P03.11.A Potential role of pre-radiotherapy MRI for target delineation in high-grade gliomas: a multicenter retro-prospective cohort study

Background

The optimal timing for target identification in high-grade glioma (HGG) remains unclear due to variability in the hyper-signal T2/FLAIR between MRI performed at diagnosis, post-surgery and at radiotherapy (RT) start. The aim of this study was to retrospectively confirm that RT planned on delayed MRI might allow to spare more normal tissue without decreasing local tumour control, in order to prospectively evaluate the best standard and advanced MRI and metabolic imaging sequences for clinical tumor volume (CTV) adaptation.

Material and Methods

We analyzed a retrospective cohort of consecutive patients with HGG treated from 2017 to 2020. All patients had a diagnostic MRI and another performed immediately post-surgery or pre-RT. Target volumes were contoured, based on T2/FLAIR, on diagnostic and post-surgery MRI in group A, while in group B on pre-RT MRI. We analyzed GTV and CTV volume, and the percentage increase between them. Moreover, we compared the two groups in terms of clinical-pathological characteristics and progression-free survival (PFS) and overall survival (OS). A prospective study, started on January 2022, has enrolled patients with HGG evaluated by advanced sequences MRI at diagnosis, post-surgery and pre-RT. In addition, some selected patients have undergone diagnostic DOPA-PET and pre-RT DOPA-PET. 2 MRI-guided contours have been performed for each patient: adapted on T2/FLAIR post-surgery and CTV-adapt on pre-RT, to assess study objectives.

Results

In retrospective cohort we analyzed 54 patients (25 group A, 29 group B). The median age of patients was 61 years (IQR 17,75), 93% had an ECOG PS of 0 or 1, 51 were symptomatic at diagnosis. Patients in group B had more frequently MGMT methylation (59 % vs. 28%, p=0.01) while less frequently frontal lobe involvement (60% vs. 24%, p=0.01). The median percentage increase between GTV and CTV was higher in group A than B: 431% (range 62%-7335%) vs 385% (range 53%-3174%), respectively. No significant difference in the pattern of relapse was observed, since >90% of disease recurrences were in-field in both groups. Median PFS and OS of the overall population were 9.5 months (95% CI 7 - 12) and 18.5 months (95% CI 16 - 24), respectively. Patients in group B had a significant better PFS as compared to those in group A (p=0.03), but similar OS. Nevertheless, imbalance in MTMT methylation status between the two groups was a major driver for PFS. Overall, 37 out of 51 patients had improvement in neurological symptoms (p<0.001), with no difference between the two groups (p=0.54).

Conclusion

Our data suggest that CTV adaptation to pre-RT T2/FLAIR may allow reducing RT volume, without affecting symptoms relieving and disease control. Results from the prospective study will help identifying the best adaptation of CTV guided by T2/FLAIR, advanced MRI sequences and metabolic imaging, in order to optimize efficacy and safety of treatment planning.

Functional and radiological outcomes after bridging therapy versus direct thrombectomy in stroke patients with unknown onset: Bridging therapy versus direct thrombectomy in unknown onset stroke patients with 10-point ASPECTS

BACKGROUND AND PURPOSE

The aim was to assess functional and radiological outcomes after bridging therapy (intravenous thrombolysis plus mechanical thrombectomy) versus direct mechanical thrombectomy (MT) in unknown onset stroke patients.

METHODS

A cohort study was conducted on prospectively collected data from unknown onset stroke patients who received endovascular procedures at ≤6 h from symptom recognition or awakening time.

