Publications by authors named "Marios-Nikos Psychogios"

88 Publications

Mechanical Thrombectomy for Distal Occlusions: Efficacy, Functional and Safety Outcomes: Insight from the STAR collaboration.

World Neurosurg 2021 May 8. Epub 2021 May 8.

Texas Stroke Institute, Dallas-Fort Worth, TX.

Background: Mechanical thrombectomy (MT) is the standard of care for the treatment of proximal anterior circulation large vessel occlusions. However, little is known about its efficacy and safety in the treatment of distal intracranial occlusions.

Methods: This is a multicenter retrospective study of patients treated with MT at 15 comprehensive centers between January 2015 - December 2018. The study cohort was divided into two groups based on the location of occlusion (proximal versus distal). Distal occlusion was defined as occlusion of M3 segment of the middle cerebral artery, any segment of the anterior cerebral artery or any segment of the posterior cerebral artery. Only isolated distal occlusion was included. Good outcome was defined as 90-day modified Rankin scale 0-2.

Results: A total of 4710 patients were included in this study, of whom 189 (4%) had MT for distal occlusions. Compared to the proximal occlusion group, distal occlusion group had a higher rate of good outcome (45% vs. 36%; p=0.03) and a lower rate of successful reperfusion (78% vs. 84%; p=0.04). However, the differences did not retain significance in adjusted models. Otherwise there was no difference in the rate of hemorrhagic complications, mortality or procedure-related complications between the two groups. Successful reperfusion, age and admission stroke severity emerged as predictors of good functional outcome in the distal occlusion group.

Conclusions: Thrombectomies of distal vessels achieve high rate of successful reperfusion with similar safety profile to those in more proximal locations.
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http://dx.doi.org/10.1016/j.wneu.2021.04.136DOI Listing
May 2021

Mechanical thrombectomy in acute ischaemic stroke patients with pre-interventional intracranial haemorrhage following intravenous thrombolysis.

Neuroradiol J 2021 Apr 12:19714009211009112. Epub 2021 Apr 12.

Department of Radiology, Neuroradiology and Nuclear Medicine, Ruhr-University Bochum, Germany.

Background: Data on outcome of endovascular treatment in patients with acute ischaemic stroke due to large vessel occlusion suffering from intravenous thrombolysis-associated intracranial haemorrhage prior to mechanical thrombectomy remain scarce. Addressing this subject, we report our multicentre experience.

Methods: A retrospective analysis of consecutive acute ischaemic stroke patients treated with mechanical thrombectomy due to large vessel occlusion despite the pre-interventional occurrence of intravenous thrombolysis-associated intracranial haemorrhage was performed at five tertiary care centres between January 2010-September 2020. Baseline demographics, aetiology of stroke and intracranial haemorrhage, angiographic outcome assessed by the Thrombolysis in Cerebral Infarction score and clinical outcome evaluated by the modified Rankin Scale at 90 days were recorded.

Results: In total, six patients were included in the study. Five individuals demonstrated cerebral intraparenchymal haemorrhage on pre-interventional imaging; in one patient additional subdural haematoma was observed and one patient suffered from isolated subarachnoid haemorrhage. All patients except one were treated by the 'drip-and-ship' paradigm. Successful reperfusion was achieved in 4/6 (67%) individuals. In 5/6 (83%) patients, the pre-interventional intracranial haemorrhage had aggravated in post-interventional computed tomography with space-occupying effect. Overall, five patients had died during the hospital stay. The clinical outcome of the survivor was modified Rankin Scale=4 at 90 days follow-up.

Conclusion: Mechanical thrombectomy in patients with intravenous thrombolysis-associated intracranial haemorrhage is technically feasible. The clinical outcome of this subgroup of stroke patients, however, appears to be devastating with high mortality and only carefully selected patients might benefit from endovascular treatment.
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http://dx.doi.org/10.1177/19714009211009112DOI Listing
April 2021

Neuroimaging of Acute Intracerebral Hemorrhage.

J Clin Med 2021 Mar 5;10(5). Epub 2021 Mar 5.

ASST Valcamonica, UOSD Neurology, Esine (BS), 25040 Brescia, Italy.

Intracerebral hemorrhage (ICH) accounts for 10% to 20% of all strokes worldwide and is associated with high morbidity and mortality. Neuroimaging is clinically important for the rapid diagnosis of ICH and underlying etiologies, but also for identification of ICH expansion, often as-sociated with an increased risk for poor outcome. In this context, rapid assessment of early hema-toma expansion risk is both an opportunity for therapeutic intervention and a potential hazard for hematoma evacuation surgery. In this review, we provide an overview of the current literature surrounding the use of multimodal neuroimaging of ICH for etiological diagnosis, prediction of early hematoma expansion, and prognostication of neurological outcome. Specifically, we discuss standard imaging using computed tomography, the value of different vascular imaging modalities to identify underlying causes and present recent advances in magnetic resonance imaging and computed tomography perfusion.
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http://dx.doi.org/10.3390/jcm10051086DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7962049PMC
March 2021

Global Impact of COVID-19 on Stroke Care and Intravenous Thrombolysis.

Neurology 2021 Mar 25. Epub 2021 Mar 25.

Department of Neurology, University of North Carolina at Chapel Hill, North Carolina, USA.

Objective: The objectives of this study were to measure the global impact of the pandemic on the volumes for intravenous thrombolysis (IVT), IVT transfers, and stroke hospitalizations over 4 months at the height of the pandemic (March 1 to June 30, 2020) compared with two control 4-month periods.

Methods: We conducted a cross-sectional, observational, retrospective study across 6 continents, 70 countries, and 457 stroke centers. Diagnoses were identified by their ICD-10 codes and/or classifications in stroke databases.

Results: There were 91,373 stroke admissions in the 4 months immediately before compared to 80,894 admissions during the pandemic months, representing an 11.5% (95%CI, -11.7 to - 11.3, p<0.0001) decline. There were 13,334 IVT therapies in the 4 months preceding compared to 11,570 procedures during the pandemic, representing a 13.2% (95%CI, -13.8 to -12.7, p<0.0001) drop. Interfacility IVT transfers decreased from 1,337 to 1,178, or an 11.9% decrease (95%CI, -13.7 to -10.3, p=0.001). Recovery of stroke hospitalization volume (9.5%, 95%CI 9.2-9.8, p<0.0001) was noted over the two later (May, June) versus the two earlier (March, April) pandemic months. There was a 1.48% stroke rate across 119,967 COVID-19 hospitalizations. SARS-CoV-2 infection was noted in 3.3% (1,722/52,026) of all stroke admissions.

