Publications by authors named "Franziska Dorn"

106 Publications

[Thrombectomy in clinical practice-What do we learn from registry studies?]

Nervenarzt 2021 May 3. Epub 2021 May 3.

Klinik für Neuroradiologie, Universitätsklinikum Bonn, Bonn, Deutschland.

Background: In 2015, randomized controlled trials (RCT) provided high-level evidence for the efficacy of endovascular thrombectomy in selected patients with acute ischemic stroke due to large vessel occlusion of the anterior circulation. Ever since, thrombectomy is strongly recommended for these patients and has been broadly implemented in clinical practice.

Objective: To determine whether registry studies depicting real-life data provide additional information beyond RCTs.

Material And Methods: Literature review of RCTs and registry studies related to thrombectomy.

Results: Data from registry studies on thrombectomy are important to 1. evaluate whether RCT results can be directly transferred into clinical practice, 2. comparatively describe the efficacy of thrombectomy in patient groups underrepresented in RCTs, such as older patients, 3. compare device performances and assess technical developments, and 4. determine how treatment processes and outcomes change over time.

Conclusion: Beyond RCTs, registry studies are imperative for the continuous analysis and improvement of treatment processes and outcomes as well as technical devices in daily clinical practice.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00115-021-01122-zDOI Listing
May 2021

Correction to: Radiation dose and fluoroscopy time of modern endovascular treatment techniques in patients with saccular unruptured intracranial aneurysms.

Eur Radiol 2021 May 3. Epub 2021 May 3.

Institute of Neuroradiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00330-021-07874-1DOI Listing
May 2021

Intrasaccular Flow Disruption with the Woven EndoBridge for Narrow-Necked Aneurysms: A Safety and Feasibility Study.

World Neurosurg 2021 Apr 15. Epub 2021 Apr 15.

Department of Radiology and Neuroradiology, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany.

Objective: The Woven EndoBridge (WEB) received U.S. Food and Drug Administration approval for endovascular treatment of wide-necked bifurcation aneurysms. We evaluated the feasibility, safety, and efficacy of the WEB for treatment of narrow-necked aneurysms.

Methods: This multicenter study included 17 narrow-necked aneurysms, defined by a neck width <4 mm and a dome-to-neck ratio >2. Aneurysm characteristics, treatment strategies, technical success, complications, and angiographic outcomes were retrospectively assessed.

Results: Aneurysm locations included the internal carotid artery (7 cases), anterior communicating artery (4 cases), middle cerebral artery (4 cases), and basilar artery (2 cases). The median aneurysm size was 7.4 mm with a median neck width of 2.3 mm. The technical success rate was 100%. There were no neurological complications. Angiographic control revealed complete and adequate occlusion in 13 of 15 (86.7%) and 14 of 15 (93.3%) cases, respectively, after 6 months and in 6 of 7 (85.6%) and 7 of 7 (100%) cases, respectively, after a median of 13 months. Two aneurysms were retreated with flow diverters.

Conclusions: WEB embolization of narrow-necked aneurysms was technically feasible and safe and might be considered as an alternative treatment option to conventional coiling in selected cases.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.wneu.2021.04.018DOI Listing
April 2021

Magnetic Resonance Imaging-Based Robotic Radiosurgery of Arteriovenous Malformations.

Front Oncol 2020 9;10:608750. Epub 2021 Mar 9.

European Cyberknife Center Munich-Grosshadern, Munich, Germany.

Objective: CyberKnife offers CT- and MRI-based treatment planning without the need for stereotactically acquired DSA. The literature on CyberKnife treatment of cerebral AVMs is sparse. Here, a large series focusing on cerebral AVMs treated by the frameless CyberKnife stereotactic radiosurgery (SRS) system was analyzed.

Methods: In this retrospective study, patients with cerebral AVMs treated by CyberKnife SRS between 2005 and 2019 were included. Planning was MRI- and CT-based. Conventional DSA was not coregistered to the MRI and CT scans used for treatment planning and was only used as an adjunct. Obliteration dynamics and clinical outcome were analyzed.

Results: 215 patients were included. 53.0% received SRS as first treatment; the rest underwent previous surgery, embolization, SRS, or a combination. Most AVMs were classified as Spetzler-Martin grade I to III (54.9%). Hemorrhage before treatment occurred in 46.0%. Patients suffered from headache (28.8%), and seizures (14.0%) in the majority of cases. The median SRS dose was 18 Gy and the median target volume was 2.4 cm³. New neurological deficits occurred in 5.1% after SRS, with all but one patient recovering. The yearly post-SRS hemorrhage incidence was 1.3%. In 152 patients who were followed-up for at least three years, 47.4% showed complete AVM obliteration within this period. Cox regression analysis revealed Spetzler-Martin grade (P = 0.006) to be the only independent predictor of complete obliteration.

Conclusions: Although data on radiotherapy of AVMs is available, this is one of the largest series, focusing exclusively on CyberKnife treatment. Safety and efficacy compared favorably to frame-based systems. Non-invasive treatment planning, with a frameless SRS robotic system might provide higher patient comfort, a less invasive treatment option, and lower radiation exposure.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3389/fonc.2020.608750DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7986716PMC
March 2021

Past medical history of tumors other than meningioma is a negative prognostic factor for tumor recurrence in meningiomas WHO grade I.

Acta Neurochir (Wien) 2021 Mar 5. Epub 2021 Mar 5.

Department of Neurosurgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377, Munich, Germany.

Background: Prognostic markers for meningioma recurrence are needed to guide patient management. Apart from rare hereditary syndromes, the impact of a previous unrelated tumor disease on meningioma recurrence has not been described before.

Methods: We retrospectively searched our database for patients with meningioma WHO grade I and complete resection provided between 2002 and 2016. Demographical, clinical, pathological, and outcome data were recorded. The following covariates were included in the statistical model: age, sex, clinical history of unrelated tumor disease, and localization (skull base vs. convexity). Particular interest was paid to the patients' past medical history. The study endpoint was date of tumor recurrence on imaging. Prognostic factors were obtained from multivariate proportional hazards models.

