Publications by authors named "Gerhard Schön"

118 Publications

Accuracy of preoperative CT staging of acute colonic diverticulitis using the classification of diverticular disease (CDD) - Is there a beneficial impact of water enema and visceral obesity?

Eur J Radiol 2021 Jun 6;141:109813. Epub 2021 Jun 6.

Department of Diagnostic and Interventional Radiology and Nuclear Medicine, Center for Radiology and Endoscopy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany. Electronic address:

Purpose: We evaluated the accuracy of preoperative CT in staging colonic diverticulitis (ACD) by using the classification of diverticular disease (CDD) and investigated the diagnostic impact of water enema (WE) and visceral obesity.

Methods: In this retrospective study, the radiological and hospital information system was searched for patients who underwent CT for clinically suspected ACD prior to surgery between 2009 and 2019. From the initial population (n = 164), we included 155 patients (94.5 %) (85 women; mean age: 58 ± 13 years) matching the following inclusion criteria: i.) clinically suspected ACD, ii.) i.v. contrast-enhanced CT, iii.) surgery for ACD within 1 week after CT, iv.) histopathological report that proved ACD. The remaining 9 patients (5.5 %) were excluded because histopathological reports were lacking (n = 3) or CT was performed without intravenous contrast agent (n = 6). WE (+ butylscopolamine i.v.) was performed in 93 patients (group A, 60 %). 62 patients (group B, 40 %) had no WE. Visceral-to-subcutaneous fat ratio (V/S) was determined for each patient. Two radiologists blinded for final diagnosis independently staged ACD according to CDD and assessed prevalence and confidence ratings of ACD-related CT-findings: pericolonic fat stranding, covered- and free-perforation, local and generalized peritonitis, abscess. Interobserver-agreement of CT-findings were assessed and effects of WE and V/S ratio on the diagnostic accuracy of CT with surgical and histopathological findings as reference were determined by calculating a logistic regression model.

Results: CT-staging showed high accuracy (94 %) and excellent interrater-correlation (ICC 0.96) for staging ACD. WE had no positive impact neither on diagnostic accuracy of staging, nor on confidence ratings of ACD-related CT-findings (all p > 0.5). Confidence ratings were significantly higher in examinations without WE for perforation, peritonitis as well as abscesses (all p < 0.5). Confidence ratings for the assessment of local peritonitis improved significantly with higher V/S (p = 0.049). The increase of V/S significantly correlated with the probability for correct CDD staging of ACD in CT (p = 0.023).

Conclusion: Increase of visceral obesity significantly improves accuracy of CT in preoperative staging acute colonic diverticulitis. However, independently of the degree of visceral obesity, water enema has no diagnostic benefit and may therefore be omitted. Overall, CT proves high accuracy in preoperative staging ACD using the classification of diverticular disease.

Level Of Evidence: Retrospective study, observational study.
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http://dx.doi.org/10.1016/j.ejrad.2021.109813DOI Listing
June 2021

Corrigendum: Neoplastic and Non-neoplastic Acute Intracerebral Hemorrhage in CT Brain Scans: Machine Learning-Based Prediction Using Radiomic Image Features.

Front Neurol 2021 21;12:687610. Epub 2021 May 21.

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

[This corrects the article DOI: 10.3389/fneur.2020.00285.].
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http://dx.doi.org/10.3389/fneur.2021.687610DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8177047PMC
May 2021

The natural history of Canavan disease: 23 new cases and comparison with patients from literature.

Orphanet J Rare Dis 2021 May 19;16(1):227. Epub 2021 May 19.

Department of Neurology, MGH, Harvard Medical School, 55 Fruit St, Boston, MA, 02114, USA.

Background: Canavan disease (CD, MIM # 271900) is a rare and devastating leukodystrophy of early childhood. To identify clinical features that could serve as endpoints for treatment trials, the clinical course of CD was studied retrospectively and prospectively in 23 CD patients. Results were compared with data of CD patients reported in three prior large series. Kaplan Meier survival analysis including log rank test was performed for pooled data of 82 CD patients (study cohort and literature patients).

Results: Onset of symptoms was between 0 and 6 months. Psychomotor development of patients was limited to abilities that are usually gained within the first year of life. Macrocephaly became apparent between 4 and 18 months of age. Seizure frequency was highest towards the end of the first decade. Ethnic background was more diverse than in studies previously reported. A CD severity score with assessment of 11 symptoms and abilities was developed.

Conclusions: Early hallmarks of CD are severe psychomotor disability and macrocephaly that develop within the first 18 months of life. While rare in the first year of life, seizures increase in frequency over time in most patients. CD occurs more frequently outside Ashkenazi Jewish communities than previously reported. Concordance of phenotypes between siblings but not patients with identical ASPA mutations suggest the influence of yet unknown modifiers. A CD severity score may allow for assessment of CD disease severity both retrospectively and prospectively.
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http://dx.doi.org/10.1186/s13023-020-01659-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8132415PMC
May 2021

Impact of intravenous alteplase on sub-angiographic emboli in high-resolution diffusion-weighted imaging following successful thrombectomy.

Eur Radiol 2021 May 8. Epub 2021 May 8.

Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.

Objective: Thrombus microfragmentation causing peripheral emboli (PE) during mechanical thrombectomy (MT) may modulate treatment effects, even in cases with successful reperfusion. This study aims to investigate whether intravenous alteplase is of potential benefit in reducing PE after successful MT.

Methods: Patients from a prospective study treated at a tertiary care stroke center between 08/2017 and 12/2019 were analyzed. The main inclusion criterion was successful reperfusion after MT (defined as expanded thrombolysis in cerebral infarction (eTICI) scale ≥ 2b50) of large vessel occlusion anterior circulation stroke. All patients received a high-resolution diffusion-weighted imaging (DWI) follow-up 24 h after MT for PE detection. Patients were grouped as "direct MT" (no alteplase) or as MT plus additional intravenous alteplase. The number and volume of ischemic core lesions and PE were then quantified and analyzed.

Results: Fifty-six patients were prospectively enrolled. Additional intravenous alteplase was administered in 46.3% (26/56). There were no statistically significant differences of PE compared by groups of direct MT and additional intravenous alteplase administration regarding mean numbers (12.1, 95% CI 8.6-15.5 vs. 11.1, 95% CI 7.0-15.1; p = 0.701), and median volume (0.70 mL, IQR 0.21-1.55 vs. 0.39 mL, IQR 0.10-1.62; p = 0.554). In uni- and multivariable linear regression analysis, higher eTICI scores were significantly associated with reduced PE, while the administration of alteplase was neither associated with numbers nor volume of peripheral emboli. Additional alteplase did not alter reperfusion success.

Conclusions: Intravenous alteplase neither affects the number nor volume of sub-angiographic DWI-PE after successful endovascular reperfusion. In the light of currently running randomized trials, further studies are warranted to validate these findings.

Key Points: • Thrombus microfragmentation during endovascular stroke treatment may cause peripheral emboli that are only detectable on diffusion-weighted imaging and may directly compromise treatment effects. • In this prospective study, the application of intravenous alteplase did not influence the occurrence of peripheral emboli detected on high-resolution diffusion-weighted imaging. • A higher degree of recanalization was associated with a reduced number and volume of peripheral emboli and better functional outcome, while contrariwise, peripheral emboli did not modify the effect of recanalization on modified Rankin Scale scores at day 90.
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http://dx.doi.org/10.1007/s00330-021-07980-0DOI Listing
May 2021

The moderating effects of social support and depressive symptoms on pain among elderly multimorbid patients-data from the multicentre, prospective, observational cohort study MultiCare.