Conclusions: The COVID-19 pandemic was associated with a global decline in the volume of stroke hospitalizations, IVT, and interfacility IVT transfers. Primary stroke centers and centers with higher COVID19 inpatient volumes experienced steeper declines. Recovery of stroke hospitalization was noted in the later pandemic months.
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http://dx.doi.org/10.1212/WNL.0000000000011885DOI Listing
March 2021

Aspirin versus anticoagulation in cervical artery dissection (TREAT-CAD): an open-label, randomised, non-inferiority trial.

Lancet Neurol 2021 05 23;20(5):341-350. Epub 2021 Mar 23.

Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland; Neurology and Neurorehabilitation, University Hospital for Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland.

Background: Cervical artery dissection is a major cause of stroke in young people (aged <50 years). Historically, clinicians have preferred using oral anticoagulation with vitamin K antagonists for patients with cervical artery dissection, although some current guidelines-based on available evidence from mostly observational studies-suggest using aspirin. If proven to be non-inferior to vitamin K antagonists, aspirin might be preferable, due to its ease of use and lower cost. We aimed to test the non-inferiority of aspirin to vitamin K antagonists in patients with cervical artery dissection.

Methods: We did a multicentre, randomised, open-label, non-inferiority trial in ten stroke centres across Switzerland, Germany, and Denmark. We randomly assigned (1:1) patients aged older than 18 years who had symptomatic, MRI-verified, cervical artery dissection within 2 weeks before enrolment, to receive either aspirin 300 mg once daily or a vitamin K antagonist (phenprocoumon, acenocoumarol, or warfarin; target international normalised ratio [INR] 2·0-3·0) for 90 days. Randomisation was computer-generated using an interactive web response system, with stratification according to participating site. Independent imaging core laboratory adjudicators were masked to treatment allocation, but investigators, patients, and clinical event adjudicators were aware of treatment allocation. The primary endpoint was a composite of clinical outcomes (stroke, major haemorrhage, or death) and MRI outcomes (new ischaemic or haemorrhagic brain lesions) in the per-protocol population, assessed at 14 days (clinical and MRI outcomes) and 90 days (clinical outcomes only) after commencing treatment. Non-inferiority of aspirin would be shown if the upper limit of the two-sided 95% CI of the absolute risk difference between groups was less than 12% (non-inferiority margin). This trial is registered with ClinicalTrials.gov, NCT02046460.

Findings: Between Sept 11, 2013, and Dec 21, 2018, we enrolled 194 patients; 100 (52%) were assigned to the aspirin group and 94 (48%) were assigned to the vitamin K antagonist group. The per-protocol population included 173 patients; 91 (53%) in the aspirin group and 82 (47%) in the vitamin K antagonist group. The primary endpoint occurred in 21 (23%) of 91 patients in the aspirin group and in 12 (15%) of 82 patients in the vitamin K antagonist group (absolute difference 8% [95% CI -4 to 21], non-inferiority p=0·55). Thus, non-inferiority of aspirin was not shown. Seven patients (8%) in the aspirin group and none in the vitamin K antagonist group had ischaemic strokes. One patient (1%) in the vitamin K antagonist group and none in the aspirin group had major extracranial haemorrhage. There were no deaths. Subclinical MRI outcomes were recorded in 14 patients (15%) in the aspirin group and in 11 patients (13%) in the vitamin K antagonist group. There were 19 adverse events in the aspirin group, and 26 in the vitamin K antagonist group.

Interpretation: Our findings did not show that aspirin was non-inferior to vitamin K antagonists in the treatment of cervical artery dissection.

Funding: Swiss National Science Foundation, Swiss Heart Foundation, Stroke Funds Basel, University Hospital Basel, University of Basel, Academic Society Basel.
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http://dx.doi.org/10.1016/S1474-4422(21)00044-2DOI Listing
May 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.
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http://dx.doi.org/10.1001/jamaneurol.2021.0001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7900924PMC
April 2021

Global impact of COVID-19 on stroke care.

Int J Stroke 2021 Mar 29:1747493021991652. Epub 2021 Mar 29.

Neurology, Grady Memorial Hospital, Emory University, Atlanta, Georgia, USA.

Background: The COVID-19 pandemic led to profound changes in the organization of health care systems worldwide.

Aims: We sought to measure the global impact of the COVID-19 pandemic on the volumes for mechanical thrombectomy, stroke, and intracranial hemorrhage hospitalizations over a three-month period at the height of the pandemic (1 March-31 May 2020) compared with two control three-month periods (immediately preceding and one year prior).

Methods: Retrospective, observational, international study, across 6 continents, 40 countries, and 187 comprehensive stroke centers. The diagnoses were identified by their ICD-10 codes and/or classifications in stroke databases at participating centers.

Results: The hospitalization volumes for any stroke, intracranial hemorrhage, and mechanical thrombectomy were 26,699, 4002, and 5191 in the three months immediately before versus 21,576, 3540, and 4533 during the first three pandemic months, representing declines of 19.2% (95%CI, -19.7 to -18.7), 11.5% (95%CI, -12.6 to -10.6), and 12.7% (95%CI, -13.6 to -11.8), respectively. The decreases were noted across centers with high, mid, and low COVID-19 hospitalization burden, and also across high, mid, and low volume stroke/mechanical thrombectomy centers. High-volume COVID-19 centers (-20.5%) had greater declines in mechanical thrombectomy volumes than mid- (-10.1%) and low-volume (-8.7%) centers (p < 0.0001). There was a 1.5% stroke rate across 54,366 COVID-19 hospitalizations. SARS-CoV-2 infection was noted in 3.9% (784/20,250) of all stroke admissions.

Conclusion: The COVID-19 pandemic was associated with a global decline in the volume of overall stroke hospitalizations, mechanical thrombectomy procedures, and intracranial hemorrhage admission volumes. Despite geographic variations, these volume reductions were observed regardless of COVID-19 hospitalization burden and pre-pandemic stroke/mechanical thrombectomy volumes.
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http://dx.doi.org/10.1177/1747493021991652DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8010375PMC
March 2021

Neural Progenitor Cell-Derived Extracellular Vesicles Enhance Blood-Brain Barrier Integrity by NF-κB (Nuclear Factor-κB)-Dependent Regulation of ABCB1 (ATP-Binding Cassette Transporter B1) in Stroke Mice.