Results: Out of 976 meningioma patients diagnosed with a meningioma WHO grade I, 416 patients fulfilled our inclusion criteria. We encountered 305 women and 111 men with a median age of 57 years (range: 21-89 years). Forty-six patients suffered from a tumor other than meningioma, and no TERT mutation was detected in these patients. There were no differences between patients with and without a positive oncological history in terms of age, tumor localization, or mitotic cell count. Clinical history of prior tumors other than meningioma showed the strongest association with meningioma recurrence (p = 0.004, HR = 3.113, CI = 1.431-6.771) both on uni- and multivariate analysis.

Conclusion: Past medical history of tumors other than meningioma might be associated with an increased risk of meningioma recurrence. A detailed pre-surgical history might help to identify patients at risk for early recurrence.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00701-021-04780-9DOI Listing
March 2021

Thrombectomy for Primary Distal Posterior Cerebral Artery Occlusion Stroke: The TOPMOST Study.

JAMA Neurol 2021 Apr;78(4):434-444

Department of Interventional Neuroradiology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain.

Importance: Clinical evidence of the potential treatment benefit of mechanical thrombectomy for posterior circulation distal, medium vessel occlusion (DMVO) is sparse.

Objective: To investigate the frequency as well as the clinical and safety outcomes of mechanical thrombectomy for isolated posterior circulation DMVO stroke and to compare them with the outcomes of standard medical treatment with or without intravenous thrombolysis (IVT) in daily clinical practice.

Design, Setting, And Participants: This multicenter case-control study analyzed patients who were treated for primary distal occlusion of the posterior cerebral artery (PCA) of the P2 or P3 segment. These patients received mechanical thrombectomy or standard medical treatment (with or without IVT) at 1 of 23 comprehensive stroke centers in Europe, the United States, and Asia between January 1, 2010, and June 30, 2020. All patients who met the inclusion criteria were matched using 1:1 propensity score matching.

Interventions: Mechanical thrombectomy or standard medical treatment with or without IVT.

Main Outcomes And Measures: Clinical end point was the improvement of National Institutes of Health Stroke Scale (NIHSS) scores at discharge from baseline. Safety end point was the occurrence of symptomatic intracranial hemorrhage and hemorrhagic complications were classified based on the Second European-Australasian Acute Stroke Study (ECASSII). Functional outcome was evaluated with the modified Rankin Scale (mRS) score at 90-day follow-up.

Results: Of 243 patients from all participating centers who met the inclusion criteria, 184 patients were matched. Among these patients, the median (interquartile range [IQR]) age was 74 (62-81) years and 95 (51.6%) were female individuals. Posterior circulation DMVOs were located in the P2 segment of the PCA in 149 patients (81.0%) and in the P3 segment in 35 patients (19.0%). At discharge, the mean NIHSS score decrease was -2.4 points (95% CI, -3.2 to -1.6) in the standard medical treatment cohort and -3.9 points (95% CI, -5.4 to -2.5) in the mechanical thrombectomy cohort, with a mean difference of -1.5 points (95% CI, 3.2 to -0.8; P = .06). Significant treatment effects of mechanical thrombectomy were observed in the subgroup of patients who had higher NIHSS scores on admission of 10 points or higher (mean difference, -5.6; 95% CI, -10.9 to -0.2; P = .04) and in the subgroup of patients without IVT (mean difference, -3.0; 95% CI, -5.0 to -0.9; P = .005). Symptomatic intracranial hemorrhage occurred in 4 of 92 patients (4.3%) in each treatment cohort.

Conclusions And Relevance: This study suggested that, although rarely performed at comprehensive stroke centers, mechanical thrombectomy for posterior circulation DMVO is a safe, and technically feasible treatment option for occlusions of the P2 or P3 segment of the PCA compared with standard medical treatment with or without IVT.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamaneurol.2021.0001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7900924PMC
April 2021

General Anesthesia versus Conscious Sedation in Mechanical Thrombectomy.

J Stroke 2021 Jan 31;23(1):103-112. Epub 2021 Jan 31.

Department of Neurology, Ludwig Maximilian University (LMU), Munich, Germany.

Background And Purpose: Anesthesia regimen in patients undergoing mechanical thrombectomy (MT) is still an unresolved issue.

Methods: We compared the effect of anesthesia regimen using data from the German Stroke Registry-Endovascular Treatment (GSR-ET) between June 2015 and December 2019. Degree of disability was rated by the modified Rankin Scale (mRS), and good outcome was defined as mRS 0-2. Successful reperfusion was assumed when the modified thrombolysis in cerebral infarction scale was 2b-3.

Results: Out of 6,635 patients, 67.1% (n=4,453) patients underwent general anesthesia (GA), 24.9% (n=1,650) conscious sedation (CS), and 3.3% (n=219) conversion from CS to GA. Rate of successful reperfusion was similar across all three groups (83.0% vs. 84.2% vs. 82.6%, P=0.149). Compared to the CA-group, the GA-group had a delay from admission to groin (71.0 minutes vs. 61.0 minutes, P<0.001), but a comparable interval from groin to flow restoration (41.0 minutes vs. 39.0 minutes). The CS-group had the lowest rate of periprocedural complications (15.0% vs. 21.0% vs. 28.3%, P<0.001). The CS-group was more likely to have a good outcome at follow-up (42.1% vs. 34.2% vs. 33.5%, P<0.001) and a lower mortality rate (23.4% vs. 34.2% vs. 26.0%, P<0.001). In multivariable analysis, GA was associated with reduced achievement of good functional outcome (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.71 to 0.94; P=0.004) and increased mortality (OR, 1.42; 95% CI, 1.23 to 1.64; P<0.001). Subgroup analysis for anterior circulation strokes (n=5,808) showed comparable results.