Aging Ment Health 2021 May 5:1-7. Epub 2021 May 5.

Department of Primary Medical Care, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.

Objectives: Depressive symptoms and chronic pain are common among patients with multimorbidity creating a complex medical condition for both the patient and the general practitioner. Perceived social support may function as a protective measure.

To examine the impact of perceived social support as a potential moderator between depressive symptoms and pain intensity and pain disability in daily activities in multimorbid patients aged 75+.

Method: Data from 3,189 patients of the German longitudinal cohort study MultiCare were obtained at baseline and follow-ups during 5 years. Multilevel linear mixed-effects analyses were conducted for pain intensity (model 1) and pain disability in daily activities (model 2). The interaction term social support by depression score was included to test for moderation.

Results: The interaction between social support and depressive symptoms was significantly associated with the pain intensity score 0.41 (SE=.17; 95-CI[.08;.74]) but not with the pain disability score 0.35 (SE=.19; 95-CI[-.01;.72]). Additionally, men and individuals with medium or higher educational level showed reduced pain intensity and disability scores. Pain disability scores increased with age and depressive symptoms. Increased pain scores were also found for body mass index and burden of multimorbidity.

Conclusion: Perceived social support amplified the association of depressive symptoms on pain intensity and did not show a protective function. The high scores of perceived social support among the participants may point to the practice of secondary gain due to the patients immense health burden.
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http://dx.doi.org/10.1080/13607863.2021.1916882DOI Listing
May 2021

Agreement between continuous and intermittent pulmonary artery thermodilution for cardiac output measurement in perioperative and intensive care medicine: a systematic review and meta-analysis.

Crit Care 2021 03 29;25(1):125. Epub 2021 Mar 29.

Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.

Background: Pulmonary artery thermodilution is the clinical reference method for cardiac output monitoring. Because both continuous and intermittent pulmonary artery thermodilution are used in clinical practice it is important to know whether cardiac output measurements by the two methods are clinically interchangeable.

Methods: We performed a systematic review and meta-analysis of clinical studies comparing cardiac output measurements assessed using continuous and intermittent pulmonary artery thermodilution in adult surgical and critically ill patients. 54 studies with 1522 patients were included in the analysis.

Results: The heterogeneity across the studies was high. The overall random effects model-derived pooled estimate of the mean of the differences was 0.08 (95%-confidence interval 0.01 to 0.16) L/min with pooled 95%-limits of agreement of - 1.68 to 1.85 L/min and a pooled percentage error of 29.7 (95%-confidence interval 20.5 to 38.9)%.

Conclusion: The heterogeneity across clinical studies comparing continuous and intermittent pulmonary artery thermodilution in adult surgical and critically ill patients is high. The overall trueness/accuracy of continuous pulmonary artery thermodilution in comparison with intermittent pulmonary artery thermodilution is good (indicated by a pooled mean of the differences < 0.1 L/min). Pooled 95%-limits of agreement of - 1.68 to 1.85 L/min and a pooled percentage error of 29.7% suggest that continuous pulmonary artery thermodilution barely passes interchangeability criteria with intermittent pulmonary artery thermodilution. PROSPERO registration number CRD42020159730.
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http://dx.doi.org/10.1186/s13054-021-03523-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8006374PMC
March 2021

Predictors of change in depressive symptoms in older and multimorbid patients: a longitudinal analysis of the multicare cohort.

Aging Ment Health 2021 Mar 25:1-10. Epub 2021 Mar 25.

Institute of General Practice, Goethe-University Frankfurt, Frankfurt am Main, Germany.

Background: Depression in older adults is becoming an increasing concern. As depressive symptoms change over time, it is important to understand the determinants of change in depressive symptoms. The aim of our study is to use a longitudinal study design to explore the predictors of change, remission and incident depression in older patients with multimorbidity.

Methods: Data from the MultiCare cohort study were used. The cohort studied 3,189 multimorbid general practice patients aged 65-85. Data were collected during personal interviews. Depressive symptoms were assessed using the Geriatric Depression Scale (GDS-15). Predictors of change in depressive symptoms were determined using multivariate linear regression, while multivariate logistic regression was used to analyze predictors of remission and incident depression. Models included depressive symptoms at baseline and follow-up, socio-demographics and data on health status and social support.

Results: Overall, 2,746 participants with complete follow-up data were analyzed. Mean age was 74.2 years, 59.2% were female, and 11.3% were classified as depressed at baseline. Burden of multimorbidity and social support were statistically significant predictors in all regression analyses. Further predictors of change in depressive symptoms were: income, pain, nursing grade, self-rated health and self-efficacy.

Limitations: The sample size for prediction of remission limited statistical certainty. Assessment of depressive symptoms using GDS-15 differs from routine clinical diagnoses of depression.

Conclusions: Predictors of change in depressive symptoms in older multimorbid patients are similar to those predicting remission and incident depression, and do not seem to differ significantly from other older patient populations with depressive symptoms.
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http://dx.doi.org/10.1080/13607863.2021.1902470DOI Listing
March 2021

Anticholinergic drug burden according to the anticholinergic drug scale and the German anticholinergic burden and their impact on cognitive function in multimorbid elderly German people: a multicentre observational study.

BMJ Open 2021 03 23;11(3):e044230. Epub 2021 Mar 23.

Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

Objectives: The aims of our study were to examine the anticholinergic drug use and to assess the association between anticholinergic burden and cognitive function in the multimorbid elderly patients of the MultiCare cohort.

Setting: MultiCare was conducted as a longitudinal cohort study in primary care, located in eight different study centres in Germany.

Participants: 3189 patients (59.3% female).

Primary And Secondary Outcome Measures: Baseline data were used for the following analyses. Drugs were classified according to the well-established anticholinergic drug scale (ADS) and the recently published German anticholinergic burden (German ACB). Cognitive function was measured using a letter digit substitution test (LDST) and a mixed-effect multivariate linear regression was performed to calculate the influence of anticholinergic burden on the cognitive function.

Results: Patients used 1764 anticholinergic drugs according to ADS and 2750 anticholinergics according to the German ACB score (prevalence 38.4% and 53.7%, respectively). The mean ADS score was 0.8 (±1.3), and the mean German ACB score was 1.2 (±1.6) per patient. The most common ADS anticholinergic was furosemide (5.8%) and the most common ACB anticholinergic was metformin (13.7%). The majority of the identified anticholinergics were drugs with low anticholinergic potential: 80.2% (ADS) and 73.4% (ACB), respectively. An increasing ADS and German ACB score was associated with reduced cognitive function according to the LDST (-0.26; p=0.008 and -0.24; p=0.003, respectively).

Conclusion: Multimorbid elderly patients are in a high risk for using anticholinergic drugs according to ADS and German ACB score. We especially need to gain greater awareness for the contribution of drugs with low anticholinergic potential from the cardiovascular system. As anticholinergic drug use is associated with reduced cognitive function in multimorbid elderly patients, the importance of rational prescribing and also deprescribing needs to be further evaluated.

