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Kniep H, Meyer L, Broocks G, Bechstein M, Heitkamp C, Winkelmeier L, Faizy T, Brekenfeld C, Flottmann F, Deb-Chatterji M, Alegiani A, Hanning U, Thomalla G, Fiehler J, Gellißen S. Thrombectomy for M2 Occlusions: Predictors of Successful and Futile Recanalization. Stroke 2023. [PMID: 37439204 DOI: 10.1161/strokeaha.123.043285] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
BACKGROUND Patient-specific factors associated with successful recanalization in mechanical thrombectomy (MT) have been evaluated for acute ischemic stroke with large vessel occlusion. However, MT for M2 occlusions is still a matter of debate, and predictors of successful and futile recanalization have not been assessed in detail. We sought to identify predictors of recanalization success in patients with M2 occlusions undergoing MT based on large-scale clinical data. METHODS All patients prospectively enrolled in the German Stroke Registry (May, 2015 to December, 2021) were screened (N=13 082). Inclusion criteria for the complete case analysis were isolated M2 occlusions. Standard descriptive statistics and multivariable logistic regression analysis were used to identify factors associated with successful recanalization (Thrombolysis in Cerebral Infarction [TICI]≥2b), complete recanalization (TICI=3) and futile recanalization (TICI≥2b with 90-day modified Rankin Scale [mRS] score >2). RESULTS One thousand two hundred ninety-four patients were included, thereof 439 (33.9%) with TICI=2b and 643 (49.7%) with TICI=3. Five hundred sixty-nine (44%) patients had good functional outcome (90-day mRS score ≤2). In multivariable logistic regression, general anesthesia (adjusted odds ratio [aOR], 1.47 [95% CI, 1.05-2.09]; P<0.05) was associated with higher probability of TICI≥2b while intraprocedural change from local to general anesthesia (aOR, 0.49 [0.26-0.95]; P<0.05) and higher pre-mRS (aOR, 0.75 [0.67-0.85]; P<0.001) lowered probability of successful recanalization. Futile recanalization was associated with higher age (aOR, 1.05 [1.04-1.07]; P<0.001), higher prestroke mRS (aOR, 3.12 [2.49-3.91]; P<0.001), higher NIHSS at admission (aOR, 1.11 [1.08-1.14]; P<0.001), diabetes (aOR, 1.96 [1.38-2.8]; P<0.001), higher number of passes (aOR, 1.29 [1.14-1.46]; P<0.001), and adverse events (aOR, 1.82 [1.2-2.74]; P<0.01). Higher Alberta Stroke Program Early CT Score (aOR, 0.85 [0.76-0.94]; P<0.01) and IV thrombolysis (aOR, 0.71 [0.52-0.97]; P<0.05) reduced risk of futile recanalization. CONCLUSIONS In patients with M2 occlusions, successful recanalization was significantly associated with general anesthesia and low prestroke mRS, while intraprocedural change from conscious sedation to general anesthesia increased risk of unsuccessful recanalization, presumably caused by difficult anatomy and movement of patients in these cases. Futile recanalization was associated with severe prestroke mRS, comorbidity diabetes, number of passes and adverse events during treatment. IV thrombolysis reduced the risk of futile recanalization.
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Affiliation(s)
- Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., G.B., M.B., C.H., L.W., T.F., C.B., F.F., U.H., J.F., S.G.)
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., G.B., M.B., C.H., L.W., T.F., C.B., F.F., U.H., J.F., S.G.)
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., G.B., M.B., C.H., L.W., T.F., C.B., F.F., U.H., J.F., S.G.)
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., G.B., M.B., C.H., L.W., T.F., C.B., F.F., U.H., J.F., S.G.)
| | - Christian Heitkamp
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., G.B., M.B., C.H., L.W., T.F., C.B., F.F., U.H., J.F., S.G.)
| | - Laurens Winkelmeier
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., G.B., M.B., C.H., L.W., T.F., C.B., F.F., U.H., J.F., S.G.)
| | - Tobias Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., G.B., M.B., C.H., L.W., T.F., C.B., F.F., U.H., J.F., S.G.)
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., G.B., M.B., C.H., L.W., T.F., C.B., F.F., U.H., J.F., S.G.)