Conclusions: We provide further evidence that CS during MT has advantages over GA in terms of complications, time intervals, and functional outcome.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5853/jos.2020.02404DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7900389PMC
January 2021

Endovascular stroke treatment in orally anticoagulated patients: an analysis from the German Stroke Registry-Endovascular Treatment.

J Neurol 2021 May 29;268(5):1762-1769. Epub 2020 Dec 29.

Department of Neurology, Ludwig-Maximilians University, Marchioninistraße 15, 81377, Munich, Germany.

Background: Endovascular treatment (ET) in orally anticoagulated (OAC) patients has not been evaluated in randomized clinical trials and data regarding this issue are sparse.

Methods: We analyzed data from the German Stroke Registry-Endovascular Treatment (GSR-ET; NCT03356392, date of registration: 22 Nov 2017). The primary outcomes were successful reperfusion defined as modified thrombolysis in cerebral infarction (mTICI 2b-3), good outcome at 3 months (modified Rankin scale [mRS] 0-2 or back to baseline), and intracranial hemorrhage (ICH) on follow-up imaging at 24 h analyzed by unadjusted univariate and adjusted binary logistic regression analysis. Additionally, we analyzed mortality at 3 months with adjusted binary logistic regression analysis.

Results: Out of 6173 patients, there were 1306 (21.2%) OAC patients, 479 (7.8%) with vitamin K antagonists (VKA) and 827 (13.4%) with non-vitamin K antagonist oral anticoagulation (NOAC). The control group consisted of 4867 (78.8%) non-OAC patients. ET efficacy with the rates of mTICI 2b-3 was similar among the three groups (85.6%, 85.3% vs 84.3%, p = 0.93 and 1). On day 90, good outcome was less frequent in OAC patients (27.8%, 27.9% vs 39.5%, p < 0.005 and < 0.005). OAC status was not associated with ICH at 24 h (NOAC: odd's ratio [OR] 0.89, 95% confidence interval [CI] 0.67-1.20; VKA: OR 1.04, CI 0.75-1.46). Binary logistic regression analysis revealed no influence of OAC status on good outcome at 3 months (NOAC: OR 1.25, CI 0.99-1.59; VKA: OR 1.18, CI 0.89-1.56) and mortality at 3 months (NOAC: OR 1.03, CI 0.81-1.30; VKA: OR 1.04, CI 0.78-1.1.37).

Conclusions: ET can be performed safely and successfully in LVO stroke patients treated with OAC. CLINICAL TRIAL REGISTRATION-URL: http://www.clinicaltrials.gov . Unique identifier: NCT03356392.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00415-020-10369-6DOI Listing
May 2021

Woven Endobridge Embolization Versus Microsurgical Clipping for Unruptured Anterior Circulation Aneurysms: A Propensity Score Analysis.

Neurosurgery 2021 03;88(4):779-784

Department of Radiology and Neuroradiology, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany.

Background: Intrasaccular flow-disruption represents a new paradigm in endovascular treatment of wide-necked bifurcation aneurysms.

Objective: To retrospectively compare Woven Endobridge (WEB) embolization with microsurgical clipping for unruptured anterior circulation aneurysms using propensity score adjustment.

Methods: A total of 63 patients treated with WEB and 103 patients treated with clipping were compared based on the intention-to-treat principle. The primary outcome measures were immediate technical treatment success, major adverse events, and 6-mo complete aneurysm occlusion.

Results: The technical success rates were 83% for WEB and 100% for clipping. Procedure-related complications occurred more often in the clipping group (13%) than the WEB group (6%, adjusted P < .01). However, the rates of major adverse events were comparable in both groups (WEB: 3%, clip: 4%, adjusted P = .53). At the 6-mo follow-up, favorable functional outcomes were achieved in 98% of the WEB embolization group and 99% of the clipping group (adjusted P = .19). Six-month complete aneurysm occlusion was obtained in 75% of the WEB group and 94% of the clipping group (adjusted P < .01).

Conclusion: Microsurgical clipping was associated with higher technical success and complete occlusion rates, whereas WEB had a lower complication rate. Favorable functional outcomes were achieved in ≥98% of both groups. The decision to use a specific treatment modality should be made on an individual basis and in accordance with the patient's preferences.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/neuros/nyaa539DOI Listing
March 2021

Safety and efficacy of mechanical thrombectomy in infective endocarditis: A matched case-control analysis from the German Stroke Registry-Endovascular Treatment.

Eur J Neurol 2021 Mar 6;28(3):861-867. Epub 2021 Jan 6.

Department of Neurology, Ludwig Maximilians University, Munich, Germany.

Background And Purpose: Up to 30% of infective endocarditis (IE) patients have ischemic stroke as a complication. Standard treatment with mechanical thrombectomy (MT) with or without intravenous thrombolysis for large vessel occlusion (LVO) has not been evaluated formally in these patients.

Methods: Patients enrolled in the German Stroke Registry-Endovascular Treatment (GSR-ET) between June 2015 and December 2019 were analyzed. Patients with stroke due to IE and patients with cardioembolic stroke and atrial fibrillation (AF) were compared using propensity score matching. Successful reperfusion was defined as modified Thrombolysis in Cerebral Infarction score = 2b-3. Modified Rankin Scale (mRS) = 0-2 at 3 months indicated good outcome.