Trial Registration Number: ISRCTN89818205.
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http://dx.doi.org/10.1136/bmjopen-2020-044230DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7993236PMC
March 2021

Imaging-Based Outcome Prediction of Acute Intracerebral Hemorrhage.

Transl Stroke Res 2021 Feb 6. Epub 2021 Feb 6.

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

We hypothesized that imaging-only-based machine learning algorithms can analyze non-enhanced CT scans of patients with acute intracerebral hemorrhage (ICH). This retrospective multicenter cohort study analyzed 520 non-enhanced CT scans and clinical data of patients with acute spontaneous ICH. Clinical outcome at hospital discharge was dichotomized into good outcome and poor outcome using different modified Rankin Scale (mRS) cut-off values. Predictive performance of a random forest machine learning approach based on filter- and texture-derived high-end image features was evaluated for differentiation of functional outcome at mRS 2, 3, and 4. Prediction of survival (mRS ≤ 5) was compared to results of the ICH Score. All models were tuned, validated, and tested in a nested 5-fold cross-validation approach. Receiver-operating-characteristic area under the curve (ROC AUC) of the machine learning classifier using image features only was 0.80 (95% CI [0.77; 0.82]) for predicting mRS ≤ 2, 0.80 (95% CI [0.78; 0.81]) for mRS ≤ 3, and 0.79 (95% CI [0.77; 0.80]) for mRS ≤ 4. Trained on survival prediction (mRS ≤ 5), the classifier reached an AUC of 0.80 (95% CI [0.78; 0.82]) which was equivalent to results of the ICH Score. If combined, the integrated model showed a significantly higher AUC of 0.84 (95% CI [0.83; 0.86], P value <0.05). Accordingly, sensitivities were significantly higher at Youden Index maximum cut-offs (77% vs. 74% sensitivity at 76% specificity, P value <0.05). Machine learning-based evaluation of quantitative high-end image features provided the same discriminatory power in predicting functional outcome as multidimensional clinical scoring systems. The integration of conventional scores and image features had synergistic effects with a statistically significant increase in AUC.
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http://dx.doi.org/10.1007/s12975-021-00891-8DOI Listing
February 2021

Training strategies for a sustainable medical care: a survey among assistant and chief physicians in a tertiary care hospital in Germany.

Innov Surg Sci 2020 Dec 21;5(3-4):20200024. Epub 2020 Dec 21.

Department of General and Visceral Surgery, Helios Kliniken Schwerin, Schwerin, Germany.

Purpose: As an essential part of the health care system, the requirements for specialist training are subject to a continuous process of change. The aim of the present study was to evaluate the current specialist training situation of all departments in a tertiary care hospital in Germany. Differences between assistant and chief physicians should be pointed out.

Materials And Methods: The analysis of the current training situation was carried out on the basis of an individually created questionnaire. The questionnaire content included career goal and specialism. The characteristic values initial training (IT), training structure (TS) and training content were measured on a numeric scale from 1 to 5. In addition, an overall assessment of the trainers' competences was performed. The questionnaire was sent to 208 assistant physicians (AP) and 34 chief physicians (CP).

Results: Totally 92 APs (44.2%) and 22 CPs (64.7%) participated. Senior physician was the most common career goal (34.1%), followed by the branch (28.6%). The importance of the topics initial training (IT) and training structure (TS) were evaluated as mean value: IT=1.5, IT=1.6; p=0.701 and TS=1.4, TS=1.5; p=0.669. The results concerning the implementation of the topics IT and TS in the daily routine show significant differences between APs and CPs (IT=2.0, IT=3.2; p=0.002; TS=1.9, TS=3.0; p<0.001). Skills lab training was acknowledged as the most important training format (CP=1.3, AP=1.5; p=0.401). The practical medical skills of the professional trainers were evaluated as high: AP: 94.6% (CP: 100.0%), as well as the training in interprofessional collaboration: AP: 79.4% (CP: 100.0%).

Conclusion: Our data underline the importance of specialist training subjects. These are partly perceived very differently by APs and CPs. Innovative concepts for the induction phase, well-structured training curricula, providing management skills, the overall use of skills labs and digital documentation might support the satisfaction and the outcome of specialist training. This could also improve quality in patient care.
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http://dx.doi.org/10.1515/iss-2020-0024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7790178PMC
December 2020

Relationship between the degree of recanalization and functional outcome in acute ischemic stroke is mediated by penumbra salvage volume.

J Neurol 2021 Jun 24;268(6):2213-2222. Epub 2021 Jan 24.

Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.

Background: The presence of metabolically viable brain tissue that may be salvageable with rapid cerebral blood flow restoration is the fundament rationale for reperfusion therapy in patients with large vessel occlusion stroke. The effect of endovascular treatment (EVT) on functional outcome largely depends on the degree of recanalization. However, the relationship of recanalization degree and penumbra salvage has not yet been investigated. We hypothesized that penumbra salvage volume mediates the effect of thrombectomy on functional outcome.

Methods: 99 acute anterior circulation stroke patients who received multimodal CT and underwent thrombectomy with resulting partial to complete reperfusion (modified thrombolysis in cerebral infarction scale (mTICI) ≥ 2a) were retrospectively analyzed. Penumbra volume was quantified on CT perfusion and penumbra salvage volume (PSV) was calculated as difference of penumbra and net infarct growth from admission to follow-up imaging.

Results: In patients with complete reperfusion (mTICI ≥ 2c), the median PSV was significantly higher than the median PSV in patients with partial or incomplete (mTICI 2a-2b) reperfusion (median 224 mL, IQR: 168-303 versus 158 mL, IQR: 129-225; p < 0.01). A higher degree of recanalization was associated with increased PSV (+ 63 mL per grade, 95% CI: 17-110; p < 0.01). Higher PSV was also associated with improved functional outcome (OR/mRS shift: 0.89; 95% CI: 0.85-0.95, p < 0.0001).

Conclusions: PSV may be an important mediator between functional outcome and recanalization degree in EVT patients and could serve as a more accurate instrument to compare treatment effects than infarct volumes.
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http://dx.doi.org/10.1007/s00415-021-10410-2DOI Listing
June 2021

Prevalence of definite antiphospholipid syndrome in carriers of the JAK2 mutation.

Thromb Res 2021 02 28;198:55-61. Epub 2020 Nov 28.

Department of Oncology, Hematology and Bone Marrow Transplantation with Section Pneumology, University Cancer Center Hamburg (UCCH), University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany. Electronic address:

Introduction: Patients with Philadelphia-negative myeloproliferative neoplasms (MPNs), particularly those carrying the JAK2 mutation, are at increased risk of thrombosis. While an association of MPNs with autoimmune disorders has been established, the prevalence of inherited or acquired thrombophilias in JAK2-positive patients remains obscure. We therefore investigated the coincidence of the JAK2 mutation with additional thrombogenic risk factors.

Methods: In a retrospective study, we analyzed all patients referred for thrombophilia work-up between 01/2011 and 08/2019, in whom additional JAK2 mutation analysis was performed because of thromboembolic events that were recurrent, atypically located and/or associated with abnormal blood counts.