Arterioscler Thromb Vasc Biol 2021 03 17;41(3):1127-1145. Epub 2020 Dec 17.

Department of Neurology (L.Z., I.G., Y.K., X.Z., M.H., M.S.W., M.B., T.R.D.), University Medical Center Göttingen, Germany.

Objective: Extracellular vesicles (EVs) derived from neural progenitor cells enhance poststroke neurological recovery, albeit the underlying mechanisms remain elusive. Since previous research described an enhanced poststroke integrity of the blood-brain barrier (BBB) upon systemic transplantation of neural progenitor cells, we examined if neural progenitor cell-derived EVs affect BBB integrity and which cellular mechanisms are involved in the process. Approach and Results: Using in vitro models of primary brain endothelial cell (EC) cultures as well as co-cultures of brain ECs (ECs) and astrocytes exposed to oxygen glucose deprivation, we examined the effects of EVs or vehicle on microvascular integrity. In vitro data were confirmed using a mouse transient middle cerebral artery occlusion model. Cultured ECs displayed increased ABCB1 (ATP-binding cassette transporter B1) levels when exposed to oxygen glucose deprivation, which was reversed by treatment with EVs. The latter was due to an EV-induced inhibition of the NF-κB (nuclear factor-κB) pathway. Using a BBB co-culture model of ECs and astrocytes exposed to oxygen glucose deprivation, EVs stabilized the BBB and ABCB1 levels without affecting the transcellular electrical resistance of ECs. Likewise, EVs yielded reduced Evans blue extravasation, decreased ABCB1 expression as well as an inhibition of the NF-κB pathway, and downstream matrix metalloproteinase 9 (MMP-9) activity in stroke mice. The EV-induced inhibition of the NF-κB pathway resulted in a poststroke modulation of immune responses.

Conclusions: Our findings suggest that EVs enhance poststroke BBB integrity via ABCB1 and MMP-9 regulation, attenuating inflammatory cell recruitment by inhibition of the NF-κB pathway. Graphic Abstract: A graphic abstract is available for this article.
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http://dx.doi.org/10.1161/ATVBAHA.120.315031DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7901534PMC
March 2021

Bridging therapy is associated with improved cognitive function after large vessel occlusion stroke - an analysis of the German Stroke Registry.

Neurol Res Pract 2020 27;2:29. Epub 2020 Jul 27.

Department of Neurology, University Medicine Göttingen, Göttingen, Germany.

Background: The targeted use of endovascular therapy (EVT), with or without intravenous thrombolysis (IVT) in acute large cerebral vessel occlusion stroke (LVOS) has been proven to be superior compared to IVT alone. Despite favorable functional outcome, many patients complain about cognitive decline after EVT. If IVT in addition to EVT has positive effects on cognitive function is unclear.

Methods: We analyzed data from the German Stroke Registry (GSR, an open, multicenter and prospective observational study) and compared cognitive function 90 days after index ischemic stroke using MoCA in patients with independent (mRS ≤ 2 pts) and excellent (mRS = 0 pts) functional outcome receiving combined EVT and IVT (EVT + IVT) vs. EVT alone (EVT-IVT).

Results: Of the 2636 GSR patients, we included 166 patients with mRS ≤ 2 at 90 days in our analysis. Of these, 103 patients (62%) received EVT + IVT, 63 patients (38%) were treated with EVT alone. There was no difference in reperfusion status between groups (mTICI ≥ 2b in both groups at 95%,  = 0.65). Median MoCA score in the EVT + IVT group was 20 pts. (18-25 IQR) vs. 18 pts. (16-21 IQR) in the EVT-IVT group ( = 0.014). There were more patients with cognitive impairment (defined as MoCA < 26 pts) in the EVT-IVT group (54 patients (86%)) compared to the EVT + IVT group (78 patients (76%)). EVT + IVT was associated with a higher MoCA score at 90 days (mRS ≤ 2:  = 0.033, B = 2.39; mRS = 0:  = 0.021, B = 4.38).

Conclusions: In Patients with good functional outcome after LVOS, rates of cognitive impairment are lower with combined EVT and IVT compared to EVT alone.

Trial Registration: ClinicalTrials.gov Identifier: NCT03356392.
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http://dx.doi.org/10.1186/s42466-020-00079-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7650060PMC
July 2020

Emerging stroke systems of care in Germany.

Handb Clin Neurol 2021 ;176:409-415

Institute of Neuroradiology, University Medical Center Goettingen, Goettingen, Germany; Department of Neuroradiology, University Hospital Basel, Basel, Switzerland. Electronic address:

In order to reduce intrahospital times for stroke patients, we have implemented various strategies throughout the last 4 years. Swift restoration of cerebral perfusion is essential for the outcomes of patients with acute ischemic stroke. Endovascular treatment (EVT) has become the standard of care to accomplish this in patients with acute stroke due to large vessel occlusion (LVO). To achieve reperfusion of ischemic brain regions as fast as possible, all in-hospital time delays have to be avoided. Therefore management of patients with acute ischemic stroke was optimized with an interdisciplinary standard operating procedure (SOP). Stroke neurologists, diagnostic as well as interventional neuroradiologists, and anesthesiologists streamlined all necessary processes from patient admission and diagnosis to EVT of eligible patients. In a second step we established a one-stop management of stroke patients, meaning that imaging was acquired with the same angiography suite use for treatment of patients with LVO. In the last section of this chapter we discuss the latest trials on stroke therapy and their implications for our current triage systems and imaging patterns.
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http://dx.doi.org/10.1016/B978-0-444-64034-5.00022-5DOI Listing
January 2021

Automated Perfusion Calculations vs. Visual Scoring of Collaterals and CBV-ASPECTS : Has the Machine Surpassed the Eye?

Clin Neuroradiol 2020 Nov 20. Epub 2020 Nov 20.

Department of Neuroradiology, Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Spitalstr. 21, 4031, Basel, Switzerland.

Purpose: Use of automated perfusion software has gained importance for imaging of stroke patients for mechanical thrombectomy (MT). We aim to compare four perfusion software packages: 1) with respect to their association with 3‑month functional outcome after successful reperfusion with MT in comparison to visual Cerebral Blood Volume - Alberta Stroke Program Early CT Score (CBV-ASPECTS) and collateral scoring and 2) with respect to their agreement in estimation of core and penumbra volume.