Results: Of 6635 patients, 55 patients (age = 69.0 ± 13.3 years, 43.6% female, median premorbid mRS (pmRS) = 1, interquartile range [IQR] = 0-1, National Institutes of Health Stroke Scale [NIHSS] = 15, IQR = 10-21) presented with septic embolic stroke due to IE and were compared to 104 patients (age = 66.5 ± 13.4 years, 39.4% female, pmRS = 0, IQR = 0-2, NIHSS = 16, IQR = 10-20) with cardioembolic stroke due to AF. Successful recanalization was achieved in 74.5% of endocarditis patients compared to 87.5% of controls (p = 0.039). Intracranial hemorrhage rates were comparable (30.9% vs. 21.6%, p = 0.175). Good functional outcome was 20.0% in patients with IE compared to 43.3% in matched patients (p = 0.006), with a significantly higher mortality (60.0% vs. 28.8%, p < 0.001). IE was strongly associated with poor outcome (odds ratio [OR] = 0.32, 95% confidence interval [CI] = 0.11-0.87, p = 0.03 for good outcome) and mortality (OR = 4.49, 95% CI = 1.80-10.68, p = 0.001).

Conclusions: Although MT results in high successful recanalization rates with acceptable safety profile, patients with LVO stroke due to IE have poor outcome.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/ene.14686DOI Listing
March 2021

The Woven EndoBridge (WEB) Versus Conventional Coiling for Treatment of Patients with Aneurysmal Subarachnoid Hemorrhage: Propensity Score-Matched Analysis of Clinical and Angiographic Outcome Data.

World Neurosurg 2021 Feb 5;146:e1326-e1334. Epub 2020 Dec 5.

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

Objective: Conventional coiling is standard for treatment of ruptured intracranial aneurysms. We compared clinical and angiographic outcomes between intrasaccular flow disruption with the Woven EndoBridge (WEB) and conventional coiling in patients with aneurysmal subarachnoid hemorrhage (aSAH) using a propensity score-matched analysis.

Methods: This is a retrospective study of consecutive patients with aSAH treated with the WEB or conventional coiling between 2010 and 2019. Baseline characteristics, procedural complications, angiographic results, and functional outcome were compared between both groups.

Results: Fifty-two patients treated with the WEB and 236 patients treated by coiling were included. The WEB group was characterized by a higher patient age (P = 0.024), a wider aneurysm neck (P < 0.001), and more frequent location at the posterior circulation (P = 0.004). Procedural complications were comparable between WEB (19.2%) and coiling (22.7%, P = 0.447). In-hospital mortality rates were higher in the coiling group (WEB: 5.8%, coiling: 17.8%; P = 0.0034). Favorable outcome (modified Rankin scale ≤2) was obtained in 51.3% after WEB embolization and in 55.0% after coiling (P = 0.653). Retreatment was performed in 26.4% of patients after WEB and in 25.8% after coiling (P = 0.935). Propensity score analysis confirmed these results and revealed higher adequate occlusion rates at midterm follow-up for WEB-treated aneurysms (WEB: 93.9%, coiling: 76.2%, P = 0.058).

Conclusions: Compared with conventional coiling, aSAH patients treated with the WEB have a similar clinical and potentially improved angiographic outcome at midterm follow-up. The WEB might be considered as an alternative to conventional coiling for the treatment of RIAs, in particular for those with wide-necked and thus challenging anatomy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.wneu.2020.11.158DOI Listing
February 2021

The clinical value of ceMRA versus DSA for follow-up of intracranial aneurysms treated by coil embolization: an assessment of occlusion classifications and impact on treatment decisions.

Eur Radiol 2020 Nov 21. Epub 2020 Nov 21.

Institute of Diagnostic and Interventional Neuroradiology, University Hospital, LMU Munich, Marchioninistr. 15, D-81377, Munich, Germany.

Objective: The aim of this study was a detailed analysis of the value of contrast-enhanced magnetic resonance angiography (ceMRA) compared to digital subtraction angiography (DSA) for follow-up imaging of intracranial aneurysms treated by coil embolization.

Methods: Patients with coiled aneurysms and follow-up exams including both DSA and 3 T ceMRA were retrospectively identified. In blinded readings, both modalities were graded according to the modified Raymond-Roy classification (MRRC) and the Meyers scale. Additionally, readers were asked to make a decision regarding retreatment/follow-up based on the respective imaging findings.

Results: The study comprised 92 patients harboring 102 coiled aneurysms. There was good intermethod agreement of DSA and ceMRA concerning both the MRRC (κ = 0.64) and the Meyers scale (κ = 0.74). Agreement regarding occlusion of < 90% of the aneurysm (Meyers grade ≥ 2) was very good (κ = 0.87). Regarding the detection of a remnant with contrast between the coil mass and the aneurysm wall (MRRC IIIb), there were 12 discrepant findings and agreement was good (κ = 0.70). Comparing treatment/follow-up decisions, the two methods agreed very well (κ = 0.92). In seven patients with discrepant treatment decisions, the authors concurred with DSA in four cases and with ceMRA in three cases when evaluating both modalities together. Interval aneurysm growth was found in more cases with ceMRA (n = 19) than with DSA (n = 16).

Conclusions: CeMRA is very unlikely to miss a relevant aneurysm remnant and thus could be suitable as the primary follow-up method. In case of remnant growth or recurrence, however, additional DSA might be required to guide treatment decisions.

Key Points: • There is high accordance between ceMRA and DSA regarding the evaluation of intracranial aneurysms treated by endovascular coil embolization, but closer analysis also revealed relevant differences. • CeMRA could be suitable as the primary follow-up imaging modality, potentially eliminating the need for routine DSA. • DSA will still be required in case of aneurysm remnant growth or recurrence as detected by ceMRA.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00330-020-07492-3DOI Listing
November 2020

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.wneu.2020.10.062DOI Listing
January 2021

A DELPHI consensus statement on antiplatelet management for intracranial stenting due to underlying atherosclerosis in the setting of mechanical thrombectomy.

Neuroradiology 2021 Apr 24;63(4):627-632. Epub 2020 Sep 24.

Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.

Purpose: There is little data and lack of consensus regarding antiplatelet management for intracranial stenting due to underlying intracranial atherosclerosis in the setting of endovascular treatment (EVT). In this DELPHI study, we aimed to assess whether consensus on antiplatelet management in this situation among experienced experts can be achieved, and what this consensus would be.