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., G.B., M.B., C.H., L.W., T.F., C.B., F.F., U.H., J.F., S.G.)
| | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Germany. (M.D.-C., G.T.)
- Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany (M.D.-C.)
| | - Anna Alegiani
- Department of Neurology, Asklepios Klinik Altona, Hamburg, Germany (A.A.)
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., G.B., M.B., C.H., L.W., T.F., C.B., F.F., U.H., J.F., S.G.)
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Germany. (M.D.-C., G.T.)
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., G.B., M.B., C.H., L.W., T.F., C.B., F.F., U.H., J.F., S.G.)
| | - Susanne Gellißen
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., G.B., M.B., C.H., L.W., T.F., C.B., F.F., U.H., J.F., S.G.)
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Sporns PB, Rusche T, Lee S, Hanning U, Meyer L, Faizy T, Fiehler J, Psychogios M, Kemmling A, Broocks G. Impact of edema formation on functional outcome in pediatric stroke patients. Eur J Neurol 2023; 30:150-154. [PMID: 36168926 DOI: 10.1111/ene.15576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 09/09/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Quantitative lesion net water uptake (NWU) has been described as an imaging biomarker reflecting vasogenic edema as an early indicator of infarct progression. We hypothesized that edema formation measured by NWU is higher in children compared to adults but despite this functional outcome may be better in children. METHODS This study analyzed children enrolled in the Save ChildS Study who had baseline and follow-up computed tomography available and the data were compared to adult patients. RESULTS Some 207 patients, of whom 13 were children and 194 were adults, were analyzed. Median NWU at baseline was 7.8% (IQR: 4.3-11.3), and there were no significant differences between children and adults (7.5% vs. 7.8%; p = 0.87). The early edema progression rate was 3.0%/h in children and 2.3%/h in adults. Median ΔNWU was 15.1% in children and 10.5% in adults. Children had significantly more often excellent (mRS 0-1; children 10/13 = 77% vs. adults 28/196 = 14%; p < 0.0001) and favorable clinical outcomes (mRS 0-2, 12/13 = 92% vs. 39/196 = 20%; p < 0.0001). CONCLUSIONS In this study, clinical outcomes in children with large vessel occlusion strokes were better than in adults despite similar clinical and imaging characteristics and similar edema formation. This may be impacted by the generally better outcomes of children after strokes but may demonstrate that the degree of early ischemic changes using Alberta Stroke Program Early Computed Tomography Score (ASPECTS) and edema progression rate may not be a reason for exclusion from endovascular thrombectomy.
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Affiliation(s)
- Peter B Sporns
- Department of Neuroradiology, University Hospital Basel, Basel, Switzerland.,Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thilo Rusche
- Department of Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Sarah Lee
- Division of Child Neurology, Department of Neurology & Neurological Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marios Psychogios
- Department of Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Andre Kemmling
- Department of Neuroradiology, University Hospital Marburg, Marburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Leischner H, Brekenfeld C, Meyer L, Broocks G, Faizy T, McDonough R, Gerloff C, Thomalla G, Deb-Chatterji M, Fiehler J, Flottmann F. Study Criteria Applied to Real Life-A Multicenter Analysis of Stroke Patients Undergoing Endovascular Treatment in Clinical Practice. J Am Heart Assoc 2021; 10:e017919. [PMID: 34779226 PMCID: PMC8751914 DOI: 10.1161/jaha.120.017919] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background Randomized controlled clinical trials (RCT) have demonstrated the efficacy of endovascular treatment in anterior circulation large vessel occlusions. However, outcome of patients treated in daily practice differs from the results of the clinical trials. We hypothesize that this is attributable to the study criteria and that application of the criteria on patients undergoing endovascular therapy in daily routine would improve their outcome. Methods and Results Data from a multicenter prospective registry of GSR‐ET (German Stroke Registry – Endovascular Treatment) was used. Inclusion criteria and selectivity of SWIFT‐PRIME (Solitaire with the Intention for Thrombectomy as Primary Endovascular Treatment trial), MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands trial), ESCAPE (Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion with Emphasis on Minimizing CT to Recanalization Times trial), DAWN (DWI or CTP Assessment with Clinical Mismatch in the Triage of Wake‐Up and Late Presenting Strokes Undergoing Neurointervention with Trevo trial) and DEFUSE‐3 (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke trial) trials were analyzed. Baseline characteristics, procedural and outcome data of patients from GSR‐ET before and after selection were compared with the results of the RCTs. Furthermore, outcome of patients who underwent endovascular treatment despite not fulfilling the RCT criteria was analyzed. A total of 2611 patients were included (median age, 75 years; 49.6% women; median National Institute of Health Stroke Scale, 16). A minority of patients met all inclusion criteria, ranging from 3% (DEFUSE‐3 criteria) to 35% (MR CLEAN criteria). Of the patients fulfilling the MR CLEAN criteria, 41% of patients had a good clinical outcome, compared with 34% of patients that did not fulfill MR CLEAN criteria. Conclusions The RCTs represent a selected population with higher rates of good clinical outcome compared with daily practice. The good outcomes of RCTs can be reproduced in clinical routine in patients who fulfill the RCT inclusion criteria. Furthermore, patients who did not meet the criteria of the RCT still had substantial rates of good clinical outcome.
