tomography scans of acute stroke patients, in whom computed tomography and diffusion-weighted imaging scans were obtained less than two hours apart, were retrospectively scored by e-ASPECTS as well as by three stroke experts and three neurology trainees blinded to any clinical information. The ground truth was defined as the ASPECTS on diffusion-weighted imaging scored by another two non-blinded independent experts on consensus basis. Sensitivity and specificity in an ASPECTS region-based and an ASPECTS score-based analysis as well as receiver-operating characteristic curves, Bland-Altman plots with mean score error, and Matthews correlation coefficients were calculated. Comparisons were made between the human scorers and e-ASPECTS with diffusion-weighted imaging being the ground truth. Two methods for clustered data were used to estimate sensitivity and specificity in the region-based analysis.

Results: In total, 34 patients were included and 680 (34 × 20) ASPECTS regions were scored. Mean time from onset to computed tomography was 172 ± 135 min and mean time difference between computed tomographyand magnetic resonance imaging was 41 ± 31 min. The region-based sensitivity (46.46% [CI: 30.8;62.1]) of e-ASPECTS was better than three trainees and one expert (p ≤ 0.01) and not statistically different from another two experts. Specificity (94.15% [CI: 91.7;96.6]) was lower than one expert and one trainee (p < 0.01) and not statistically different to the other four physicians. e-ASPECTS had the best Matthews correlation coefficient of 0.44 (experts: 0.38 ± 0.08 and trainees: 0.19 ± 0.05) and the lowest mean score error of 0.56 (experts: 1.44 ± 1.79 and trainees: 1.97 ± 2.12).

Conclusion: e-ASPECTS showed a similar performance to that of stroke experts in the assessment of brain computed tomographys of acute ischemic stroke patients with the Alberta Stroke Program Early CT score method.
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http://dx.doi.org/10.1177/1747493016632244DOI Listing
June 2016

Proper Patient Selection--The Key to Beneficial Mechanical Thrombectomy in Acute Stroke Therapy.

Cerebrovasc Dis 2015 29;40(5-6):304-6. Epub 2015 Oct 29.

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

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http://dx.doi.org/10.1159/000441096DOI Listing
September 2016

Mechanical thrombectomy using a combined CT/C-arm X-ray system.

J Neurointerv Surg 2016 Jun 2;8(6):621-5. Epub 2015 May 2.

Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany.

Background: Mechanical thrombectomy (MT) using stent-retrievers has been proven to be a safe and effective treatment in acute ischemic stroke (AIS), particularly in large vessel occlusion. Other than patient characteristics, time to recanalization is the most important factor linked to outcome. MT is usually performed in a dedicated angiography suite using a floor- and/or ceiling-mounted biplane angiographic system. Here we report our first experience of MT with a new combined CT and mobile C-arm X-ray device setup.

Methods: Patients with AIS underwent stroke imaging (non-contrast enhanced CT, CT perfusion, and CT angiography) using a commercially available 64-slice CT scanner which was modified for combined use with a C-arm system. In patients with large vessel occlusion, MT was conducted without further patient transfer within the CT imaging suite using a mobile C-arm X-ray device equipped with a 30×30 cm (12×12 inch), 1.5×1.5 k full-view flat detector which was positioned between the gantry and patient table. The safety and feasibility of this new system was assessed in preliminary patients.

Results: Angiographic imaging quality of the mobile C-arm was feasible and satisfactory for diagnostic angiography and MT. Using this setup, time between stroke imaging and groin puncture (picture-to-puncture time) was reduced by up to 35 min (including time for preparation of the patient such as intubation).

Conclusions: MT using a combined CT/C-arm system is safe and feasible. The potential advantages, particularly time saving and ensuing improvement in patient outcome, need to be assessed in a larger study.
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http://dx.doi.org/10.1136/neurintsurg-2015-011744DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4893107PMC
June 2016

MRI biomarkers in mild traumatic brain injury.

Neurology 2015 Feb 9;84(6):554-5. Epub 2015 Jan 9.

From the Department of Neuroradiology, University of Heidelberg Medical Center, Germany.

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http://dx.doi.org/10.1212/WNL.0000000000001244DOI Listing
February 2015

Novel factor xa inhibitor for the treatment of cerebral venous and sinus thrombosis: first experience in 7 patients.

Stroke 2014 Aug 24;45(8):2469-71. Epub 2014 Jun 24.

From the Departments of Neurology (C.G., D.R., P.A.R., S.N.) and Neuroradiology (C.H.), University of Heidelberg, Heidelberg, Germany.

Background And Purpose: Thrombosis of cerebral veins and sinus (cerebral venous thrombosis) is a rare stroke pathogenesis. Pharmaceutical treatment is restricted to heparin and oral anticoagulation with vitamin K antagonists (VKAs).

Methods: Between January 2012 and December 2013, we recorded data from our patients with cerebral venous thrombosis. The modified Rankin scale was used to assess clinical severity; excellent outcome was defined as modified Rankin scale 0 to 1. Recanalization was assessed on follow-up MR angiography. Patients were then divided into 2 treatment groups: phenprocoumon (VKA) and a novel factor Xa inhibitor. Clinical and radiological baseline data, outcome, recanalization status, and complications were retrospectively compared.

Results: Sixteen patients were included, and 7 were treated with rivaroxaban. Overall outcome was excellent in 93.8%, and all patients showed at least partial recanalization. No statistical significant differences were found between the groups, except the use of heparin before start of oral anticoagulation (P=0.03). One patient in the VKA and 2 patients in the factor Xa inhibitor group had minor bleeding (P=0.55) within the median (range) follow-up of 8 months (5-26).

Conclusions: Factor Xa inhibitor showed a similar clinical benefit as VKA in the treatment of cerebral venous thrombosis. Further systematic prospective evaluation is warranted.
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http://dx.doi.org/10.1161/STROKEAHA.114.006167DOI Listing
August 2014

Cerebral atrophy is an independent risk factor for unfavorable outcome after spontaneous supratentorial intracerebral hemorrhage.

Stroke 2013 Apr 14;44(4):968-71. Epub 2013 Feb 14.

Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany.

Background And Purpose: To investigate the influence of cerebral atrophy on clinical outcome in patients with supratentorial intracerebral hemorrhage.

Methods: Computed tomography scans of 320 patients included in a prospective, multicenter trial were used for a segmentation analysis to determine the supratentorial cerebral volume. A logistic regression analysis was used to explore its effect on outcome after 90 days in addition to other clinical and imaging parameters.

Results: Cerebral volume loss significantly reduced the odds for favorable outcome after 90 days (odds ratio=0.91; confidence interval, 0.85-0.99; P=0.02).

Conclusions: Cerebral atrophy is an independent predictor of unfavorable outcome after intracerebral hemorrhage, indicating reduced functional recovery potential in these individuals.
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http://dx.doi.org/10.1161/STROKEAHA.111.670901DOI Listing
April 2013

Intraoperative indocyanine green angiography for microsurgical treatment of a craniocervical dural arteriovenous fistula.

Clin Neurol Neurosurg 2012 Jul 5;114(6):696-8. Epub 2011 Dec 5.

Department of Neurosurgery, Heidelberg University Hospital, Germany.

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http://dx.doi.org/10.1016/j.clineuro.2011.11.022DOI Listing
July 2012