Methods: We used a modified DELPHI approach to address unanswered questions in antiplatelet management for intracranial stenting due to underlying atherosclerosis in the setting of EVT. An expert-panel (19 neurointerventionalists from 8 countries) answered structured, anonymized on-line questionnaires with iterative feedback-loops. Panel-consensus was defined as agreement ≥ 70% for binary closed-ended questions/≥ 50% for closed-ended questions with > 2 response options.

Results: Panel members answered a total of 5 survey rounds. They acknowledged that there is insufficient data for evidence-based recommendations in many aspects of antiplatelet management for intracranial stenting due to underlying atherosclerosis in the setting of EVT. They believed that antiplatelet management should follow a standardized regimen, irrespective of imaging findings and reperfusion quality. There was no consensus on the timing of antiplatelet-therapy initiation. Aspirin was the preferred antiplatelet agent for the peri-procedural period, and oral Aspirin in combination with a P2Y12 inhibitor was the favored postprocedural regimen.

Conclusion: Data on antiplatelet management for intracranial stenting due to underlying atherosclerosis in the setting of EVT are limited. Panel-members in this study achieved consensus on postprocedural antiplatelet management but did not agree upon a preprocedural and intraprocedural antiplatelet regimen. Further prospective studies to optimize antiplatelet regimens are needed.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00234-020-02556-zDOI Listing
April 2021

Endovascular treatment of basilar tip aneurysms in the era of endosaccular flow disruption: a comparative study.

Neuroradiology 2021 Apr 23;63(4):619-626. Epub 2020 Sep 23.

Department of Neuroradiology, Ludwig Maximilian University, Munich, Germany.

Purpose: This study aims to compare endosaccular flow disruptor (EFD) for treatment of basilar tip aneurysm (BTA) with coiling in terms of safety and efficacy.

Methods: We retrospectively reviewed patients treated with an EFD for BTAs at our institution between 2013 and 2019 to standard coiling from the same period (control group). Patient demographics, aneurysm characteristics, procedural data, complications and clinical and angiographic outcome were compared between groups.

Results: Twenty-three (56%) patients were treated with an EFD and eighteen (44%) patients were treated with coiling. Average aneurysm size was 8 mm in the EFD group and 6.9 mm in the coiling group, respectively (P = 0.2). Average fluoroscopy time, treatment DAP and air kerma were 33 min, 76 Gycm and 1.7 Gy in the EFD group and 81 min, 152 Gycm and 3.8 Gy in the coiling group, respectively (P < 0.001). In the EFD group, clinically relevant thromboembolic complications occurred in one patient (4%) vs. in 5 patients (28%) in the coiling group (P = 0.07). In each group, 4 patients had an unfavourable outcome at discharge (P = 0.7). Adequate occlusion rates were 96% in the EFD group and 100% and coiling group. Six (26%) patients were prescribed long-term antiplatelet therapy in the EFD group vs. eleven (61%) patients in the coiling group (P = 0.02).

Conclusion: Both treatment concepts provided similar technical success and safety. However, procedure time, radiation exposure and a need for long-term antiaggregation were lower with EFD.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00234-020-02555-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7966124PMC
April 2021

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

J Neurointerv Surg 2020 Sep 8. 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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/neurintsurg-2020-016303DOI Listing
September 2020

Inter-hospital transfer for mechanical thrombectomy within the supraregional stroke network NEVAS.

J Neurol 2021 Feb 5;268(2):623-631. Epub 2020 Sep 5.

Department of Neurology, Ludwig Maximilians University (LMU), Marchioninistrasse 15, 81377, Munich, Germany.

Background: Telemedicine stroke networks are mandatory to provide inter-hospital transfer for mechanical thrombectomy (MT). However, studies on patient selection in daily practice are sparse.

Methods: Here, we analyzed consecutive patients from 01/2014 to 12/2018 within the supraregional stroke network "Neurovascular Network of Southwest Bavaria" (NEVAS) in terms of diagnoses after consultation, inter-hospital transfer and predictors for performing MT. Degree of disability was rated by the modified Rankin Scale (mRS), good outcome was defined as mRS ≤ 2. Successful reperfusion was assumed when the modified thrombolysis in cerebral infarction (mTICI) was 2b-3.

Results: Of 5722 telemedicine consultations, in 14.1% inter-hospital transfer was performed, mostly because of large vessel occlusion (LVO) stroke. A total of n = 350 patients with LVO were shipped via NEVAS to our center for MT. While n = 52 recanalized spontaneously, MT-treatment was performed in n = 178 patients. MT-treated patients had more severe strokes according to the median National institute of health stroke scale (NIHSS) (16 vs. 13, p < 0.001), were more often treated with intravenous thrombolysis (64.5% vs. 51.7%, p = 0.026) and arrived significantly earlier in our center (184.5 versus 228.0 min, p < 0.001). Good outcome (27.5% vs. 30.8%, p = 0.35) and mortality (32.6% versus 23.5%, p = 0.79) were comparable in MT-treated versus no-MT-treated patients. In patients with middle cerebral artery occlusion in the M1 segment or carotid artery occlusion good outcome was twice as often in the MT-group (21.8% vs. 12.8%, p = 0.184). Independent predictors for performing MT were higher NIHSS (OR 1.096), higher ASPECTS (OR 1.28), and earlier time window (OR 0.99).

Conclusion: Within a telemedicine network stroke care can successfully be organized as only a minority of patients has to be transferred. Our data provide clinical evidence that all MT-eligible patients should be shipped with the fastest transportation modality as possible.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00415-020-10165-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7880976PMC
February 2021

Bornavirus Encephalitis Shows a Characteristic Magnetic Resonance Phenotype in Humans.

Ann Neurol 2020 10 29;88(4):723-735. Epub 2020 Aug 29.

Department of Radiology, Center of Neuroradiology, University Hospital Regensburg, Regensburg, Germany.