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Affiliation(s)
- Hannes Leischner
- Department of Neuroradiological Diagnostics and Intervention University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Caspar Brekenfeld
- Department of Neuroradiological Diagnostics and Intervention University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Lukas Meyer
- Department of Neuroradiological Diagnostics and Intervention University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Gabriel Broocks
- Department of Neuroradiological Diagnostics and Intervention University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Tobias Faizy
- Department of Neuroradiological Diagnostics and Intervention University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Rosalie McDonough
- Department of Neuroradiological Diagnostics and Intervention University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Christian Gerloff
- Department of Neurology University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Götz Thomalla
- Department of Neurology University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Milani Deb-Chatterji
- Department of Neurology University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Jens Fiehler
- Department of Neuroradiological Diagnostics and Intervention University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Fabian Flottmann
- Department of Neuroradiological Diagnostics and Intervention University Medical Center Hamburg-Eppendorf Hamburg Germany
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Nawabi J, Elsayed S, Morotti A, Speth A, Liu M, Kniep H, McDonough R, Broocks G, Faizy T, Can E, Sporns PB, Fiehler J, Hamm B, Penzkofer T, Bohner G, Schlunk F, Hanning U. Perihematomal Edema and Clinical Outcome in Intracerebral Hemorrhage Related to Different Oral Anticoagulants. J Clin Med 2021; 10:2234. [PMID: 34063991 PMCID: PMC8196746 DOI: 10.3390/jcm10112234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 05/05/2021] [Accepted: 05/11/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND There is a need to examine the effects of different types of oral anticoagulant-associated intracerebral hemorrhage (OAC-ICH) on perihematomal edema (PHE), which is gaining considerable appeal as a biomarker for secondary brain injury and clinical outcome. METHODS In a large multicenter approach, computed tomography-derived imaging markers for PHE (absolute PHE, relative PHE (rPHE), edema expansion distance (EED)) were calculated for patients with OAC-ICH and NON-OAC-ICH. Exploratory analysis for non-vitamin-K-antagonist OAC (NOAC) and vitamin-K-antagonists (VKA) was performed. The predictive performance of logistic regression models, employing predictors of poor functional outcome (modified Rankin scale 4-6), was explored. RESULTS Of 811 retrospectively enrolled patients, 212 (26.14%) had an OAC-ICH. Mean rPHE and mean EED were significantly lower in patients with OAC-ICH compared to NON-OAC-ICH, p-value 0.001 and 0.007; whereas, mean absolute PHE did not differ, p-value 0.091. Mean EED was also significantly lower in NOAC compared to NON-OAC-ICH, p-value 0.05. Absolute PHE was an independent predictor of poor clinical outcome in NON-OAC-ICH (OR 1.02; 95%CI 1.002-1.028; p-value 0.027), but not in OAC-ICH (p-value 0.45). CONCLUSION Quantitative markers of early PHE (rPHE and EED) were lower in patients with OAC-ICH compared to those with NON-OAC-ICH, with significantly lower levels of EED in NOAC compared to NON-OAC-ICH. Increase of early PHE volume did not increase the likelihood of poor outcome in OAC-ICH, but was independently associated with poor outcome in NON-OAC-ICH. The results underline the importance of etiology-specific treatment strategies. Further prospective studies are needed.