Methods: This retrospective, multicenter cohort study (2015-2019) analyzed data from 8 centers. We included patients who were functionally independent before and underwent successful MT of the middle cerebral artery. Primary outcome measurements were the relationship of core and penumbra volume calculated by each software, qualitative assessment of collaterals and CBV-APECTS with 3‑month functional outcome and disability (modified Rankin scale >2). Quantitative differences between perfusion software measurements were also assessed.

Results: A total of 215 patients (57% women, median age 77 years) from 8 centers fulfilled the inclusion criteria. Multivariable analyses showed a significant association of RAPID core (common odds ratio, cOR 1.02; p = 0.015), CBV-ASPECTS (cOR 0.78; p = 0.007) and collaterals (cOR 0.78; p = 0.001) with 3‑month functional outcome (shift analysis), while RAPID core (OR 1.02; p = 0.018), CBV-ASPECTS (OR 0.77; p = 0.024), collaterals (OR 0.78; p = 0.007) and OLEA core (OR 1.02; p = 0.029) were significantly associated with 3‑month functional disability. Mean differences on core estimates between VEOcore and RAPID were 13.4 ml, between syngo.via and RAPID 30.0 ml and between OLEA and RAPID -3.2 ml.

Conclusion: Collateral scoring, CBV-ASPECTS and RAPID were independently associated with functional outcome at 90 days. Core and Penumbra estimates using automated software packages varied significantly and should therefore be used with caution.
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http://dx.doi.org/10.1007/s00062-020-00974-3DOI Listing
November 2020

T1 Mapping Quantifies Spinal Cord Compression in Patients With Various Degrees of Cervical Spinal Canal Stenosis.

Front Neurol 2020 30;11:574604. Epub 2020 Oct 30.

Department of Neurology, University Medical Center Göttingen, Göttingen, Germany.

Age-related degeneration of the cervical spinal column is the most common cause of spinal cord lesions. T1 mapping has been shown to indicate the grade and site of spinal cord compression in low grade spinal canal stenosis (SCS). Aim of our study was to further investigate the diagnostic potential of a novel T1 mapping method at 0.75 mm resolution and 4 s acquisition time in 31 patients with various grades of degenerative cervical SCS. T1 mapping was performed in axial sections of the stenosis as well as above and below. Included subjects received standard T2-weighted MRI of the cervical spine (including SCS-grading 0-III), electrophysiological, and clinical examination. We found that patients with cervical SCS showed a significant difference in T1 relaxation times within the stenosis (727 ± 66 ms, mean ± standard deviation) in comparison to non-stenotic segments above (854 ± 104 ms, < 0.001) and below (893 ± 137 ms, < 0.001). There was no difference in mean T1 in non-stenotic segments in patients ( = 0.232) or between segments in controls ( = 0.272). Mean difference of the T1 relaxation times was significantly higher in grade III stenosis (234 ± 45) vs. in grade II stenosis (176 ± 45, = 0.037) vs. in grade I stenosis (90 ± 87 ms, = 0.010). A higher difference in T1 relaxation time was associated with a central efferent conduction deficit. In conclusion, T1 mapping may be useful as a tool for SCS quantification in all grades of SCS, including high-grade stenosis with myelopathy signal in conventional T2-weighted imaging.
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http://dx.doi.org/10.3389/fneur.2020.574604DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7662110PMC
October 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.
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http://dx.doi.org/10.1212/WNL.0000000000011107DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7884981PMC
January 2021

[Management of unruptured intracranial Aneurysms].

Ther Umsch 2020 ;77(8):391-399

Abteilung für interventionelle und diagnostische Neuroradiologie, Klinik für Radiologie und Nuklearmedizin, Universitätsspital Basel.

Management of unruptured intracranial Aneurysms Unruptured intracranial aneurysms (UIAs) are a common coincidental finding in cranial imaging of patients with non-correlated symptoms such as headache or dizziness. With an estimated prevalence of around 1 - 2 % in the general population, these UIAs often present clinicians with difficult decisions. This is particularly the case since, despite extensive research in this area, the natural course of UIAs is still poorly understood and the risk of rupture cannot be specified. Due to often catastrophically clinical outcomes as a result of an aneurysmal subarachnoid haemorrhage (mortality-rates of up to 51 %), the desire for intervention and the emotional burden on the patient in the case of diagnosis of an UIA is often very high. For this reason, the knowledge of average rupture rates, factors that influence them, but also knowledge of the complication rates and the result of interventions is essential for the clinician in order to arrive together with the patient at a responsible and reasonable decision regarding the treatment of an UIA. In this review, we present the current state of science regarding the natural course of UIAs, the possibilities of intervention and strategies in patient management based on current guidelines.
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http://dx.doi.org/10.1024/0040-5930/a001209DOI Listing
October 2020

Evolution of Cortical and White Matter Lesion Load in Early-Stage Multiple Sclerosis: Correlation With Neuroaxonal Damage and Clinical Changes.

Front Neurol 2020 4;11:973. Epub 2020 Sep 4.

Translational Imaging in Neurology (ThINk) Basel, Department of Biomedical Engineering, Basel University Hospital, University of Basel, Basel, Switzerland.

Changes in cortical and white matter lesion (CL, WML) load are pivotal metrics to diagnose and monitor multiple sclerosis patients. Yet, the relationship between (i) changes in CL/WML load and disease progression and between (ii) changes in CL/WML load and neurodegeneration at early MS stages is not yet established. In this work, we have assessed the hypothesis that the combined CL and WML load as well as their 2-years evolution are surrogate markers of neurodegeneration and clinical progression at early MS stages. To achieve this goal, we have studied a group of RRMS patients and have investigated the impact of both CL and WML load on neuroaxonal damage as measured by serum neurofilament light chain (sNfL). Next, we have explored whether changes in CL/WML load over 2 years in the same cohort of early-MS are related to motor and cognitive changes. Thirty-two RRMS patients (<5 years disease duration) underwent: (i) 3T MRI for CL/WML detection and clinical assessment at baseline and 2-years follow-up; and (ii) baseline blood test for sNfL. The correlation between the number and volume of CL/WML and sNfL was assessed by using the Spearman's rank correlation coefficient and a generalized linear model (GLM). A GLM was also used to assess the relationship between (i) the number/volume of new, enlarged, resolved, shrunken, stable lesions and (ii) the difference in clinical scores between two time-points. At baseline, sNfL levels correlated with both total CL count/volume (ρ = 0.6/0.7, Corr- <0.017/Corr- < 0.001) and with total WML count/volume (ρ = 0.6/0.6, Corr- < 0.01 for both). Baseline sNfL levels also correlated with new WML count/volume (ρ = 0.6/0.5, Corr-P < 0.01/Corr-P < 0.05) but not with new CL. Longitudinal changes in CL and WML count and volume were significantly associated with (i) sustained attention, auditory information, processing speed and flexibility ( < 0.01), (ii) verbal memory ( < 0.01); (iii) verbal fluency ( < 0.05); and (iv) hand-motor function ( < 0.05). : Changes in cortical and white matter focal damage in early MS patients correlate with global neuroaxonal damage and is associated to cognitive performances.
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http://dx.doi.org/10.3389/fneur.2020.00973DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7498574PMC
September 2020

