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Samaniego EA, Dabus G, Meyers PM, Kan PT, Frösen J, Lanzino G, Welch BG, Volovici V, Gonzalez F, Fifi J, Charbel FT, Hoh BL, Khalessi A, Marks MP, Berenstein A, Pereira VM, Bain M, Colby GP, Narayanan S, Tateshima S, Siddiqui AH, Wakhloo AK, Arthur AS, Lawton MT. Most Promising Approaches to Improve Brain AVM Management: ARISE I Consensus Recommendations. Stroke 2024; 55:1449-1463. [PMID: 38648282 DOI: 10.1161/strokeaha.124.046725] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 03/01/2024] [Indexed: 04/25/2024]
Abstract
Brain arteriovenous malformations (bAVMs) are complex, and rare arteriovenous shunts that present with a wide range of signs and symptoms, with intracerebral hemorrhage being the most severe. Despite prior societal position statements, there is no consensus on the management of these lesions. ARISE (Aneurysm/bAVM/cSDH Roundtable Discussion With Industry and Stroke Experts) was convened to discuss evidence-based approaches and enhance our understanding of these complex lesions. ARISE identified the need to develop scales to predict the risk of rupture of bAVMs, and the use of common data elements to perform prospective registries and clinical studies. Additionally, the group underscored the need for comprehensive patient management with specialized centers with expertise in cranial and spinal microsurgery, neurological endovascular surgery, and stereotactic radiosurgery. The collection of prospective multicenter data and gross specimens was deemed essential for improving bAVM characterization, genetic evaluation, and phenotyping. Finally, bAVMs should be managed within a multidisciplinary framework, with clinical studies and research conducted collaboratively across multiple centers, harnessing the collective expertise and centralization of resources.
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Affiliation(s)
- Edgar A Samaniego
- Department of Neurology, Neurosurgery and Radiology, University of Iowa (E.A.S.)
| | - Guilherme Dabus
- Department of Neurosurgery, Baptist Health, Miami, FL (G.D.)
| | - Philip M Meyers
- Department of Radiology and Neurological Surgery, Columbia University, New York (P.M.M.)
| | - Peter T Kan
- Department of Neurological Surgery, University of Texas Medical Branch Galveston (P.T.K.)
| | - Juhana Frösen
- Department of Rehabilitation, Tampere University Hospital, Finland (J.F.)
| | | | - Babu G Welch
- Departments of Neurological Surgery and Radiology; The University of Texas Southwestern, Dallas (B.G.W.)
| | - Victor Volovici
- Department of Neurosurgery, Erasmus MC University Medical Centre, Rotterdam, the Netherlands (V.V.)
| | - Fernando Gonzalez
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD (F.G.)
| | - Johana Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York (J.F., A.B.)
| | - Fady T Charbel
- Department of Neurosurgery, University of Illinois at Chicago (F.T.C.)
| | - Brian L Hoh
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville (B.L.H.)
| | | | - Michael P Marks
- Interventional Neuroradiology Division, Stanford University Medical Center, Palo Alto, CA (M.P.M.)
| | - Alejandro Berenstein
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York (J.F., A.B.)
| | - Victor M Pereira
- Department of Neurosurgery, St. Michael's Hospital, Toronto, Canada (V.M.P.)
| | - Mark Bain
- Department of Neurological Surgery, Cleveland Clinic, OH (M.B.)
| | - Geoffrey P Colby
- Department of Neurosurgery, University of California Los Angeles (G.P.C.)
| | - Sandra Narayanan
- Neurointerventional Program and Comprehensive Stroke Program, Pacific Neuroscience Institute, Santa Monica, CA (S.N.)
| | - Satoshi Tateshima
- Division of Interventional Neuroradiology, Ronald Reagan UCLA Medical Center, Los Angeles (S.T.)
| | - Adnan H Siddiqui
- Department of Neurosurgery, Gates Vascular Institute, Buffalo, New York (A.H.S.)
| | - Ajay K Wakhloo
- Department of Radiology, Tufts University School of Medicine, Boston, MA (A.K.W.)
| | - Adam S Arthur
- Department of Neurosurgery, Semmes-Murphey Clinic, University of Tennessee Health Science Center, Memphis (A.S.A.)
| | - Michael T Lawton
- Neurosurgery, Barrow Neurological Institute, Phoenix, AZ (M.T.L.)
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Bhatia KD, Lee H, Kortman H, Klostranec J, Guest W, Wälchli T, Radovanovic I, Krings T, Pereira VM. Endovascular Management of Intracranial Dural AVFs: Transvenous Approach. AJNR Am J Neuroradiol 2022; 43:510-516. [PMID: 34649915 DOI: 10.3174/ajnr.a7300] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 07/09/2021] [Indexed: 11/07/2022]
Abstract
In this third review article on the endovascular management of intracranial dural AVFs, we discuss transvenous embolization approaches. Transvenous embolization is increasingly popular and now the first-line approach for ventral dural AVFs involving the cavernous sinus and hypoglossal canal. In addition, transvenous embolization is increasingly used in lateral epidural dural AVFs in high-risk locations such as the petrous and ethmoid regions. The advantage of transvenous embolization in these locations is the ability to retrogradely embolize the draining vein and fistula while reducing the risk of ischemic cranial neuropathy or brain parenchymal infarction commonly feared from a transarterial approach. By means of coils ± ethylene-vinyl alcohol copolymer, transvenous embolization can achieve angiographic cure rates of 80%-90% in ventral locations. Potential complications include transient cranial neuropathy, neurologic deterioration due to venous outflow obstruction, and perforation while navigating pial veins. Transvenous embolization should be considered when dural AVFs arise in proximity to the vasa nervosum or extracranial-intracranial anastomoses.