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Affiliation(s)
- Jawed Nawabi
- Department of Radiology, Charité-Universitätsmedizin Berlin, Campus Mitte, Humboldt-Universität zu Berlin, 10117 Berlin, Germany; (E.C.); (B.H.); (T.P.)
- BIH Biomedical Innovation Academy, Berlin Institute of Health (BIH), 10178 Berlin, Germany;
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, 20246 Hamburg, Germany; (S.E.); (H.K.); (R.M.); (G.B.); (P.B.S.); (J.F.); (U.H.)
| | - Sarah Elsayed
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, 20246 Hamburg, Germany; (S.E.); (H.K.); (R.M.); (G.B.); (P.B.S.); (J.F.); (U.H.)
| | - Andrea Morotti
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, 25123 Brescia, Italy;
| | - Anna Speth
- Department of Neuroradiology, Charité-Universitätsmedizin Berlin, Campus Mitte, Humboldt-Universität zu Berlin, Berlin Institute of Health, Freie Universität Berlin, 10117 Berlin, Germany; (A.S.); (M.L.); (G.B.)
| | - Melanie Liu
- Department of Neuroradiology, Charité-Universitätsmedizin Berlin, Campus Mitte, Humboldt-Universität zu Berlin, Berlin Institute of Health, Freie Universität Berlin, 10117 Berlin, Germany; (A.S.); (M.L.); (G.B.)
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, 20246 Hamburg, Germany; (S.E.); (H.K.); (R.M.); (G.B.); (P.B.S.); (J.F.); (U.H.)
| | - Rosalie McDonough
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, 20246 Hamburg, Germany; (S.E.); (H.K.); (R.M.); (G.B.); (P.B.S.); (J.F.); (U.H.)
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, 20246 Hamburg, Germany; (S.E.); (H.K.); (R.M.); (G.B.); (P.B.S.); (J.F.); (U.H.)
| | - Tobias Faizy
- Department of Radiology, Stanford University School of Medicine, Stanford, CA 94305, USA;
| | - Elif Can
- Department of Radiology, Charité-Universitätsmedizin Berlin, Campus Mitte, Humboldt-Universität zu Berlin, 10117 Berlin, Germany; (E.C.); (B.H.); (T.P.)
| | - Peter B. Sporns
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, 20246 Hamburg, Germany; (S.E.); (H.K.); (R.M.); (G.B.); (P.B.S.); (J.F.); (U.H.)
- Department of Neuroradiology, Clinic for Radiology and Nuclear Medicine, University Hospital Basel, 4031 Basel, Switzerland
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, 20246 Hamburg, Germany; (S.E.); (H.K.); (R.M.); (G.B.); (P.B.S.); (J.F.); (U.H.)
| | - Bernd Hamm
- Department of Radiology, Charité-Universitätsmedizin Berlin, Campus Mitte, Humboldt-Universität zu Berlin, 10117 Berlin, Germany; (E.C.); (B.H.); (T.P.)
| | - Tobias Penzkofer
- Department of Radiology, Charité-Universitätsmedizin Berlin, Campus Mitte, Humboldt-Universität zu Berlin, 10117 Berlin, Germany; (E.C.); (B.H.); (T.P.)
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, 20246 Hamburg, Germany; (S.E.); (H.K.); (R.M.); (G.B.); (P.B.S.); (J.F.); (U.H.)
| | - Georg Bohner
- Department of Neuroradiology, Charité-Universitätsmedizin Berlin, Campus Mitte, Humboldt-Universität zu Berlin, Berlin Institute of Health, Freie Universität Berlin, 10117 Berlin, Germany; (A.S.); (M.L.); (G.B.)
| | - Frieder Schlunk
- BIH Biomedical Innovation Academy, Berlin Institute of Health (BIH), 10178 Berlin, Germany;
- Department of Neuroradiology, Charité-Universitätsmedizin Berlin, Campus Mitte, Humboldt-Universität zu Berlin, Berlin Institute of Health, Freie Universität Berlin, 10117 Berlin, Germany; (A.S.); (M.L.); (G.B.)