Results: Of 472 tested patients, 49 (10.4%) were JAK2-positive. While the frequency of inherited thrombophilias (factor V Leiden and prothrombin G20210A mutation, deficiency of antithrombin, protein C, protein S) was not different between the two groups, the prevalence of definite antiphospholipid syndrome (APS), mostly associated with a moderate- or high-risk antibody profile, was significantly higher in patients with (22.4%) than in those without (8.4%) JAK2 mutation (p < 0.01). All evaluable JAK2-positive patients with APS were subsequently diagnosed with MPN. In patients with JAK2 mutation, presence of concomitant APS was associated with a significantly younger age (49 ± 14 vs. 60 ± 15 years) at the time of thrombophilia work-up (p < 0.05).

Conclusion: We found a significant association between JAK2-positive MPN and definite APS. The presence of concomitant APS in patients carrying the JAK2 mutation may lead to earlier manifestation of thromboembolic events and may warrant more aggressive antithrombotic treatment strategies to prevent recurrence.
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http://dx.doi.org/10.1016/j.thromres.2020.11.027DOI Listing
February 2021

Effect of thrombectomy on oedema progression and clinical outcome in patients with a poor collateral profile.

Stroke Vasc Neurol 2020 Nov 18. Epub 2020 Nov 18.

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

Background And Purpose: The impact of the cerebral collateral circulation on lesion progression and clinical outcome in ischaemic stroke is well established. Moreover, collateral status modifies the effect of endovascular treatment and was therefore used to select patients for therapy in prior trials. The purpose of this study was to quantify the effect of vessel recanalisation on lesion pathophysiology and clinical outcome in patients with a poor collateral profile.

Materials And Methods: 129 patients who had an ischaemic stroke with large vessel occlusion in the anterior circulation and a collateral score (CS) of 0-2 were included. Collateral profile was defined using an established 5-point scoring system in CT angiography. Lesion progression was determined using quantitative lesion water uptake measurements on admission and follow-up CT (FCT), and clinical outcome was assessed using modified Rankin Scale (mRS) scores after 90 days.

Results: Oedema formation in FCT was significantly lower in patients with vessel recanalisation compared with patients with persistent vessel occlusion (mean 19.5%, 95% CI: 17% to 22% vs mean 27%, 95% CI: 25% to 29%; p<0.0001). In a multivariable linear regression analysis, vessel recanalisation was significantly associated with oedema formation in FCT (ß=-7.31, SD=0.015, p<0.0001), adjusted for CS, age and Alberta Stroke Program Early CT Score (ASPECTS). Functional outcome was significantly better in patients following successful recanalisation (mRS at day 90: 4.5, IQR: 2-6 vs 5, IQR: 5-6, p<0.001).

Conclusion: Although poor collaterals are known to be associated with poor outcome, endovascular recanalisation was still associated with significant oedema reduction and comparably better outcome in this patient group. Patients with poor collaterals should not generally be excluded from thrombectomy.
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http://dx.doi.org/10.1136/svn-2020-000570DOI Listing
November 2020

Computed tomography-based triage of extensive baseline infarction: ASPECTS and collaterals versus perfusion imaging for outcome prediction.

J Neurointerv Surg 2020 Nov 9. Epub 2020 Nov 9.

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

Background: Patients presenting with large baseline infarctions are often excluded from mechanical thrombectomy (MT) due to uncertainty surrounding its effect on outcome. We hypothesized that computed tomography perfusion (CTP)-based selection may be predictive of functional outcome in low Alberta Stroke Program Early CT Score (ASPECTS) patients.

Methods: This was a double-center, retrospective analysis of patients presenting with ASPECTS≤5 who received multimodal admission CT imaging between May 2015 and June 2020. The predicted ischemic core (pCore) was defined as a reduction in cerebral blood flow (rCBF), while mismatch volume was defined using time to maximum (Tmax). The pCore perfusion mismatch ratio (CPMR) was also calculated. These parameters (pCore, mismatch volume, and CPMR), as well as a combined radiological score consisting of ASPECTS and collateral status (ASCO score), were tested in logistic regression and receiver operating characteristic (ROC) analyses. The primary outcome was favorable modified Rankin Scale (mRS) at discharge (≤3).

Results: A total of 113 patients met the inclusion criteria. The median ischemic core volume was 74.1 mL (IQR 43.8-121.8). The ASCO score was associated with favorable outcome at discharge (aOR 3.7, 95% CI 1.8 to 10.7, P=0.002), while no association was observed for the CTP parameters. A model including the ASCO score also had significantly higher area under the curve (AUC) values compared with the CTP-based model (0.88 vs 0.64, P=0.018).

Conclusions: The ASCO score was superior to the CTP-based model for the prediction of good functional outcome and could represent a quick, practical, and easily implemented method for the selection of low ASPECTS patients most likely benefit from MT.
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http://dx.doi.org/10.1136/neurintsurg-2020-016848DOI Listing
November 2020

Early Prediction of Malignant Cerebellar Edema in Posterior Circulation Stroke Using Quantitative Lesion Water Uptake.

Neurosurgery 2021 02;88(3):531-537

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

Background: Malignant cerebellar edema (MCE) is a life-threatening complication of ischemic posterior circulation stroke that requires timely diagnosis and management. Yet, there is no established imaging biomarker that may serve as predictor of MCE. Early edematous water uptake can be determined using quantitative lesion water uptake, but this biomarker has only been applied in anterior circulation strokes.

Objective: To test the hypothesis that lesion water uptake in early posterior circulation stroke predicts MCE.

Methods: A total 179 patients with posterior circulation stroke and multimodal admission CT were included. A total of 35 (19.5%) patients developed MCE defined by using an established 10-point scale in follow-up CT, of which ≥4 points are considered malignant. Posterior circulation net water uptake (pcNWU) was quantified in admission CT based on CT densitometry and compared with posterior circulation Acute Stroke Prognosis Early CT Score (pc-ASPECTS) as predictor of MCE using receiver operating curve (ROC) analysis and logistic regression analysis.

Results: Acute pcNWU within the early ischemic lesion was 24.6% (±8.4) for malignant and 7.2% (±7.4) for nonmalignant infarctions, respectively (P < .0001). Based on ROC analysis, pcNWU above 14.9% identified MCE with high discriminative power (area under the curve: 0.94; 95% CI: 0.89-0.97). Early pcNWU (odds ratio [OR]: 1.28; 95% CI: 1.15-1.42, P < .0001) and pc-ASPECTS (OR: 0.71, 95% CI: 0.53-0.95, P = .02) were associated with MCE, adjusted for age and recanalization status.

Conclusion: Quantitative pcNWU in early posterior circulation stroke is an important marker for MCE. Besides pc-ASPECTS, lesion water uptake measurements may further support identifying patients at risk for MCE at an early stage indicating stricter monitoring and consideration for further therapeutic measures.
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http://dx.doi.org/10.1093/neuros/nyaa438DOI Listing
February 2021

Hospitalization for Acute Respiratory Tract Infection in a Low-Antibiotic-Prescribing Setting: Cross-Sectional Data from General Practice.

Antibiotics (Basel) 2020 Sep 29;9(10). Epub 2020 Sep 29.

Institute of General Practice, Rostock University Medical Center, 18057 Rostock, Germany.