RESULTS

Of the 349 patients with a 10-point Alberta Stroke Program Early Computed Tomography Score (ASPECTS), 248 received bridging and 101 received direct MT. Of the 134 patients with 6-9-point ASPECTS, 123 received bridging and 111 received direct MT. Each patient treated with bridging was propensity score matched with a patient treated with direct MT for age, sex, study period, pre-stroke disability, stroke severity, type of stroke onset, symptom recognition to groin time (or awakening to groin time), ASPECTS and procedure time. In the two matched groups with 10-point ASPECTS (n = 73 vs. n = 73), bridging was associated with higher rates of excellent outcome (46.6% vs. 28.8%; odds ratio 2.302, 95% confidence interval 1.010-5.244) and successful recanalization (83.6% vs. 63%; odds ratio 3.028, 95% confidence interval 1.369-6.693) compared with direct MT; no significant association was found between bridging and direct MT with regard to rate of symptomatic intracerebral hemorrhage (0% vs. 1.4%). In the two matched groups with 6-9-point ASPECTS (n = 45 vs. n = 45), no significant associations were found between bridging and direct MT with regard to rates of excellent functional outcome (44.4% vs. 31.1%), successful recanalization (73.3% vs. 76.5%) and symptomatic intracerebral hemorrhage (0% vs. 0%).

CONCLUSIONS

Bridging at ≤ 6 h of symptom recognition or awakening time was associated with better functional and radiological outcomes in unknown onset stroke patients with 10-point ASPECTS.

Thromboaspiration technique as first approach for endovascular treatment of acute ischemic stroke: initial experience at nine Italian stroke centers

BACKGROUND AND PURPOSE

Aspiration thrombectomy of large vessel occlusions has made a comeback among recanalization techniques thanks to recent advances in catheter technology resulting in faster recanalization and promising clinical results when used either alone or as an adjunct to stent retriever. This multicenter retrospective study reports angiographic data, complications, and clinical outcome in patients treated with aspiration thrombectomy as the first-line option.

MATERIALS AND METHODS

We analysed the clinical and procedural data of patients treated from January 2014 to March 2015. Recanalization was assessed according to the Thrombolysis in Cerebral Infarction score. Clinical outcome was evaluated at discharge and after 3 months.

RESULTS

Overall, 152 patients (mean age 68 years) were treated. Sites of occlusion were 90.8% anterior circulation (including 16.4% tandem extracranial/intracranial occlusions) and 9.2% basilar artery. In 79 patients administration of intravenous tissue plasminogen activator was attempted. Recanalization of the target vessel was obtained in 115/152 cases (75.6%) whereas direct aspiration alone was successful in 83/152 cases (54.6%) with an average puncture to revascularization time of 44.67 min. Symptomatic intracranial hemorrhage occurred in 7.8% and embolization to new territories in 1.9%. 77 patients (50.6%) had a good outcome at 90-day follow-up: 55/96 in the direct aspiration alone group and 22/56 in the aspiration-stent retriever group.

CONCLUSIONS

Direct aspiration thrombectomy appears a feasible technique with good revascularization results achieved in more than half the patients. In light of the self-reported data, inhomogeneous patient selection, absence of a core imaging laboratory, and a non-standardized approach, the results should be validated in a larger trial.

Venous congestive myelopathy in spinal dural arteriovenous fistula mimicking neoplasia

Spinal dural arteriovenous fistulas (SDAVF) are the most common acquired arteriovenous shunts that occur in adults. By increasing venous pressure in the spinal venous system they are a cause of venous congestive myelopathy. We report the case of a patient with a SDAVF mimicking, on magnetic resonance imaging, the presence of a spinal cord tumour due to an unusual pattern of enhancement after gadolinium administration.

Carotid stenting with filter protection. Correlation of ACT values with angiographic and histopathologic findings

BACKGROUND AND PURPOSE

Filter cerebral protection during carotid stenting has been proposed as a new tool to reduce brain embolism. Angiographic findings (filter patency), pathological analysis of the collected materials inside the filters and coagulation parameters were analyzed to identify potential down sides in the use of these protection devices.

METHODS

29 consecutive endovascular treatments with filter cerebral protection in 27 patients affected by symptomatic internal carotid stenosis>70% were considered. Angiographic findings, activated clotting times and histopathologic specimens were recorded and correlated.