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, 20246 Hamburg, Germany; (S.E.); (H.K.); (R.M.); (G.B.); (P.B.S.); (J.F.); (U.H.)
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Steffen P, Beyer LS, McDonough R, Thaler C, Faizy T, Fiehler J, Gbadamosi J, Habermann CR, Schönfeld MH. Improved Detectability of Brain Stem Ischemia by Combining Axial and Coronal Diffusion-Weighted Imaging. Stroke 2021; 52:1843-1846. [PMID: 33813862 DOI: 10.1161/strokeaha.120.032457] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE To evaluate the benefit of a coronal diffusion-weighted imaging (DWI) in addition to standard axial DWI for the detection of brain stem infarctions. METHODS A retrospective analysis of patients with symptoms consistent with acute and subacute brain stem infarction who received magnetic resonance imaging, including axial and coronal DWI. Diffusion restrictions were identified by 2 independent raters blinded for the final clinical diagnosis in 3 separate reading steps: axial DWI, coronal DWI, and combined axial and coronal DWI. Lesion location and certainty level were both documented for each reading step. In cases of reader disagreement, an additional consensus reading was performed. RESULTS Two hundred thirty-nine patients were included. Of these, 124 patients (51.9%) were clinically diagnosed with brain stem infarction. Sensitivity, specificity, positive, and negative predictive values were best for combined DWI assessment (90.3%, 99.1%, 99.1%, and 90.5%) compared with axial (85.5%, 94.9%, 94.6%, and 85.8%) and coronal DWI alone (87.9%, 96.5%, 96.5%, and 88.1%). Diffusion restriction on combined DWI was diagnosed in 112/124 patients compared with 106/124 on axial DWI and 109/124 on coronal DWI. Interobserver agreement for the detection of brain stem lesions was the highest in the combined rating step (Cohen κ coefficient=0.94). CONCLUSIONS Coronal DWI sequences might improve the detection rate of brain stem infarction compared with standard axial DWI. The combined coronal and axial DWI provides the best detection rate while minimally increasing scan times.
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Affiliation(s)
- Paul Steffen
- Department of Diagnostic and Interventional Radiology (P.S., L.-S.B., C.T., T.F., C.R.H.), Marienkrankenhaus Hamburg, Germany.,Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (P.S., R.M., C.T., T.F., J.F., M.H.S.)
| | - Lara-Sophie Beyer
- Department of Diagnostic and Interventional Radiology (P.S., L.-S.B., C.T., T.F., C.R.H.), Marienkrankenhaus Hamburg, Germany
| | - Rosalie McDonough
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (P.S., R.M., C.T., T.F., J.F., M.H.S.)
| | - Christian Thaler
- Department of Diagnostic and Interventional Radiology (P.S., L.-S.B., C.T., T.F., C.R.H.), Marienkrankenhaus Hamburg, Germany.,Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (P.S., R.M., C.T., T.F., J.F., M.H.S.)
| | - Tobias Faizy
- Department of Diagnostic and Interventional Radiology (P.S., L.-S.B., C.T., T.F., C.R.H.), Marienkrankenhaus Hamburg, Germany.,Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (P.S., R.M., C.T., T.F., J.F., M.H.S.)
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (P.S., R.M., C.T., T.F., J.F., M.H.S.)
| | | | - Christian R Habermann
- Department of Diagnostic and Interventional Radiology (P.S., L.-S.B., C.T., T.F., C.R.H.), Marienkrankenhaus Hamburg, Germany
| | - Michael H Schönfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (P.S., R.M., C.T., T.F., J.F., M.H.S.).,Department of Diagnostic and Interventional Radiology, University Hospital Cologne, Germany (M.H.S.)