Modeling the Optimal Transportation for Acute Stroke Treatment : Impact of Diurnal Variations in Traffic Rate.

Clin Neuroradiol 2020 Jul 16. Epub 2020 Jul 16.

Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Haus Ost 22 (O 22), Martinistr. 52, 20246, Hamburg, Germany.

Purpose: Prolonged transfer times between the primary stroke center (PSC) and the comprehensive stroke center (CSC) are one of the major causes of treatment delay for endovascular stroke treatment. We aimed to analyze the effect of the diurnal variations in traffic rates at weekdays and weekends on the catchment area size of three transportation paradigms, i.e. mothership, drip-and-ship (DS) and drip-and-drive (DD).

Methods: A conditional probability model that predicts the probability of good outcome for patients with suspected large vessel occlusion was used to analyze the prehospital stroke triage in northwest Germany and produce catchment area maps. Transportation times were calculated during each hour of a weekday and a Sunday using Google Maps. For comparison, real DD transportation times from our CSC in Hamburg-Eppendorf (blinded for review) to a PSC in Lüneburg were prospectively recorded.

Result: On weekdays, the mothership catchment area was the largest (≥40,000 km, 63%) except for a decrease during morning rush hours, when the DD catchment area was highest (30,879 km, 48%). The DS catchment area was higher than the DD catchment area during the afternoon rush hours both during the week as well as on Sundays.

Conclusion: Our study showed a considerable impact of the diurnal variations in traffic rate and direction of travel on optimal stroke transportation. Stroke systems of care should take real time traffic information into account.
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http://dx.doi.org/10.1007/s00062-020-00933-yDOI Listing
July 2020

Neurointerventional Robotics: Challenges and Opportunities.

Clin Neuroradiol 2020 06;30(2):203-208

Department of Clinical Neurosciences, Foothills Medical Centre, University of Calgary, 1403 29th St. NW, T2N2T9, Calgary, AB, Canada.

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http://dx.doi.org/10.1007/s00062-020-00913-2DOI Listing
June 2020

Angioplasty with the scepter C dual lumen balloon catheter and postprocedural result evaluation in patients with subarachnoid hemorrhage related vasospasms.

BMC Neurol 2020 Jun 29;20(1):260. Epub 2020 Jun 29.

Department of Neuroradiology, University Medical Center Goettingen, Robert-Koch-Str. 40, 37075, Gottingen, Germany.

Background: Delayed cerebral ischemia is one of the leading causes of death and disability in patients with subarachnoid hemorrhage (SAH). Transluminal balloon angioplasty (TBA) is a therapeutic option for vasospasms affecting proximal intracranial arteries.

Methods: Aim of this study was to report our experience using the Scepter C balloon catheter in the treatment of cerebral vasospasms due to SAH and evaluate the postprocedural result with the iFlow tool. We reviewed cases of patients treated at our hospital from 2014 to 2018. Patients were screened with transcranial doppler sonography (TCD) and multimodal computed tomography. In case of significant vasospasms, patients were transferred to the angiography suite and treated. We used the iFlow tool to quantify and evaluate the angiographic results by measuring and comparing peak density values on angiograms before and after the mechanical dilation.

Results: The use of the Scepter C balloon catheter was feasible in all cases. Vasospasms of the anterior cerebral artery were treated in ten cases. We didn't observe complications or vasospasm recurrences of the treated arteries. The temporal difference between distal vessels and the proximal reference vessel was significantly reduced from a mean of 53%, prior to dilatation, to 26% after the treatment. The difference between pre-dilatation and post-dilatation values was statistically significant for the anterior circulation at the proximal as well as at the distal vessels.

Conclusions: We successfully treated endovascularly patients suffering from cerebral vasospasms refractory to medical treatment using the Scepter C balloon catheter. We didn't observe any complications. The therapeutic effect could be easily and reliably assessed with the iFlow tool.
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http://dx.doi.org/10.1186/s12883-020-01792-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7322884PMC
June 2020

Neuroimaging of Pediatric Intracerebral Hemorrhage.

J Clin Med 2020 May 18;9(5). Epub 2020 May 18.

Pediatric Radiology Department, Necker Enfants Malades & GHU Paris, Sainte-Anne Hospital, Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR S1266, INSERM, Université de Paris, 75015 Paris, France.

Hemorrhagic strokes account for half of all strokes seen in children, and the etiologies of these hemorrhagic strokes differ greatly from those seen in adult patients. This review gives an overview about incidence and etiologies as well as presentation of children with intracerebral hemorrhage and with differential diagnoses in the emergency department. Most importantly it describes how neuroimaging of children with intracerebral hemorrhage should be tailored to specific situations and clinical contexts and recommends specific imaging protocols for acute and repeat imaging. In this context it is important to keep in mind the high prevalence of underlying vascular lesions and adapt the imaging protocol accordingly, meaning that vascular imaging plays a key role regardless of modality. Magnetic resonance imaging (MRI), including advanced sequences, should be favored whenever possible at the acute phase.
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http://dx.doi.org/10.3390/jcm9051518DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7290500PMC
May 2020

Thrombectomy Technique Predicts Outcome in Posterior Circulation Stroke-Insights from the STAR Collaboration.

Neurosurgery 2020 10;87(5):982-991

Department of Neurosurgery, University of Florida, Gainesville, Florida.

Background: Randomized controlled trials evaluating mechanical thrombectomy (MT) for acute ischemic stroke predominantly studied anterior circulation patients. Both procedural and clinical predictors of outcome in posterior circulation patients have not been evaluated in large cohort studies.