RESULTS

Satisfactory dilatation of the stenosis was always achieved with a complication rate of 3% (1 transient neurological deficit). During the procedure, 9 filters (31%) appeared occluded, with temporary flow impairment. Histopathologic examination demonstrated material inside the filters in 86% of cases but this material was fibrin alone in 38% and plaque debris in 48%. Significant statistical correlation (p=0.009) was found between low activated clotting time and occlusion of the filter.

CONCLUSION

Distal protection filters can collect plaque fragments occurring during carotid stenting. Significant proportion of the debris found in the filters consisted of thrombotic material. Precise monitoring of heparin anticoagulation is recommended to prevent filter occlusion.

[Endovascular treatment of carotid stenosis]

PURPOSE

To evaluate the efficacy and risks of endovascular treatment of carotid stenosis by percutaneous angioplasty and stenting, and to point out the potential indications of this technique compared to surgery.

MATERIAL AND METHODS

From June 1996 to May 2000 we performed 84 endovascular treatments of epiaortic vessels in 79 patients with age ranging from 42 to 80. Sixty-eight symptomatic carotid stenosis greater than 70% were treated in 63 patients: 28 (41%) were post-surgical restenosis of the carotid bifurcation after carotid endarterectomy and 40 (59%) were primitive carotid stenosis. In 14 cases (20%) there was occlusion of the contralateral internal carotid artery. All the procedures were performed in the angiographic suite, with local groin anesthesia and with femoral arterial approach. Angioplasty alone was done in 9 cases (13%) while stents were positioned in 59 cases (87%). The stenoses were pre-dilated in 57% of the procedures, and post-dilated in 61%. In 8 patients (12%) the endovascular treatment was performed during distal cerebral protection. During the follow-up period patients underwent echo-Doppler studies after 24 hours, at 6 and 12 months.

RESULTS AND DISCUSSION

The stenotic tracts were successfully dilated in all the patients, with a residual stenosis less than 30% in 94% of cases. We didn't observe any complication in the 30 days post-operative period. One permanent neurological deficit (1.5 %) and 1 transient neurological deficit (1.5%) were observed in 2 patients within 1 hour after treatment. Other 2 patients complained a transient ortostatic hypotension. Combined major stroke and death rates was of 1,5% after 30 days post-operative follow-up. The presence of associated occlusion of the contralateral internal carotid and the presence of cardiological failure or pulmonary insufficiency has not influenced the outcome. No new clinical complication has been reported during the follow-up while the restenosis rate after the endovascular procedure is 1.5%. Our results with the endovascular treatment of the carotid stenosis appear not significantly different from those reported by the main surgical publications and trails about the carotid endarterectomy. In particular in our experience the complication rate is similar to surgery, probably due to our patient selection and to the evolution of the materials for endovascular therapy.

CONCLUSIONS

Our experience points out an improvement of the efficacy and safety of the endovascular technique. We confirm the indication of the angioplasty and stenting in post-surgical restenosis and in patients with high surgical risk. Moreover we think that the endovascular treatment can be performed also in primitive carotid stenosis with acceptable complication risk.

Stenting of the extracranial internal carotid artery for dissecting aneurysm

Symptomatic dissecting aneurysms of the extracranial internal carotid artery are not frequent. Medical treatment of these lesions can be ineffective and surgical options present high morbidity. We describe a case successfully treated with endovascular therapy, using a self-expanding stent. The advantages of the endovascular treatment and the rationale of the use of self-expanding stents are discussed.

Haemangioma of the zygoma: case report

Haemangioma of bone in the zygoma is extremely rare. We report two cases presenting with swelling of the zygomatic region. The literature is reviewed and CT, angiographic and MRI findings are discussed.