Objective: The number of diagnosed fatal encephalitis cases in humans caused by the classical Borna disease virus (BoDV-1) has been increasing, ever since it was proved that BoDV-1 can cause human infections. However, awareness of this entity is low, and a specific imaging pattern has not yet been identified. We therefore provide the first comprehensive description of the morphology of human BoDV-1 encephalitis, with histopathological verification of imaging abnormalities.

Methods: In an institutional review board-approved multicenter study, we carried out a retrospective analysis of 55 magnetic resonance imaging (MRI) examinations of 19 patients with confirmed BoDV-1 encephalitis. Fifty brain regions were analyzed systematically (T1w, T2w, T2*w, T1w + Gd, and DWI), in order to discern a specific pattern of inflammation. Histopathological analysis of 25 locations in one patient served as correlation for MRI abnormalities.

Results: Baseline imaging, acquired at a mean of 11 ± 10 days after symptom onset, in addition to follow-up scans of 16 patients, revealed characteristic T2 hyperintensities with a predilection for the head of the caudate nucleus, insula, and cortical spread to the limbic system, whereas the occipital lobes and cerebellar hemispheres were unaffected. This gradient was confirmed by histology. Nine patients (47.4%) developed T1 hyperintensities of the basal ganglia, corresponding to accumulated lipid phagocytes on histology and typical for late-stage necrosis.

Interpretation: BoDV-1 encephalitis shows a distinct pattern of inflammation in both the early and late stages of the disease. Its appearance can mimic sporadic Creutzfeldt-Jakob disease on MRI and should be considered a differential diagnosis in the case of atypical clinical presentation. ANN NEUROL 2020;88:723-735.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/ana.25873DOI Listing
October 2020

Head or Neck First? Speed and Rates of Reperfusion in Thrombectomy for Tandem Large Vessel Occlusion Strokes.

Interv Neurol 2020 Jan 15;8(2-6):92-100. Epub 2019 Feb 15.

Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nancy, Nancy, France.

Background: We aim to evaluate the speed and rates of reperfusion in tandem large vessel occlusion acute stroke patients undergoing upfront cervical lesion treatment (Neck-First: angioplasty and/or stent before thrombectomy) as compared to direct intracranial occlusion therapy (Head-First) in a large international multicenter cohort.

Methods: The Thrombectomy In TANdem Lesions (TITAN) collaboration pooled individual data of prospectively collected thrombectomy international databases for all consecutive anterior circulation tandem patients who underwent emergent thrombectomy. The co-primary outcome measures were rates of successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b/3) and time from groin puncture to successful reperfusion.

Results: In total, 289 patients with tandem atherosclerotic etiology were included in the analysis (182 Neck-First and 107 Head-First patients). Except for differences in the Alberta Stroke Program Early CT Score (ASPECTS; median 8 [range 7-10] Neck-First vs. 7 [range 6-8] Head-First; < 0.001) and cervical internal carotid artery (ICA) lesion severity (complete occlusion in 35% of the Neck-First vs. 57% of the Head-First patients; < 0.001), patient characteristics were well balanced. After adjustments, there was no difference in successful reperfusion rates between the study groups (odds ratio associated with Neck-First: 1.18 [95% confidence interval, 0.60-2.17]). The time to successful reperfusion from groin puncture was significantly shorter in the Head-First group after adjustments (median 56 min [range 39-90] vs. 70 [range 50-102]; = 0.001). No significant differences in the rates of full reperfusion, symptomatic hemorrhage, 90-day independence, or mortality were observed. Sensitivity analysis excluding patients with complete cervical ICA occlusion yielded similar results.

Conclusions: The upfront approach of the intracranial lesion in patients with tandem large vessel occlusion strokes leads to similar reperfusion rates but faster reperfusion as compared to initial cervical revascularization followed by mechanical thrombectomy. Controlled studies are warranted.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1159/000496292DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7253855PMC
January 2020

Patient reported long-term outcome after endovascular therapy of indirect dural carotid cavernous fistulas.

PLoS One 2020 10;15(4):e0231261. Epub 2020 Apr 10.

Institute of Neuroradiology, University Hospital, LMU Munich, Munich, Germany.

Purpose: Patient-reported long-term follow-up after endovascular treatment of indirect carotid cavernous fistulas is important, but rarely addressed in literature. We report on this issue with a special focus on the patient's view and its impact on the indication evaluation process.

Methods: We retrospectively reviewed the records of all patients (n = 33) with a minimum follow-up interval of at least 36 and up to 166 months after endovascular treatment of an indirect carotid cavernous fistula (Barrow B-D) at our institution (treated from 01/2003 to 06/2015). We determined treatment details including primary therapy success and complication rate and quote the patient's subjective perception of the long-term treatment success using a standardized interview form.

Results: As a primary result the fistula was completely occluded in 25/33 cases (76%), while a downgrading was achieved in 8/33 (24%) of the cases. Secondary occlusion was observed in three out of eight patients (38%). In the long-term interview (response rate: 91%, median follow-up interval: 114 months) 87% of the patients reported high satisfaction with the long-term therapy result. Endovascular treatment achieved a sustainable relief from all eye-related symptoms in 89% and from pulsatile tinnitus in 57% of the cases.

Conclusions: In addition to good results in terms of angiographic and clinical cure, endovascular treatment is also perceived as beneficial by most of the patients. This is another important argument in favor of an endovascular treatment.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0231261PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7147764PMC
July 2020

Radiation dose and fluoroscopy time of modern endovascular treatment techniques in patients with saccular unruptured intracranial aneurysms.

Eur Radiol 2020 Aug 19;30(8):4504-4513. Epub 2020 Mar 19.

Institute of Neuroradiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany.