Objective: To investigate technical and clinical predictors of functional independence after posterior circulation MT while comparing different frontline thrombectomy techniques.

Methods: In a retrospective multicenter international study of 3045 patients undergoing MT for stroke between 06/2014 and 12/2018, 345 patients had posterior circulation strokes. MT was performed using aspiration, stent retriever, or combined approach. Functional outcomes were assessed using the 90-d modified Rankin score dichotomized into good (0-2) and poor outcomes (3-6).

Results: We included 2700 patients with anterior circulation and 345 patients with posterior circulation strokes. Posterior patients (age: 60 ± 14, 46% females) presented with mainly basilar occlusion (80%) and were treated using contact aspiration or ADAPT (39%), stent retriever (31%) or combined approach (19%). Compared to anterior strokes, posterior strokes had delayed treatment (500 vs 340 min, P < .001), higher national institute of health stroke scale (NIHSS) (17.1 vs 15.7, P < .01) and lower rates of good outcomes (31% vs 43%, P < .01). In posterior MT, diabetes (OR = 0.28, 95%CI: 0.12-0.65), admission NIHSS (OR = 0.9, 95%CI: 0.86-0.94), and use of stent retriever (OR = 0.26, 95%CI: 0.11-0.62) or combined approach (OR = 0.35, 95%CI: 0.12-1.01) vs ADAPT were associated with lower odds of good outcome. Stent retriever use was associated with lower odds of good outcomes compared to ADAPT even when including patients with only basilar occlusion or with successful recanalization only.

Conclusion: Despite similar safety profiles, use of ADAPT is associated with higher rates of functional independence after posterior circulation thrombectomy compared to stent retriever or combined approach in large "real-world" retrospective study.
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http://dx.doi.org/10.1093/neuros/nyaa179DOI Listing
October 2020

Correction to: SMART coils for intracranial aneurysm repair - a single center experience.

BMC Neurol 2020 May 14;20(1):188. Epub 2020 May 14.

Department of Diagnostic and Interventional Neuroradiology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany.

An amendment to this paper has been published and can be accessed via the original article.
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http://dx.doi.org/10.1186/s12883-020-01767-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7222698PMC
May 2020

Effective dose to patient measurements for flat-detector computed tomography protocols in acute stroke care.

Eur Radiol 2020 Sep 28;30(9):5082-5088. Epub 2020 Apr 28.

Department of Neuroradiology, Clinic of Radiology & Nuclear Medicine, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland.

Objectives: The aim was to measure the effective dose of flat-detector CT (FDCT) whole-brain imaging, biphasic FDCT angiography (FDCT-A), and FDCT perfusion (FDCT-P) protocols and compare it to previously reported effective dose values of multidetector CT (MDCT) applications.

Materials: We measured effective dose according to the IRCP 103 using an anthropomorphic phantom equipped with thermoluminescent dosimeters (TLDs). Placement was according to anatomical positions of each organ. In total, 60 TLDs (≥ 4 TLDs/organ) were placed into and onto the phantom to account for all relevant organs. Organs within the primary beam were covered with more TLDs. Additionally, we measured dose to the eye lens with two TLDs per eye. Protocols which we routinely use in clinical practice were measured on a biplane angiography system.

Results: The effective dose of the 20-s protocol/7-s protocol for whole-brain imaging was 2.6 mSv/2.4 mSv. The radiation dose to the eye lens was 24/23 mGy. For the biphasic high-/low-dose FDCT-A protocol, the effective dose was 8.9/2.8 mSv respectively. The eye lens dose was 60/14 mGy. The contribution of bolus tracking to the effective dose was 0.66 mSv (assuming average duration of 14 s). The multisweep FDCT-P protocol had an effective dose of 5.9 mSv and an eye lens dose of 46 mGy.

Conclusion: Except for the high-dose biphasic FDCT-A protocol, FDCT applications used in neuroradiology have effective doses, which do not deviate more than 1 mSv from previously reported values for MDCT applications. However, the effective dose to the eye lens in commonly used stroke paradigms exceeds the recommended annual dose twofold.

Key Points: • Flat-detector computed tomography (FDCT) can be used for acute and periinterventional imaging of acute stroke patients and in neurointerventions. • Except for the high-dose FDCT angiography protocol, the effective doses do not deviate more than 1 mSv from previously reported values for multidetector CT applications. • Strategies to decrease the effective lens dose especially in younger patients should be evaluated in the future.
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http://dx.doi.org/10.1007/s00330-020-06891-wDOI Listing
September 2020

Blood Pressure Goals and Clinical Outcomes after Successful Endovascular Therapy: A Multicenter Study.

Ann Neurol 2020 06 3;87(6):830-839. Epub 2020 Apr 3.

Department of Neurology, Stroke Unit, University Hospital of Nancy, Nancy, France.

Objective: Elevated systolic blood pressure (SBP) after successful revascularization (SR) via endovascular therapy (EVT) is a known predictor of poor outcome. However, the optimal SBP goal following EVT is still unknown. Our objective was to compare functional and safety outcomes between different SBP goals after EVT with SR.

Methods: This international multicenter study included 8 comprehensive stroke centers and patients with anterior circulation large vessel occlusion who were treated with EVT and achieved SR. SR was defined as modified thrombolysis in cerebral ischemia 2b to 3. Patients were divided into 3 groups based on SBP goal in the first 24 hours after EVT. Inverse probability of treatment weighting (IPTW) propensity analysis was used to assess the effect of different SBP goals on clinical outcomes.

Results: A total of 1,019 patients were included. On IPTW analysis, the SBP goal of <140mmHg was associated with a higher likelihood of good functional outcome and lower odds of hemicraniectomy compared to SBP goal of <180mmHg. Similarly, SBP goal of <160mmHg was associated with lower odds of mortality compared to SBP goal of <180mmHg. In subgroup analysis including only patients with pre-EVT SBP of ≥140mmHg, an SBP of <140mmHg was associated with a higher likelihood of good functional outcome, lower odds of symptomatic intracranial hemorrhage, and lower odds of requirement for hemicraniectomy compared to SBP goal of <180mmHg.

Interpretation: SBP goals of <140 and < 160mmHg following SR with EVT appear to be associated with better clinical outcomes than SBP of <180mmHg. ANN NEUROL 2020;87:830-839.
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http://dx.doi.org/10.1002/ana.25716DOI Listing
June 2020

Efficacy and safety of nerinetide for the treatment of acute ischaemic stroke (ESCAPE-NA1): a multicentre, double-blind, randomised controlled trial.