Background: Acute respiratory tract infections (ARTI) are the main cause of inappropriate antibiotic prescribing. To date, there is limited evidence concerning whether low levels of antibiotic prescribing may impact patient safety. We investigate whether antibiotic prescribing for patients seeking primary care for ARTI correlates with the odds for hospitalization.

Methods: Analysis of patient baseline data ( = 3669) within a cluster-randomized controlled trial. Adult patients suffering from ARTI in German primary care are included. The main outcome measure is acute hospitalization for respiratory infection and for any acute disease from 0 to 42 days after initial consultation.

Results: Neither the antibiotic status of individual patients (OR 0.91; 95% CI: 0.49 to 1.69; -value = 0.769) nor the physician-specific antibiotic prescription rates for ARTI (OR 1.22; 95% CI: 1.00 to 1.49; -value = 0.054) had a significant effect on hospitalization. The following factors increased the odds for hospitalization: patient's age, the ARTI being defined as lower respiratory tract infections (such as bronchitis) by the physician, the physician's perception of disease severity, and being cared for within group practices (versus treated in single-handed practices).

Conclusions: In a low-antibiotic-prescribing primary care setting such as Germany, lack of treatment with antibiotics for ARTI did not result in higher odds for hospitalization in an adult population.
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http://dx.doi.org/10.3390/antibiotics9100653DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7600502PMC
September 2020

Efficiency of Percutaneous Stent Angioplasty in Renal Artery Stenosis - 15 Years of Experience at a Single Center.

Rofo 2021 Mar 1;193(3):298-304. Epub 2020 Oct 1.

Radiologie München, München, Germany.

Purpose:  To determine the therapeutic efficiency of percutaneous revascularization in renal artery stenosis (RAS), as well as the role of comprehensive factors such as patient selection and degree of artery stenosis, on clinical outcome.

Methods And Materials:  101 patients with hemodynamically relevant RAS underwent percutaneous angioplasty (PTA). 65.7 % were male (mean age: 64 years; range: 18-84). The clinical data was retrospectively analyzed. The serum creatinine (Cr), glomerular filtration rate (GFR), and blood pressure (BP) levels pre- and postprocedural, between 6 months and 1 year, were retrospectively collected and statistically analyzed.

Results:  Follow-up data was available in 34 (33.7 %) and 28 patients (27.7 %) for Cr and MAP, respectively. A significant drop in mean arterial pressure (MAP) was observed on follow-up (mean -5.27 mmHg). Higher baseline Cr and MAP values showed a more pronounced drop in the follow-up (Cr: p 0.002; difference to baseline -0.25 mg/dL, 95 %CI:-0.36, -0.07 and BP p < 0.001; diff. to baseline -0.72 mmHg; 95 %CI: -1.4, -0.40). There was no association between comorbidities, gender, and degree of stenosis with renal and BP outcome. No significant improvement in renal function was observed on follow-up (mean Cr drop: -0.015 mg/dL). The age group 51-60 years showed a significant improvement in BP (p 0.030; diff. to baseline -19.2 mmHg; 95 %CI: -34, -4.3). There was a slight reduction in antihypertensive medication following angioplasty (0.2 fewer). Minor complications were recorded in five procedures (4.9 %).

Conclusion:  Percutaneous renal artery revascularization in the presence of atherosclerotic RAS is a safe procedure associated with a significant drop in post-procedural BP. No significant improvement in renal function was observed. Further prospective studies focused on patient selection are necessary.

Key Points:   · Percutaneous stent angioplasty in renal artery stenosis is associated with a significant improvement in post-procedural blood pressure control.. · There is no improvement in renal function after percutaneous stent angioplasty for renal artery stenosis (RAS).. · Percutaneous stent angioplasty is a safe procedure..

Citation Format: · Guerreiro H, Avanesov M, Dinnies S et al. Efficiency of Percutaneous Stent Angioplasty in Renal Artery Stenosis - 15 Years of Experience at a Single Center. Fortschr Röntgenstr 2021; 193: 298 - 304.
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http://dx.doi.org/10.1055/a-1236-4195DOI Listing
March 2021

Lesion Age Imaging in Acute Stroke: Water Uptake in CT Versus DWI-FLAIR Mismatch.

Ann Neurol 2020 12 2;88(6):1144-1152. Epub 2020 Oct 2.

Department of Neuroradiology, Westpfalz-Klinikum, Kaiserslautern, Germany.

Purpose: In acute ischemic stroke with unknown time of onset, magnetic resonance (MR)-based diffusion-weighted imaging (DWI) and fluid-attenuated inversion recovery (FLAIR) estimates lesion age to guide intravenous thrombolysis. Computed tomography (CT)-based quantitative net water uptake (NWU) may be a potential alternative. The purpose of this study was to directly compare CT-based NWU to magnetic resonance imaging (MRI) at identifying patients with lesion age < 4.5 hours from symptom onset.

Methods: Fifty patients with acute anterior circulation stroke were analyzed with both imaging modalities at admission between 0.5 and 8.0 hours after known symptom onset. DWI-FLAIR lesion mismatch was rated and NWU was measured in admission CT. An established NWU threshold (11.5%) was used to classify patients within and beyond 4.5 hours. Multiparametric MRI signal was compared with NWU using logistic regression analyses. The empirical distribution of NWU was analyzed in a consecutive cohort of patients with wake-up stroke.

Results: The median time between CT and MRI was 35 minutes (interquartile range [IQR] = 24-50). The accuracy of DWI-FLAIR mismatch was 68.8% (95% confidence interval [CI] = 53.7-81.3%) with a sensitivity of 58% and specificity of 82%. The accuracy of NWU threshold was 86.0% (95% CI = 73.3-94.2%) with a sensitivity of 91% and specificity of 78%. The area under the curve (AUC) of multiparametric MRI signal to classify lesion age <4.5 hours was 0.86 (95% CI = 0.64-0.97), and the AUC of quantitative NWU was 0.91 (95% CI = 0.78-0.98). Among 87 patients with wake-up stroke, 46 patients (53%) showed low NWU (< 11.5%).

Conclusion: The predictive power of CT-based lesion water imaging to identify patients within the time window of thrombolysis was comparable to multiparametric DWI-FLAIR MRI. A significant proportion of patients with wake-up stroke exhibit low NWU and may therefore be potentially suitable for thrombolysis. ANN NEUROL 2020;88:1144-1152.
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http://dx.doi.org/10.1002/ana.25903DOI Listing
December 2020

Early clinical surrogates for outcome prediction after stroke thrombectomy in daily clinical practice.

J Neurol Neurosurg Psychiatry 2020 10;91(10):1055-1059

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

Background And Purpose: To investigate early clinical surrogates for long-term independency of patients treated with thrombectomy for large vessel occlusion stroke in daily clinical routine.

Methods: All patients with anterior circulation stroke enrolled in the German Stroke Registry-Endovascular Treatment from 07/2015 to 04/2018 were analysed. National Institute of Health Stroke Scale (NIHSS) on admission, NIHSS percentage change, NIHSS delta and NIHSS at 24 hours as well as existing binary definitions of early neurological improvement (ENI; improvement of 8 (major ENI)/10 (dramatic ENI) NIHSS points or reaching 0/1 were compared for predicting functional outcome at 90 days using the modified Rankin Scale (mRS). Excellent and favourable outcome were defined as 0-1 and 0-2, respectively.