Objectives: Modern endovascular treatment of unruptured intracranial aneurysms (UIAs) demands for observance of diagnostic reference levels (DRLs). The national DRL (250 Gy cm) is only defined for coiling. We provide dosimetric data for the following procedures: coiling, flow diverter (FD), Woven EndoBridge (WEB), combined techniques.

Methods: A retrospective single-centre study of saccular UIAs treated between 2015 and 2019. Regarding dosimetric analysis, the parameters dose area product (DAP) and fluoroscopy time were investigated for the following variables: endovascular technique, aneurysm location, DSA protocol, aneurysm size, and patient age.

Results: Eighty-seven patients (59 females, mean age 54 years) were included. Total mean and median DAP (Gy cm) were 119 ± 73 (89-149) and 94 (73; 130) for coiling, 128 ± 53 (106-151) and 134 (80; 176) for FD, 128 ± 56 (102-153) and 118 (90; 176) for WEB, and 165 ± 102 (110-219) and 131 (98; 209) for combined techniques (p > .05). Regarding the aneurysm location, neither DAP nor fluoroscopy time was significantly different (p > .05). The lowest and highest fluoroscopy times were recorded for WEB and combined techniques, respectively (median 26 and 94 min; p < .001). A low-dose protocol yielded a 43% reduction of DAP (p < .001). Significantly positive correlations were found between DAP and both aneurysm size (r = .320, p = .003) and patient age (r = .214, p = .046).

Conclusions: This UIA study establishes novel local DRLs for modern endovascular techniques such as FD and WEB. A low-dose protocol yielded a significant reduction of radiation dose.

Key Points: • This paper establishes local diagnostic reference levels for modern endovascular treatment techniques of unruptured intracranial aneurysms, including flow diverter stenting and Woven EndoBridge device. • Dose area product was not significantly different between endovascular techniques and aneurysm locations, but associated with aneurysm size and patient age. • A low-dose protocol yielded a significant reduction of dose area product and is particularly useful when applying materials with a high radiopacity (e.g. platinum coils).
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00330-020-06777-xDOI Listing
August 2020

Impact of Antiplatelet Therapy During Endovascular Therapy for Tandem Occlusions: A Collaborative Pooled Analysis.

Stroke 2020 05 19;51(5):1522-1529. Epub 2020 Mar 19.

From the Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nancy, France (F.Z., R.A., S.B., B.G.).

Background and Purpose- Antiplatelet agents could be used in the setting of endovascular therapy for tandem occlusions to reduce the risk of de novo intracranial embolic migration, reocclusion of the extracranial internal carotid artery lesion, or in-stent thrombosis in case of carotid stent placement but have to be balanced with the intracerebral hemorrhagic transformation risk. In this study, we aim to investigate the impact of acute antiplatelet therapy administration on outcomes during endovascular therapy for anterior circulation tandem occlusions. Methods- This is a retrospective analysis of a collaborative pooled analysis of 11 prospective databases from the multicenter observational TITAN registry (Thrombectomy in Tandem Lesions). Patients were divided into groups based on the number of antiplatelet administered during endovascular therapy. The primary outcome was favorable outcome, defined as a modified Rankin Scale score of 0 to 2 at 90 days. Results- This study included a total of 369 patients; 145 (39.3%) did not receive any antiplatelet agent and 224 (60.7%) received at least 1 antiplatelet agent during the procedure. Rate of favorable outcome was nonsignificantly higher in patients treated with antiplatelet therapy (58.3%) compared with those treated without antiplatelet (46.0%; adjusted odds ratio, 1.38 [95% CI, 0.78-2.43]; =0.26). Rate of 90-day mortality was significantly lower in patients treated with antiplatelet therapy (11.2% versus 18.7%; adjusted odds ratio, 0.47 [95% CI, 0.22-0.98]; =0.042), without increasing the risk of any intracerebral hemorrhage. Successful reperfusion (modified Thrombolysis in Cerebral Ischemia score 2b-3) rate was significantly better in the antiplatelet therapy group (83.9% versus 71.0%; adjusted odds ratio, 1.89 [95% CI, 1.01-3.64]; =0.045). Conclusions- Administration of antiplatelet therapy during endovascular therapy for anterior circulation tandem occlusions was safe and was associated with a lower 90-day mortality. Optimal antiplatelet therapy remains to be assessed, especially when emergent carotid artery stenting is performed. Further randomized controlled trials are needed.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/STROKEAHA.119.028231DOI Listing
May 2020

Retreatment strategies for recurrent and residual aneurysms after treatment with flow-diverter devices.

Neuroradiology 2020 Aug 5;62(8):1019-1028. Epub 2020 Mar 5.

Department of Neuroradiology, LMU University Hospital of Munich, Munich, Germany.

Purpose: The management of residual or persistent intracranial aneurysms after flow-diversion therapy is not well defined in the literature. In this multicentric study, we report clinical and angiographic outcomes of 11 patients that underwent retreatment for 12 aneurysms initially treated with flow-diverter stents.

Methods: The median patient age was 53 years. Aneurysms (median size, 7.3 mm) were located at the internal carotid artery in 9 cases, and at the posterior circulation in 3. Treatment strategies, complications, and angiographic outcome were retrospectively assessed.

Results: Retreatment was feasible in all cases and performed by overlapping flow-diverter implantation. Overall, 12 side vessels were covered during retreatment, whereof 10 (83.3%) remained patent until mid-term follow-up. There were no further technical or symptomatic complications and no treatment-related morbidity. Angiographic follow-up (median, 17 months) showed improved aneurysm occlusion in all patients. Complete or near-complete aneurysm occlusion was achieved in 11 aneurysms (91.7%).

Conclusion: Required retreatment after failed flow-diversion therapy can be performed with adequate safety and efficacy by placement of additional flow-diverter stents.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00234-020-02389-wDOI Listing
August 2020

Emergency Intracranial Stenting in Acute Stroke: Predictors for Poor Outcome and for Complications.

J Am Heart Assoc 2020 03 3;9(5):e012795. Epub 2020 Mar 3.

Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg-Eppendorf Hamburg Germany.

Background Stent-retriever thrombectomy is the first-line therapy in acute stroke with intracranial large vessel occlusion. In case of failure of stent-retriever thrombectomy, rescue stent angioplasty might be the only treatment option to achieve permanent recanalization. This study aims at identifying predictors for poor outcome and complications in a large, multicenter cohort receiving rescue stent angioplasty. Methods and Results We performed a retrospective analysis of patients with large vessel occlusion who were treated with rescue stent angioplasty after stent-retriever thrombectomy between 2012 and 2018 in 7 neurovascular centers. We defined 2 binary outcomes: (1) functional clinical outcome (good modified Rankin Scale, 0-2; and poor modified Rankin Scale, 4-6) and (2) early symptomatic intracerebral hemorrhage. Impacts of clinical, radiological, and interventional parameters on outcomewere assessed in uni- and multivariable logistic regression models. Two hundred ten patients were included with target vessels located within the anterior circulation (136 of 210; 64.8%) and posterior circulation (74 of 210; 35.2%). Symptomatic intracerebral hemorrhage occured in 22 patients, 86.4% (19 of 22) after anterior and 13.6% (3 of 22) after posterior circulation large vessel occlusion. Good functional outcome was observed in 44.8% (73 of 163). A higher National Institutes of Health Stroke Scale on admission (adjusted odds ratio, 1.10; 0.002), a higher premorbid modified Rankin Scale (adjusted odds ratio, 2.02; =0.049), and a modified Thrombolysis in Cerebral Infarction score of 0 to 2a after stenting (adjusted odds ratio, 23.24; <0.001) were independent predictors of poor functional outcome. Conclusions Use of rescue stent angioplasty can be considered for acute intracranial large vessel occlusion in cases after unsuccessful stent-retriever thrombectomy. Likelihood of symptomatic intracerebral hemorrhage is higher in anterior circulation stroke.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/JAHA.119.012795DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7335566PMC
March 2020

Intracranial Stenting After Failed Thrombectomy in Patients With Moderately Severe Stroke: A Multicenter Cohort Study.

Front Neurol 2020 14;11:97. Epub 2020 Feb 14.

Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

Recently, acute intracranial stenting (ICS) has gained more interest as a potential bailout strategy for large vessel occlusions (LVO) that are refractory to thrombectomy. However, there are currently no reports on ICS in patients with moderately severe stroke discussing the question if implementing a permanent stent is feasible and leads to improved recanalization after failed thrombectomy. We analyzed a large multicenter database of patients receiving ICS for anterior circulation LVO after failed thrombectomy. Inclusion criteria were defined as: Moderately severe stroke (National Institute Health Stroke Scale (NIHSS) ≤9 on admission), anterior circulation LVO, acute ICS after failed stent retriever MT. Primary endpoint was the rate of improved successful recanalization after ICS defined as a modified Thrombolysis In cerebral Infarction (mTICI) score≥2b. Favorable neurological outcome was defined as an early neurological improvement (ENI) of 4 points or reaching 0 with respect to baseline NIHSS. Forty-one patients met the inclusion criteria. A median of 2 retrievals were performed (IQR 1-4) prior decision-making for ICS. ICS led in 90.2% (37/41) of cases to a final mTICI≥2b with significant improvement ( < 0.001) after the last retrieval attempt. The median NIHSS decreased ( = 0.178) from 7 (IQR 3.5-8) on admission to 2.5 (IQR 0-8.25) at discharge. ENI was observed in 47.4% (18/38). sICH occurred in 4.8% (2/41). ICS after failed thrombectomy appears to effectively improve recanalization rates in patients with moderately severe strokes. Thus, ICS should be considered also for patients with baseline NIHSS ≤9 if thrombectomy fails.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3389/fneur.2020.00097DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7034674PMC
February 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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/STROKEAHA.119.028221DOI Listing
April 2020

Ischemic Core Volume Combined with the Relative Perfusion Ratio for Stroke Outcome Prediction after Endovascular Thrombectomy.

J Neuroimaging 2020 05 10;30(3):321-326. Epub 2020 Feb 10.

Department of Radiology, University Hospital, LMU Munich, Munich, Germany.

Background And Purpose: Imaging-based selection of stroke patients for endovascular thrombectomy (EVT) remains an ongoing challenge. Our aim was to determine the value of a combined parameter of ischemic core volume (ICV) and the relative degree of cerebral blood flow in the penumbra for morphologic and clinical outcome prediction.

Methods: In this Institutional Review Board (IRB)-approved prospective observational study, 221 consecutive patients with large vessel occlusion anterior circulation stroke within 6 hours of symptom onset and subsequent EVT were included between June 2015 and August 2017. Admission computed tomography perfusion was analyzed using automated threshold-based algorithms. Perfusion-weighted ICV (pw-ICV) was calculated by multiplying ICV with the relative cerebral blood flow reduction within the penumbra. Functional outcome was assessed by standardized assessment of the modified Rankin scale (mRS) after 3 months.

Results: In multivariate analyses, pw-ICV was significantly associated with final infarction volume (FIV) (β = .38, P < .001) after adjustment for penumbra volume, age, sex and time from symptom onset. In separate multivariate analysis with either pw-ICV or ICV, pw-ICV outperformed ICV for the prediction of FIV (Akaike's information criterion: 1,072 vs. 1,089; conditional variable importance: 1,494 vs. 955). There was also a highly significant association between FIV and clinical outcome as measured by an mRS score of 2 or less (odds ratio per 10 mL = .78, P < .001). Both pw-ICV and ICV were significantly associated with NIHSS improvement (both P<.05).

Conclusion: In EVT-treated stroke patients, pw-ICV outperforms the more commonly used ICV in the prediction of morphological and functional outcome.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/jon.12695DOI Listing
May 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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00062-019-00874-1DOI Listing
March 2021