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6
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Broocks G, Kemmling A, Faizy T, McDonough R, Van Horn N, Bechstein M, Meyer L, Schön G, Nawabi J, Fiehler J, Kniep H, Hanning U. Effect of thrombectomy on oedema progression and clinical outcome in patients with a poor collateral profile. Stroke Vasc Neurol 2020; 6:222-229. [PMID: 33208492 PMCID: PMC8258058 DOI: 10.1136/svn-2020-000570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 10/10/2020] [Accepted: 10/23/2020] [Indexed: 11/17/2022] Open
Abstract
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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Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andre Kemmling
- Institute of Neuroradiology, University Hospital of Luebeck, Luebeck, Germany.,Neuroradiology, Westpfalzklinikum, Kaiserslautern, Germany
| | - Tobias Faizy
- Department of Diagnostic and Interventional Neuroradiology, Stanford University, Stanford, California, USA
| | - Rosalie McDonough
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Noel Van Horn
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Schön
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Jawed Nawabi
- Department of Radiology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Schönfeld MH, Kabiri R, Kniep HC, Meyer L, McDonough R, Sedlacik J, Ernst M, Broocks G, Faizy T, Schön G, Cheng B, Thomalla G, Fiehler J, Hanning U. 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; 11:386. [PMID: 32457694 PMCID: PMC7221024 DOI: 10.3389/fneur.2020.00386] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 04/17/2020] [Indexed: 01/19/2023] Open
Abstract
Background: 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). Methods: 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. Results: 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. Conclusions: 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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Affiliation(s)
- Michael H Schönfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Reza Kabiri
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge C Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rosalie McDonough
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Sedlacik
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Biomedical Engineering Department, Centre for the Developing Brain, School of Biomedical Engineering & Imaging Sciences, King's College London, London, United Kingdom
| | - Marielle Ernst
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bastian Cheng
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Broocks G, Kniep H, Schramm P, Hanning U, Flottmann F, Faizy T, Schönfeld M, Meyer L, Schön G, Aulmann L, Machner B, Royl G, Fiehler J, Kemmling A. Patients with low Alberta Stroke Program Early CT Score (ASPECTS) but good collaterals benefit from endovascular recanalization. J Neurointerv Surg 2019; 12:747-752. [DOI: 10.1136/neurintsurg-2019-015308] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 10/17/2019] [Accepted: 10/29/2019] [Indexed: 11/04/2022]
Abstract
BackgroundBenefit 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.MethodsIschemic 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.Results27/100 (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 .ConclusionEndovascular 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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Thaler C, Faizy T, Sedlacik J, Holst B, Stellmann JP, Young KL, Heesen C, Fiehler J, Siemonsen S. T1- Thresholds in Black Holes Increase Clinical-Radiological Correlation in Multiple Sclerosis Patients. PLoS One 2015; 10:e0144693. [PMID: 26659852 PMCID: PMC4676682 DOI: 10.1371/journal.pone.0144693] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 11/23/2015] [Indexed: 12/05/2022] Open
Abstract
Background Magnetic Resonance Imaging (MRI) is an established tool in diagnosing and evaluating disease activity in Multiple Sclerosis (MS). While clinical-radiological correlations are limited in general, hypointense T1 lesions (also known as Black Holes (BH)) have shown some promising results. The definition of BHs is very heterogeneous and depends on subjective visual evaluation. Objective We aimed to improve clinical-radiological correlations by defining BHs using T1 relaxation time (T1-RT) thresholds to achieve best possible correlation between BH lesion volume and clinical disability. Method 40 patients with mainly relapsing-remitting MS underwent MRI including 3-dimensional fluid attenuated inversion recovery (FLAIR), magnetization-prepared rapid gradient echo (MPRAGE) before and after Gadolinium (GD) injection and double inversion-contrast magnetization-prepared rapid gradient echo (MP2RAGE) sequences. BHs (BHvis) were marked by two raters on native T1-weighted (T1w)-MPRAGE, contrast-enhancing lesions (CE lesions) on T1w-MPRAGE after GD and FLAIR lesions (total-FLAIR lesions) were detected separately. BHvis and total-FLAIR lesion maps were registered to MP2RAGE images, and the mean T1-RT were calculated for all lesion ROIs. Mean T1 values of the cortex (CTX) were calculated for each patient. Subsequently, Spearman rank correlations between clinical scores (Expanded Disability Status Scale and Multiple Sclerosis Functional Composite) and lesion volume were determined for different T1-RT thresholds. Results Significant differences in T1-RT were obtained between all different lesion types with highest T1 values in visually marked BHs (BHvis: 1453.3±213.4 ms, total-FLAIR lesions: 1394.33±187.38 ms, CTX: 1305.6±35.8 ms; p<0.05). Significant correlations between BHvis/total-FLAIR lesion volume and clinical disability were obtained for a wide range of T1-RT thresholds. The highest correlation for BHvis and total-FLAIR lesion masks were found at T1-RT>1500 ms (Expanded Disability Status Scale vs. lesion volume: rBHvis = 0.442 and rtotal-FLAIR = 0.497, p<0.05; Multiple Sclerosis Functional Composite vs. lesion volume: rBHvis = -0.53 and rtotal-FLAIR = -0.627, p<0.05). Conclusion Clinical-radiological correlations in MS patients are increased by application of T1-RT thresholds. With the short acquisition time of the MP2RAGE sequences, quantitative T1 maps could be easily established in clinical studies.