Results: Among 2262 endovasculary treated patients with acute ischaemic anterior circulation stroke, NIHSS at 24 hours had the highest discriminative ability to predict excellent (receiver operator characteristics (ROC) area under the curve (AUC) 0.86 (0.84-0.88)) and favourable long-term functional outcome (ROC AUC 0.86 (0.85-0.88)) in comparison to NIHSS percentage change (ROC AUC mRS ≤1: 0.81 (0.78-0.83) mRS ≤2: 0.81 (0.79-0.83)), NIHSS delta change (ROC AUC mRS ≤1: 0.74 (0.72-0.77), mRS ≤2: 0.77 (0.74-0.79)) and NIHSS admission (ROC AUC mRS ≤1: 0.70 (0.68-0.73), mRS ≤2: 0.67 (0.68-0.71)). Advanced age was the only independent predictor (adjusted OR 1.05, 95% CI 1.03 to 1.07, p<0.001) for turning the outcome prognosis from favourable (mRS ≤2) to poor (mRS ≥4) at 90 days.

Conclusion: The NIHSS at 24 hours postintervention with a threshold of ≤8 points serves best as a surrogate for long-term functional outcome after thrombectomy for anterior circulation stroke in daily clinical practice. Only advanced age significantly decreases its predictive value.
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http://dx.doi.org/10.1136/jnnp-2020-323742DOI Listing
October 2020

Personalised haemodynamic management targeting baseline cardiac index in high-risk patients undergoing major abdominal surgery: a randomised single-centre clinical trial.

Br J Anaesth 2020 08;125(2):122-132

Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine; Outcomes Research Consortium, Cleveland, OH, USA.

Background: Despite several clinical trials on haemodynamic therapy, the optimal intraoperative haemodynamic management for high-risk patients undergoing major abdominal surgery remains unclear. We tested the hypothesis that personalised haemodynamic management targeting each individual's baseline cardiac index at rest reduces postoperative morbidity.

Methods: In this single-centre trial, 188 high-risk patients undergoing major abdominal surgery were randomised to either routine management or personalised haemodynamic management requiring clinicians to maintain personal baseline cardiac index (determined at rest preoperatively) using an algorithm that guided intraoperative i.v. fluid and/or dobutamine administration. The primary outcome was a composite of major complications (European Perioperative Clinical Outcome definitions) or death within 30 days of surgery. Secondary outcomes included postoperative morbidity (assessed by a postoperative morbidity survey), hospital length of stay, mortality within 90 days of surgery, and neurocognitive function assessed after postoperative Day 3.

Results: The primary outcome occurred in 29.8% (28/94) of patients in the personalised management group, compared with 55.3% (52/94) of patients in the routine management group (relative risk: 0.54, 95% confidence interval [CI]: 0.38 to 0.77; absolute risk reduction: -25.5%, 95% CI: -39.2% to -11.9%; P<0.001). One patient assigned to the personalised management group, compared with five assigned to the routine management group, died within 30 days after surgery (P=0.097). There were no clinically relevant differences between the two groups for secondary outcomes.

Conclusions: In high-risk patients undergoing major abdominal surgery, personalised haemodynamic management reduces a composite outcome of major postoperative complications or death within 30 days after surgery compared with routine care.

Clinical Trial Registration: NCT02834377.
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http://dx.doi.org/10.1016/j.bja.2020.04.094DOI Listing
August 2020

Neoplastic and Non-neoplastic Acute Intracerebral Hemorrhage in CT Brain Scans: Machine Learning-Based Prediction Using Radiomic Image Features.

Front Neurol 2020 5;11:285. Epub 2020 May 5.

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

Early differentiation of neoplastic and non-neoplastic intracerebral hemorrhage (ICH) can be difficult in initial radiological evaluation, especially for extensive ICHs. The aim of this study was to evaluate the potential of a machine learning-based prediction of etiology for acute ICHs based on quantitative radiomic image features extracted from initial non-contrast-enhanced computed tomography (NECT) brain scans. The analysis included NECT brain scans from 77 patients with acute ICH ( = 50 non-neoplastic, = 27 neoplastic). Radiomic features including shape, histogram, and texture markers were extracted from non-, wavelet-, and log-sigma-filtered images using regions of interest of ICH and perihematomal edema (PHE). Six thousand and ninety quantitative predictors were evaluated utilizing random forest algorithms with five-fold model-external cross-validation. Model stability was assessed through comparative analysis of 10 randomly drawn cross-validation sets. Classifier performance was compared with predictions of two radiologists employing the Matthews correlation coefficient (MCC). The receiver operating characteristic (ROC) area under the curve (AUC) of the test sets for predicting neoplastic vs. non-neoplastic ICHs was 0.89 [95% CI (0.70; 0.99); < 0.001], and specificities and sensitivities reached >80%. Compared to the radiologists' predictions, the machine learning algorithm yielded equal or superior results for all evaluated metrics. The MCC of the proposed algorithm at its optimal operating point (0.69) was significantly higher than the MCC of the radiologist readers (0.54); = 0.01. Evaluating quantitative features of acute NECT images in a machine learning algorithm provided high discriminatory power in predicting non-neoplastic vs. neoplastic ICHs. Utilized in the clinical routine, the proposed approach could improve patient care at low risk and costs.
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http://dx.doi.org/10.3389/fneur.2020.00285DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7232581PMC
May 2020

Continuous noninvasive pulse wave analysis using finger cuff technologies for arterial blood pressure and cardiac output monitoring in perioperative and intensive care medicine: a systematic review and meta-analysis.

Br J Anaesth 2020 07 29;125(1):25-37. Epub 2020 May 29.

Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.

Background: Finger cuff technologies allow continuous noninvasive arterial blood pressure (AP) and cardiac output/index (CO/CI) monitoring.

Methods: We performed a meta-analysis of studies comparing finger cuff-derived AP and CO/CI measurements with invasive measurements in surgical or critically ill patients. We calculated overall random effects model-derived pooled estimates of the mean of the differences and of the percentage error (PE; CO/CI studies) with 95%-confidence intervals (95%-CI), pooled 95%-limits of agreement (95%-LOA), Cochran's Q and I (for heterogeneity).

Results: The pooled mean of the differences (95%-CI) was 4.2 (2.8 to 5.62) mm Hg with pooled 95%-LOA of -14.0 to 22.5 mm Hg for mean AP (Q=230.4 [P<0.001], I=91%). For mean AP, the mean of the differences between finger cuff technologies and the reference method was ≤5±8 mm Hg in 9/27 data sets (33%). The pooled mean of the differences (95%-CI) was -0.13 (-0.43 to 0.18) L min with pooled 95%-LOA of -2.56 to 2.23 L min for CO (Q=66.7 [P<0.001], I=90%) and 0.07 (0.01 to 0.13) L min m with pooled 95%-LOA of -1.20 to 1.15 L min m for CI (Q=5.8 [P=0.326], I=0%). The overall random effects model-derived pooled estimate of the PE (95%-CI) was 43 (37 to 49)% (Q=48.6 [P<0.001], I=63%). In 4/19 data sets (21%) the PE was ≤30%, and in 10/19 data sets (53%) it was ≤45%.