[Percutaneous vertebral biopsy. Assessment of results]

The results were reviewed of 81 percutaneous trephine biopsies performed under fluoroscopic or CT guidance from January, 1989, to August, 1994, in 78 patients with thoracic or lumbar vertebral lesions. All the patients presented abnormal findings at conventional radiography and questionable CT or MR findings. A fine-needle sample was obtained as a complementary tool in 9 patients and material for microbiologic culture in 5 patients. Clinical and pathologic findings were correlated for each patient. Biopsy always permitted to obtain sufficient material for the histologic examination; its overall accuracy was 91%. The technique exhibited the highest diagnostic sensitivity in vertebral tumors (100%) and the lowest sensitivity in vertebral infections (69%). Complementary fine-needle sampling was useful especially in small osteolytic lesions, while the microbiologic examination was often negative. There was only one pneumothorax due to the maneuver. To conclude, percutaneous trephine biopsy of thoracic and lumbar spine lesions is a valuable tool for tumor diagnosis which usually spares the patients open surgery.

Excess prevalence of supraaortic artery lesions in renovascular hypertension: an arteriographic study

PURPOSE

High renin or renovascular hypertension (RVH) has been associated with a higher risk of stroke than low-to-normal renin hypertension. Our present purpose was to investigate the angiographic prevalence and distribution of lesions of the supraaortic arteries in a series of consecutive patients with RVH compared with control patients with low-to-normal renin primary hypertension (PH).

METHODS

Thirty-two consecutive hypertensives (21 females, 11 males, aged 23-72 years) were investigated by renal and aortic arch digital subtraction arteriography (DSA). None of them had any history or symptoms of cerebrovascular disease. In each, the presence and severity of lesions at 17 different segments of the supraaortic arteries were evaluated and a score for supraaortic lesions was then calculated based on the number and severity of lesions. RVH was diagnosed in 16 patients with renal artery stenoses and normalization of blood pressure after percutaneous transluminal renal angioplasty (PTRA) (n = 12) or surgery (n = 4). The cause of renal artery obstruction was fibrodysplasia in 5 patients (31%) and atherosclerosis in 11 (69%). PH was diagnosed in 16 patients based on a normal renal DSA and exclusion of all other possible causes of hypertension.

RESULTS

The RVH and PH groups were similar with respect to age, sex, body mass index, diabetes, smoking habits, serum triglycerides, cholesterol, and blood pressure values, and differed only in plasma renin activity (6.0 +/- 1.7 ng AngI/ml/h in RVH vs. 1.4 +/- 0.3 in PH, mean +/- SEM, p = 0.008). The score for supraaortic arterial lesions was significantly higher in RVH than in PH (181 +/- 32 vs. 17 +/- 9, p = 0.001). This difference was also evident when the five patients with fibrodysplasia were compared with five age- and sex-matched PH patients. The sites most frequently involved were the carotid artery bulb and the internal carotid artery sinus. At each affected site the score was higher for RVH than for PH.

CONCLUSION

For the same demographic features and risk profile, RVH was associated with a higher prevalence and severity of supraaortic artery lesions than PH.

Intravascular ultrasound evaluation for assessment and therapeutic decisions in aortic diseases

Intravascular sonography (IVS) was employed in several aortic pathologies. Acute dissecting aneurysm, chronic or recurrent dissection in previously repaired aneurysm, iatrogenic (postcatheterism) dissection, noncommunicating dissection (mural hematoma), chronic and acute partial thrombosis, and mural fibrosis following aspecific aortitis were studied. The stationary and dynamic observations combined with angiographic findings provided useful information for characterization of the lesions and for therapeutic decisions. In all 14 patients studied, supplemental data achieved from IVS suggest that a combination of angiography and IVS is the most nearly complete examination for concomitant and fast diagnostic workup.