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Affiliation(s)
- Christian Thaler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
- * E-mail:
| | - Tobias Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Sedlacik
- Department of Diagnostic and Interventional Neuroradiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Brigitte Holst
- Department of Diagnostic and Interventional Neuroradiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Jan-Patrick Stellmann
- Department of Neurology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
- Institute for Neuroimmunology and Clinical MS Research, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Kim Lea Young
- Department of Neurology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
- Institute for Neuroimmunology and Clinical MS Research, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Christoph Heesen
- Department of Neurology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
- Institute for Neuroimmunology and Clinical MS Research, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Siemonsen
- Department of Diagnostic and Interventional Neuroradiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
- Institute for Neuroimmunology and Clinical MS Research, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
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Faizy T, Kamper L, Meletiadis K, Kusenack U, Haage P. [Endovascular therapy of an iatrogenic renal-artery-perforation after fenestrated-aortic-repair (fEVAR)]. Dtsch Med Wochenschr 2014; 139:1707-10. [PMID: 25116019 DOI: 10.1055/s-0034-1370231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
HISTORY AND ADMISSION FINDINGS A 75-year-old patient was initially hospitalized for therapy-evaluation of a an acquaint infrarenal abdominal-aortic-aneurysm, with a maximum diameter of 5.3 cm. Medical history showed a known contained rupture of the aneurysm. Except for a substituted Hypothyroidism and a COPD Stadium II (GOLD), there were no other previous diseases known. EXAMINATIONS Laboratory showed a slight normochrome, normocytic anemia (hemoglobin 13 g/dl, MCV and MCH were normal) together with a decreased total amount of erythrocytes of 3.89/pl. TSH value was increased significantly at 7.960 mU/l. Initially creatinine was measured at 1.02 mg/dl. Sonography and CT-scan of the abdominal vessels had shown no new insights other than the aneurysm of the abdominal aorta. A surgical revision was indicated. TREATMENT AND COURSE After primarily uncomplicated implantation of a fenestrated EVAR, the patient showed a progressive hemoglobin loss concomitant with a considerable increase of renal retention parameters. A "spurium"/false aneurysm of the right renal artery was found, which moreover showed a retroperitoneal bleeding. The patient subsequently underwent successful endovascular therapy in our clinic and was dismissed from the hospital in good condition and without further complications. Follow up controls showed no signs of new pathologies. CONCLUSION "Direct" post-operative complications after EVAR are a rarity. In our case, the interventional endovascular approach of the bleeding from the right renal artery was a successful and sufficient treatment of the potentially life-threatening complication.
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Affiliation(s)
- T Faizy
- Zentrum für Radiologie, Helios Klinikum Wuppertal; Klinikum der Universität Witten/Herdecke
| | - L Kamper
- Zentrum für Radiologie, Helios Klinikum Wuppertal; Klinikum der Universität Witten/Herdecke
| | - K Meletiadis
- Klinik für Gefäßchirurgie, Helios Klinikum Wuppertal; Klinikum der Universität Witten/Herdecke
| | - U Kusenack
- Klinik für Gefäßchirurgie, Helios Klinikum Wuppertal; Klinikum der Universität Witten/Herdecke
| | - P Haage
- Zentrum für Radiologie, Helios Klinikum Wuppertal; Klinikum der Universität Witten/Herdecke
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