Conclusions: Study heterogeneity was high. Several studies showed interchangeability between AP and CO/CI measurements using finger cuff technologies and reference methods. However, the pooled results of this meta-analysis indicate that AP and CO/CI measurements using finger cuff technologies and reference methods are not interchangeable in surgical or critically ill patients.

Clinical Trial Number: PROSPERO registration number: CRD42019119266.
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http://dx.doi.org/10.1016/j.bja.2020.03.013DOI Listing
July 2020

Effect of Balloon Guide Catheter Utilization on the Incidence of Sub-angiographic Peripheral Emboli on High-Resolution DWI After Thrombectomy: A Prospective Observational Study.

Front Neurol 2020 7;11:386. Epub 2020 May 7.

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

Thrombus fragmentation causing distal emboli is a feared complication during mechanical thrombectomy (MT). We aimed to investigate the impact of procedural parameters and thrombus properties on the incidence of peripheral emboli after MT for large vessel occlusions (LVO). We performed a prospective analysis of patients with LVO stroke successfully treated with MT, defined as a score of 2b, 2c, or 3 on the thrombolysis in cerebral infarction (TICI) scale. A follow-up MRI including high-resolution diffusion-weighted imaging (DWI) was performed within 24 h following MT. The primary endpoint was the number and volume of peripheral emboli, classified as punctuate DWI lesions distant to the diffusion-restricted core lesion. Further analysis included the influence of baseline characteristics, procedural and outcome parameters, and thrombus properties on peripheral emboli. Thirty-seven patients with successful MT met the inclusion criteria. Use of a balloon guide catheter (BGC) and TICI were the only independent predictors for a reduced number of peripheral emboli. The use of a BGC led to a significant reduction in the number and volume of peripheral emboli, with a median number/volume of peripheral emboli of 4.5/287 μl (IQR 1.25-8.25/76-569 μl) vs. 12/938 μl (IQR 4-19/242-1,836 μl). In cases where BGC was not employed, the number of peripheral emboli increased with decreasing TICI scores. BGC-aided MT reduces the number of peripheral emboli in successful but incomplete reperfusion (TICI 2b and 2c). The effectiveness of this strategy therefore goes above and beyond that which can be demonstrated by the TICI score alone.
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http://dx.doi.org/10.3389/fneur.2020.00386DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7221024PMC
May 2020

Endoscopic vacuum therapy versus stenting for postoperative esophago-enteric anastomotic leakage: systematic review and meta-analysis.

Endoscopy 2020 08 21;52(8):632-642. Epub 2020 Apr 21.

Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

Background: Esophageal anastomotic leakage still represents a challenging complication after esophageal surgery. Endoscopically placed self-expandable metal stents (SEMS) are the treatment of choice, but since the introduction of endoscopic vacuum therapy (EVT) for esophageal leakage 10 years ago, increasing evidence has demonstrated that EVT might be a superior alternative. Therefore, we performed a systematic review and meta-analysis to compare the effectiveness and related morbidity of SEMS and EVT in the treatment of esophageal leak.

Methods: We systematically searched for studies comparing SEMS and EVT to treat anastomotic leakage after esophageal surgery. Predefined end points including outcome, treatment success, endoscopy, treatment duration, hospitalization time, morbidity, and mortality were assessed and included in the meta-analysis.

Results: Five retrospective studies including 274 patients matched the inclusion criteria. Compared with stenting, EVT was significantly associated with a higher rate of leak closure (odds ratio [OR] 3.14, 95 % confidence interval [CI] 1.23 to 7.98), more endoscopic device changes (pooled median difference of 3.09; 95 %CI 1.54 to 4.64]), a shorter duration of treatment (pooled median difference -11.90 days; 95 %CI -18.59 to -5.21 days), and a lower mortality rate (OR 0.39, 95 %CI 0.18 to 0.83). There were no significant differences in short-term and major complications.

Conclusions: Owing to the retrospective quality of the studies with potential biases, the results of the meta-analysis must be interpreted with caution. However, the analysis indicates the potential benefit of EVT, which should be further investigated with standardized and prospectively collected data.
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http://dx.doi.org/10.1055/a-1149-1741DOI Listing
August 2020

Inter- and Intrarater Agreement of Spot Sign and Noncontrast CT Markers for Early Intracerebral Hemorrhage Expansion.

J Clin Med 2020 Apr 4;9(4). Epub 2020 Apr 4.

Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany.

Background: The aim of this study was to assess the inter- and intrarater reliability of noncontrast CT (NCCT) markers [Black Hole Sign (BH), Blend Sign (BS), Island Sign (IS), and Hypodensities (HD)] and Spot Sign (SS) on CTA in patients with spontaneous intracerebral hemorrhage (ICH).

Methods: Patients with spontaneous ICH at three German tertiary stroke centers were retrospectively included. Each CT scan was rated for four NCCT markers and SS on CTA by two radiology residents. Raters were blind to all demographic and outcome data. Inter- and intrarater agreement was determined by Cohen's kappa (κ) coefficient and percentage of agreement.

Results: Interrater agreement was excellent in 473 included patients, ranging from 96% to 99%. Interrater κ ranged from 0.85 (95% CI [0.78-0.91]) to 0.97 (95% CI [0.94-0.99]) for NCCT markers and 0.93 (95% CI [0.88-0.98]) for SS, all -values < 0.001. Intrarrater agreement ranged from 96% to 100%, with κ ranging from 0.85 (95% CI [0.78-0.91]) to 1.00 (95% CI [0.10-0.85]) for NCCT markers and 0.96 (95% CI [0.92-1.00]) for SS, all -values < 0.001.

Conclusions: NCCT imaging findings and SS on CTA have good-to-excellent inter- and intrarater reliabilities, with the highest agreement for BH and SS.
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http://dx.doi.org/10.3390/jcm9041020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7231301PMC
April 2020

Ischemic lesion water homeostasis after thrombectomy for large vessel occlusion stroke within the anterior circulation: The impact of age.

J Cereb Blood Flow Metab 2021 Jan 4;41(1):45-52. Epub 2020 Apr 4.

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

The effect of age on lesion pathophysiology in the context of thrombectomy has been poorly investigated. We aimed to investigate the impact of age on ischemic lesion water homeostasis measured with net water uptake (NWU) within a multicenter cohort of patients receiving thrombectomy for anterior circulation large vessel occlusion (LVO) stroke. Lesion-NWU was quantified in multimodal CT on admission and 24 h for calculating Δ-NWU as their difference. The impact of age and procedural parameters on Δ-NWU was analyzed. Multivariable regression analysis was performed to identify significant predictors for Δ-NWU. Two hundred and four patients with anterior circulation stroke were included in the retrospective analysis. Comparison of younger and elderly patients showed no significant differences in NWU on admission but significantly higher Δ-NWU ( = 0.005) on follow-up CT in younger patients. In multivariable regression analysis, higher age was independently associated with lowered Δ-NWU (95% confidence interval: -0.59 to -0.16,  < 0.001). Although successful recanalization (TICI ≥ 2b) significantly reduced Δ-NWU progression by 6.4% ( < 0.001), younger age was still independently associated with higher Δ-NWU ( < 0.001). Younger age is significantly associated with increased brain edema formation after thrombectomy for LVO stroke. Younger patients might be particularly receptive targets for future adjuvant neuroprotective drugs that influence ischemic edema formation.
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http://dx.doi.org/10.1177/0271678X20915792DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7747157PMC
January 2021

The Myelin Water Fraction Serves as a Marker for Age-Related Myelin Alterations in the Cerebral White Matter - A Multiparametric MRI Aging Study.