[The percutaneous transluminal angioplasty of Brescia-Cimino arteriovenous fistulae. An evaluation of the results]

The average patency time after creating an endogenous arteriovenous Brescia-Cimino fistula for hemodialysis is limited. May 1990 through October 1992, 29 PTAs were performed in 23 patients with malfunctioning hemodialysis Brescia-Cimino fistulas of the forearm, by cannulation of the venous anastomotic branch and by balloon catheter dilatation. Thirty-six venous stenoses, 7 arterial anastomotic stenoses and 1 venous occlusion were treated. In 5 patients a second dilatation became necessary due to recurrent fistula malfunction after a mean period of 5 months. Twenty-eight of 29 PTAs (96%) were immediately successful. The primary patency rates were 79% at 6 months, 61% at 1 year and 61% again at 2 years. The secondary patency rates were 90%, 83% and 83%, respectively. Three post-PTA fistula thromboses (10%) were observed: two of them were successfully treated by local fibrinolysis while in the extant case a new A-V shunt was created. In our opinion, PTA is the treatment of choice for malfunctioning Brescia-Cimino fistulas; the incidence of complications was low in our series.

Arterial complications of pancreatitis: diagnostic and therapeutic role of radiology

Hemorrhage from pseudoaneurysm complicating pancreatitis is an infrequent but very severe condition. In most cases, acute, massive gastrointestinal bleeding is typical at onset, and prognosis of these cases is usually poor. Nine cases of arterial lesions secondary to pancreatic inflammation are presented, eight related to chronic pancreatitis and one to acute postoperative pancreatitis. Five patients were evaluated during emergency episodes because of acutely gastrointestinal bleeding (four cases), and pseudocyst acute bleeding (one case). Four patients were selectively evaluated: three had a history of self-limiting gastrointestinal hemorrhage, whereas one had experienced no episodes of gastrointestinal hemorrhage. Angiography was performed in all cases and was always diagnostic, even in the two cases of very small pseudoaneurysms. Transcatheter arterial blockade was attempted in five patients and failed to control the hemorrhage in one acutely bleeding patient because of irreversible shock. Two cases of pancreatic hemorrhage not related to a pseudocyst were effectively and permanently treated by embolization. A case of a pseudoaneurysm associated with a pseudocyst required surgery in addition to embolization for a definite treatment. Nevertheless, when a pseudoaneurysm or a pseudocyst hemorrhages acutely, transcatheter arterial blockade can control the hemorrhage and improve the hemodynamic status of the patient before surgery.

[Chemoembolization in the therapy of hepatocarcinoma. A 3-year experience]

This study was aimed at evaluating the efficacy of chemoembolization (CE) to improve survival in patients with hepatocellular carcinoma (HCC). Our results were compared with the natural history of HCC. Sixty-two consecutive patients with HCC in Okuda's stages I and II underwent CE. Forty-seven patients were treated with CE alone; 9 patients had CE prior to surgery, and 6 patients had it after surgery because of recurrent HCC. One hundred and nine CEs (mean: 1.8 CEs/patient) were performed with Lipiodol UF, epirubicin and gelatin sponge. Actuarial survival was calculated considering Okuda's stage, neoplasm size, and evidence of pseudocapsule. The mean cumulative survival of the 47 patients treated with CE alone was 13.2 months; survival (+/- SE) at 12, 24 and 36 months was 0.75 (+/- 0.07), 0.46 (+/- 0.10) and 0.28 (+/- 0.12). Survival was not affected by Okuda's stage, neoplasm size, evidence of pseudocapsule (p > 0.05). Nevertheless, the patients with early HCC had better prognosis. Eighteen patients (42.9%) died during follow-up, 12 of whom (66.7%) from hepatic failure. The mean survival of patients with recurrence of HCC after surgery was 41 months (range: 24.8-74.9 months) since initial diagnosis of HCC, and 14.8 months (range: 7.1-29.6 months) since diagnosis of recurrence. Two of these patients died from hepatic failure. All the patients who underwent also surgery after CE are still alive (mean survival: 14.7 months). Histologic findings of resected specimens revealed viable neoplastic cells in all cases. Twenty-one major complications (20.2%) occurred in 18 patients (29%); the outcome of complications was favorable in all but one patient who died from sepsis. CE is a reliable and safe treatment for unresectable HCC. Small HCCs should be preferably treated with surgery or, alternatively, with percutaneous alcohol injection.