Lancet 2020 03 20;395(10227):878-887. Epub 2020 Feb 20.

McMaster University, Hamilton, ON, Canada.

Background: Nerinetide, an eicosapeptide that interferes with post-synaptic density protein 95, is a neuroprotectant that is effective in preclinical stroke models of ischaemia-reperfusion. In this trial, we assessed the efficacy and safety of nerinetide in human ischaemia-reperfusion that occurs with rapid endovascular thrombectomy in patients who had an acute ischaemic stroke.

Methods: For this multicentre, double-blind, randomised, placebo-controlled study done in 48 acute care hospitals in eight countries, we enrolled patients with acute ischaemic stroke due to large vessel occlusion within a 12 h treatment window. Eligible patients were aged 18 years or older with a disabling ischaemic stroke at the time of randomisation, had been functioning independently in the community before the stroke, had an Alberta Stroke Program Early CT Score (ASPECTS) greater than 4, and vascular imaging showing moderate-to-good collateral filling, as determined by multiphase CT angiography. Patients were randomly assigned (1:1) to receive intravenous nerinetide in a single dose of 2·6 mg/kg, up to a maximum dose of 270 mg, on the basis of estimated or actual weight (if known) or saline placebo by use of a real-time, dynamic, internet-based, stratified randomised minimisation procedure. Patients were stratified by intravenous alteplase treatment and declared endovascular device choice. All trial personnel and patients were masked to sequence and treatment allocation. All patients underwent endovascular thrombectomy and received alteplase in usual care when indicated. The primary outcome was a favourable functional outcome 90 days after randomisation, defined as a modified Rankin Scale (mRS) score of 0-2. Secondary outcomes were measures of neurological disability, functional independence in activities of daily living, excellent functional outcome (mRS 0-1), and mortality. The analysis was done in the intention-to-treat population and adjusted for age, sex, baseline National Institutes of Health Stroke Scale score, ASPECTS, occlusion location, site, alteplase use, and declared first device. The safety population included all patients who received any amount of study drug. This trial is registered with ClinicalTrials.gov, NCT02930018.

Findings: Between March 1, 2017, and Aug 12, 2019, 1105 patients were randomly assigned to receive nerinetide (n=549) or placebo (n=556). 337 (61·4%) of 549 patients with nerinetide and 329 (59·2%) of 556 with placebo achieved an mRS score of 0-2 at 90 days (adjusted risk ratio 1·04, 95% CI 0·96-1·14; p=0·35). Secondary outcomes were similar between groups. We observed evidence of treatment effect modification resulting in inhibition of treatment effect in patients receiving alteplase. Serious adverse events occurred equally between groups.

Interpretation: Nerinetide did not improve the proportion of patients achieving good clinical outcomes after endovascular thrombectomy compared with patients receiving placebo.

Funding: Canadian Institutes for Health Research, Alberta Innovates, and NoNO.
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http://dx.doi.org/10.1016/S0140-6736(20)30258-0DOI Listing
March 2020

SMART coils for intracranial aneurysm repair - a single center experience.

BMC Neurol 2020 Jan 29;20(1):38. Epub 2020 Jan 29.

Department of diagnostic and interventional Neuroradiology, University Medical Center Göttingen, Robert Koch Str. 40, 37075, Göttingen, Germany.

Background: Due to uniform stiffness of standard platinum coils, dense packing of intracranial aneurysms can be difficult to achieve, since stiffer coils can cause microcatheter prolapse or coil migration. SMART coils have a varying softness along the length of the coils to improve deliverability. We report our initial 2 year experience with the SMART coil system, including direct and follow-up results.

Methods: We performed a retrospective study of all patients who underwent coil embolization of an intracranial aneurysm with SMART coils between July 2016 and August 2018 at our institution. We analyzed clinical and angiographic data before and directly after treatment as well as at 6 months follow-up.

Results: A total of 49 patients harboring 49 aneurysms were treated; 23 (47%) were ruptured aneurysms. Most aneurysms (57%) were located in the anterior circulation. Median patient age was 55 (31-88), 63% were female. Mean aneurysm size was: neck 3.4 (±1.5), height 6.3 (±2.9) and width 5.2 (±2.3) mm. SMART coils were solely used in 96% of cases. Initial favorable angiographic results were achieved in 45 (92%) of 49 cases, which were stable at 6 months in 26/29 (90%). Thromboembolic complications occurred in 4 (8%) cases without clinical sequelae; microcatheter prolapse occurred in 1 case. No aneurysm rupture or device malfunction was observed.

Conclusion: The treatment of ruptured and unruptured intracranial aneurysms with SMART Coils was safe and efficacious in our cohort.
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http://dx.doi.org/10.1186/s12883-020-1623-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6988290PMC
January 2020

Initial Experience with Transradial Access for Cerebrovascular Procedures: Is It Feasible and Safe?

World Neurosurg 2020 Apr 17;136:e593-e600. Epub 2020 Jan 17.

Institute for Diagnostic and Interventional Neuroradiology, University Hospital Goettingen, Goettingen, Germany; Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland.

Background: Despite the proven benefit of transradial access over transfemoral access in cardiac procedures, the transition for cerebrovascular procedures has only been slowly enforced. We present our experience with transradial access in cerebral diagnostic angiographies and neurointerventional procedures.

Methods: We performed a retrospective analysis of patients who underwent transradial access for cerebrovascular procedures in 3 German centers between February 2017 and May 2019. Demographics, technical features, and complications were evaluated.

Results: Transradial access was successful in 40/45 endovascular procedures (89%). Selected catheterization of the intended vessels was obtained in 95% of cases (40/42). The rate of procedure-related vascular complications was 2% (1/45).

Conclusions: In this small retrospective series, transradial access proved to be safe and efficient. In the future, it is planned to further promote it as a standard access alternative for more patients.
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http://dx.doi.org/10.1016/j.wneu.2020.01.078DOI Listing
April 2020

The role of gadolinium in magnetic resonance imaging for early prostate cancer diagnosis: A diagnostic accuracy study.

PLoS One 2019 23;14(12):e0227031. Epub 2019 Dec 23.

Institute of Diagnostic and Interventional Radiology, University Hospital Jena, Jena, Germany.