Front Neurosci 2020 24;14:136. Epub 2020 Feb 24.

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

Quantitative MRI modalities, such as diffusion tensor imaging (DTI) or magnetization transfer imaging (MTI) are sensitive to the neuronal effects of aging of the cerebral white matter (WM), but lack the specificity for myelin content. Myelin water imaging (MWI) is highly specific for myelin and may be more sensitive for the detection of changes in myelin content inside the cerebral WM microstructure. In this multiparametric imaging study, we evaluated the performance of myelin water fraction (MWF) estimates as a marker for myelin alterations during normal-aging. Multiparametric MRI data derived from DTI, MTI and a novel, recently-proposed MWF-map processing and reconstruction algorithm were acquired from 54 healthy subjects (aged 18-79 years) and region-based multivariate regression analysis was performed. MWFs significantly decreased with age in most WM regions (except corticospinal tract) and changes of MWFs were associated with changes of radial diffusivity, indicating either substantial alterations or preservation of myelin content in these regions. Decreases of fractional anisotropy and magnetization transfer ratio were associated with lower MWFs in commissural fiber tracts only. Mean diffusivity had no regional effects on MWF. We conclude that MWF estimates are sensitive for the assessment of age-related myelin alterations in the cerebral WM of normal-aging brains.
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http://dx.doi.org/10.3389/fnins.2020.00136DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7050496PMC
February 2020

Is multiple sclerosis progression associated with the HLA-DR15 haplotype?

Mult Scler J Exp Transl Clin 2019 Oct-Dec;5(4):2055217319894615. Epub 2019 Dec 9.

HLA Laboratory, University Medical Center Hamburg-Eppendorf, Germany.

Background: The prevalence of multiple sclerosis is associated with the major histocompatibility complex class II DR15 haplotype HLA-DRB1*15:01∼HLA-DRB5*01:01.

Objective: To assess whether multiple sclerosis progression is associated with the main susceptibility haplotype HLA-DRB1*15:01∼HLA-DRB5*01:01.

Methods: Patients ( = 1230) and healthy controls ( = 2110) were genotyped for HLA-DRB1 and HLA-DRB5. The baseline Expanded Disability Status Scale (EDSS) score was determined and patients were followed for at least 3 years.

Results: After follow-up of the consecutive cohort 349 patients were classified as having clinical isolated syndrome and 881 patients as having multiple sclerosis. The susceptibility allele HLA-DRB1*15:01 was more frequent in clinical isolated syndrome (odds ratio 1.56) and multiple sclerosis (odds ratio 3.17) compared to controls. HLA- DRB1*15:01 was the only enriched HLA-DRB1 allele in multiple sclerosis patients. Comparison of clinical characteristics between HLA-DRB1*15:01∼HLA-DRB5*01:01 negative and positive patients with multiple sclerosis showed that baseline EDSS score, disease duration and frequency of the category secondary progressive multiple sclerosis with relapse were increased in the HLA-DRB1*15:01∼HLA-DRB5*01:01 positive group.

Conclusion: The study confirmed HLA-DRB1*15:01 and HLA-DRB5*01:01 as the main susceptibility alleles and showed weak indirect evidence for a role in progression of the disease.
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http://dx.doi.org/10.1177/2055217319894615DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6902395PMC
December 2019

Patients with low Alberta Stroke Program Early CT Score (ASPECTS) but good collaterals benefit from endovascular recanalization.

J Neurointerv Surg 2020 Aug 26;12(8):747-752. Epub 2019 Nov 26.

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

Background: Benefit of thrombectomy in patients with a low initial Alberta Stroke Program Early CT Score (ASPECTS) is still uncertain. We hypothesized that, despite low ASPECTS, patients may benefit from endovascular recanalization if good collaterals are present.

Methods: Ischemic stroke patients with large vessel occlusion in the anterior circulation and an ASPECTS of ≤5 were analyzed. Collateral status (CS) was assessed using a 5-point-scoring system in CT angiography with poor CS defined as CS=0-1. Clinical outcome was determined using the modified Rankin Scale (mRS) score after 90 days. Edema formation was measured in admission and follow-up CT by net water uptake.

Results: 27/100 (27%) patients exhibited a CS of 2-4. 50 patients underwent successful vessel recanalization and 50 patients had a persistent vessel occlusion. In multivariable logistic regression analysis, collateral status (OR 3.0; p=0.003) and vessel recanalization (OR 12.2; p=0.009) significantly increased the likelihood of a good outcome (mRS 0-3). A 1-point increase in CS was associated with 1.9% (95% CI 0.2% to 3.7%) lowered lesion water uptake in follow-up CT .

Conclusion: Endovascular recanalization in patients with ASPECTS of ≤5 but good collaterals was linked to improved clinical outcome and attenuated edema formation. Collateral status may serve as selection criterion for thrombectomy in low ASPECTS patients.
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http://dx.doi.org/10.1136/neurintsurg-2019-015308DOI Listing
August 2020

Elevated blood glucose is associated with aggravated brain edema in acute stroke.

J Neurol 2020 Feb 30;267(2):440-448. Epub 2019 Oct 30.

Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.

Background And Purpose: Clinical outcome after endovascular thrombectomy in patients with acute ischemic stroke still varies significantly. Higher blood glucose levels (BGL) have been associated with worse clinical outcome, but the pathophysiological causes are not yet understood. We hypothesized that higher levels of BGL are associated with more pronounced ischemic brain edema and worse clinical outcome mediated by cerebral collateral circulation.

Methods: 178 acute ischemic stroke patients who underwent mechanical thrombectomy were included. Early ischemic brain edema was determined using quantitative lesion water uptake on initial computed tomography (CT) and collateral status was assessed with an established 5-point scoring system in CT-angiography. Good clinical outcome was defined as functional independence (modified Rankin Scale [mRS] score 0-2). Multivariable logistic regression analysis was performed to predict functional independence and linear regression analyses to investigate the impact of BGL and collateral status on water uptake.

Results: The mean BGL at admission was significantly lower in patients with good outcome at 90 days (116.5 versus 138.5 mg/dl; p < 0.001) and early water uptake was lower (6.3% versus 9.6%; p < 0.001). The likelihood for good outcome declined with increasing BGL (odds ratio [OR] per 100 mg/dl BGL increase: 0.15; 95% CI 0.02-0.86; p = 0.039). Worse collaterals (1% water uptake per point, 95% CI 0.4-1.7%) and higher BGL (0.6% per 10 mg/dl BGL, 95% CI 0.3-0.8%) were significantly associated with increased water uptake.

Conclusion: Elevated admission BGL were associated with increased early brain edema and poor clinical outcome mediated by collateral status. Patients with higher BGL might be targeted by adjuvant anti-edematous treatment.
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http://dx.doi.org/10.1007/s00415-019-09601-9DOI Listing
February 2020