Objective: Prostate lesions detected with multiparametric magnetic resonance imaging (mpMRI) are classified for their malignant potential according to the Prostate Imaging-Reporting And Data System (PI-RADS™2). In this study, we evaluate the diagnostic accuracy of the mpMRI with and without gadolinium, with emphasis on the added diagnostic value of the dynamic contrast enhancement (DCE).

Materials And Methods: The study was retrospective for 286 prostate lesions / 213 eligible patients, n = 116/170, and 49/59% malignant for the peripheral (Pz) and transitional zone (Tz), respectively. A stereotactic MRI-guided prostate biopsy served as the histological ground truth. All patients received a mpMRI with DCE. The influence of DCE in the prediction of malignancy was analyzed by blinded assessment of the imaging protocol without DCE and the DCE separately.

Results: Significant (CSPca) and insignificant (IPca) prostate cancers were evaluated separately to enhance the potential effects of the DCE in the detection of CSPca. The Receiver Operating Characteristics Area Under Curve (ROC-AUC), sensitivity (Se) and specificity (Spe) of PIRADS-without-DCE in the Pz was 0.70/0.47/0.86 for all cancers (IPca and CSPca merged) and 0.73/0.54/0.82 for CSPca. PIRADS-with-DCE for the same patients showed ROC-AUC/Se/Spe of 0.70/0.49/0.86 for all Pz cancers and 0.69/0.54/0.81 for CSPca in the Pz, respectively, p>0.05 chi-squared test. Similar results for the Tz, AUC/Se/Spe for PIRADS-without-DCE was 0.75/0.61/0.79 all cancers and 0.67/0.54/0.71 for CSPca, not influenced by DCE (0.66/0.47/0.81 for all Tz cancers and 0.61/0.39/0.75 for CSPca in Tz). The added Se and Spe of DCE for the detection of CSPca was 88/34% and 78/33% in the Pz and Tz, respectively.

Conclusion: DCE showed no significant added diagnostic value and lower specificity for the prediction of CSPca compared to the non-enhanced sequences. Our results support that gadolinium might be omitted without mitigating the diagnostic accuracy of the mpMRI for prostate cancer.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0227031PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6927639PMC
April 2020

One-Stop Management of 230 Consecutive Acute Stroke Patients: Report of Procedural Times and Clinical Outcome.

J Clin Med 2019 Dec 11;8(12). Epub 2019 Dec 11.

Department of Neurology, University Medical Center Goettingen, 37075 Goettingen, Germany.

Background And Purpose: Rapid thrombectomy for acute ischemic stroke caused by large vessel occlusion leads to improved outcome. Optimizing intrahospital management might diminish treatment delays. To examine if one-stop management reduces intrahospital treatment delays and improves functional outcome of acute stroke patients with large vessel occlusion.

Methods: We performed a single center, observational study from June 2016 to November 2018. Imaging was acquired with the latest generation angiography suite at a comprehensive stroke center. Two-hundred-thirty consecutive adults with suspected acute stroke presenting within 6 h after symptom onset with a moderate to severe National Institutes of Health Stroke Scale (≥10 in 2016; ≥7 since January 2017) were directly transported to the angiography suite by bypassing multidetector CT. Noncontrast flat-detector CT and biphasic flat-detector CT angiography were acquired with an angiography system. In case of a large vessel occlusion patients remained in the angiography suite, received intravenous rtPA therapy and underwent thrombectomy. As primary endpoints, door-to-reperfusion times and functional outcome at 90 days were recorded and compared in a case-control analysis with matched prior patients receiving standard management.

Results: A total of 230 patients (123 women, median age of 78 years (Interquartile Range (IQR) 69-84)) were included. Median symptom-to-door time was 130 min (IQR 70-195). Large vessel occlusion was diagnosed in 166/230 (72%) patients; 64/230 (28%) had conditions not suitable for thrombectomy. Median door-to-reperfusion time for M1 occlusions was 64 min (IQR 56-87). Compared to 43 case-matched patients triaged with multidetector CT, median door-to-reperfusion time was reduced from 102 (IQR 85-117) to 68 min (IQR 53-89; < 0.001). Rate of good functional outcome was significantly better in the one-stop management group ( = 0.029). Safety parameters (mortality, sICH, any hemorrhage) did not differ significantly between groups.

Conclusions: One-stop management for stroke triage reduces intrahospital time delays in our specific hospital setting.
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http://dx.doi.org/10.3390/jcm8122185DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6947228PMC
December 2019

Blood pressure reduction and outcome after endovascular therapy with successful reperfusion: a multicenter study.

J Neurointerv Surg 2020 Oct 5;12(10):932-936. Epub 2019 Dec 5.

Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA

Background: Elevated systolic blood pressure (SBP) after mechanical thrombectomy (MT) correlates with worse outcome. However, the association between SBP reduction (SBPr) and outcome after successful reperfusion with MT is not well established.

Objective: To investigate the association between SBPr in the first 24 hours after successful reperfusion and the functional and safety outcomes of MT.

Methods: A multicenter retrospective study, which included 10 comprehensive stroke centers, was carried out. Patients with acute ischemic stroke and anterior circulation large vessel occlusions who achieved successful reperfusion via MT were included. SBPr was calculated using the formula 100×([admission SBP-mean SBP]/admission SBP). Poor outcome was defined as a modified Rankin Scale (mRS) score of 3-6 at 90 days. Safety endpoints included symptomatic intracerebral hemorrhage, mortality, and requirement for hemicraniectomy during admission. A generalized mixed linear model was used to study the association between SBPr and outcomes.

Results: A total of 1361 patients were included in the final analysis. SBPr as a continuous variable was inversely associated with poor outcome (OR=0.97; 95% CI 0.95 to 0.98; p<0.001) but not with the safety outcomes. Subanalysis based on reperfusion status showed that SBPr was associated with lower odds of poor outcome only in patients with complete reperfusion (modified Thrombolysis in Cerebral Infarction (mTICI 3)) but not in patients with incomplete reperfusion (mTICI 2b). When SBPr was divided into categories (<1%, 1%-10%, 11%-20%, >20%), the rate of poor outcome was highest in the first group.

Conclusion: SBPr in the first 24 hours after successful reperfusion was inversely associated with poor outcome. No association between SBPr and safety outcome was found.
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http://dx.doi.org/10.1136/neurintsurg-2019-015561DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7998040PMC
October 2020