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Affiliation(s)
- K D Bhatia
- From the Division of Neuroradiology (K.D.B., H.L., H.K., J.K., W.G., T.K., V.M.P.)
- Division of Medical Imaging (K.D.B.), Sydney Children's Hospital Network, Westmead, New South Wales, Australia
- Division of Paediatrics (K.D.B.), Faculty of Medicine, University of Sydney, Camperdown, New South Wales, Australia
- Division of Paediatrics (K.D.B.), Faculty of Medicine, University of New South Wales, Kensington, New South Wales, Australia
- Division of Medical Imaging (K.D.B.), Faculty of Medicine, Macquarie University, Macquarie Park, New South Wales, Australia
| | - H Lee
- From the Division of Neuroradiology (K.D.B., H.L., H.K., J.K., W.G., T.K., V.M.P.)
- Department of Neurosurgery (H.L.), Stanford University School of Medicine, Stanford, California
| | - H Kortman
- From the Division of Neuroradiology (K.D.B., H.L., H.K., J.K., W.G., T.K., V.M.P.)
- Division of Neuroradiology (H.K.), Elisabeth-TweeSteden Ziekenhuis Hospital, Tilburg, the Netherlands
| | - J Klostranec
- From the Division of Neuroradiology (K.D.B., H.L., H.K., J.K., W.G., T.K., V.M.P.)
- Division of Interventional Neuroradiology (J.K.), McGill University Health Centre, Montreal, Quebec, Canada
| | - W Guest
- From the Division of Neuroradiology (K.D.B., H.L., H.K., J.K., W.G., T.K., V.M.P.)
- Division of Interventional Neuroradiology (W.G., V.M.P.), St. Michael's Hospital, Toronto, Ontario, Canada
| | - T Wälchli
- Division of Neurosurgery (T.W., I.R., T.K., V.M.P.), Toronto Western Hospital, Toronto, Ontario, Canada
| | - I Radovanovic
- Division of Neurosurgery (T.W., I.R., T.K., V.M.P.), Toronto Western Hospital, Toronto, Ontario, Canada
| | - T Krings
- From the Division of Neuroradiology (K.D.B., H.L., H.K., J.K., W.G., T.K., V.M.P.)
- Division of Neurosurgery (T.W., I.R., T.K., V.M.P.), Toronto Western Hospital, Toronto, Ontario, Canada
| | - V M Pereira
- From the Division of Neuroradiology (K.D.B., H.L., H.K., J.K., W.G., T.K., V.M.P.)
- Division of Neurosurgery (T.W., I.R., T.K., V.M.P.), Toronto Western Hospital, Toronto, Ontario, Canada
- Division of Interventional Neuroradiology (W.G., V.M.P.), St. Michael's Hospital, Toronto, Ontario, Canada
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Bhatia KD, Lee H, Kortman H, Klostranec J, Guest W, Wälchli T, Radovanovic I, Krings T, Pereira VM. Endovascular Management of Intracranial Dural AVFs: Principles. AJNR Am J Neuroradiol 2022; 43:160-166. [PMID: 34674996 PMCID: PMC8985683 DOI: 10.3174/ajnr.a7304] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 07/07/2021] [Indexed: 02/03/2023]
Abstract
Intracranial dural AVFs are abnormal communications between arteries that supply the dura mater and draining cortical veins or venous sinuses. They are believed to form as a response to venous insults such as thrombosis, trauma, or infection. Classification and management are dependent on the presence of drainage/reflux into cortical veins because such drainage markedly elevates the risk of hemorrhage or venous congestion, resulting in neurologic deficits. AVFs with tolerable symptoms and benign drainage patterns can be managed conservatively. Intolerable symptoms, presentation with hemorrhage/neurologic deficits, or aggressive drainage patterns are indications for intervention. Treatment options include microsurgical disconnection, endovascular transarterial embolization, transvenous embolization, or a combination. This is the first in a series of 3 articles on endovascular management of intracranial dural AVFs, in which we outline the principles and outcomes of endovascular treatment.
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Affiliation(s)
- K D Bhatia
- From the Divisions of Neuroradiology (K.D.B., H.L., H.K., J.K., W.G., T.K., V.M.P.) .,Department of Medical Imaging (K.D.B.), Sydney Children's Hospital Network, Westmead, New South Wales, Australia.,Division of Paediatrics (K.D.B.), Faculty of Medicine, University of Sydney, Camperdown, New South Wales, Australia.,Division of Paediatrics (K.D.B.), Faculty of Medicine, University of New South Wales, Kensington, New South Wales, Australia.,Division of Medical Imaging (K.D.B.), Faculty of Medicine, Macquarie University, Macquarie Park, New South Wales, Australia
| | - H Lee
- From the Divisions of Neuroradiology (K.D.B., H.L., H.K., J.K., W.G., T.K., V.M.P.)
| | - H Kortman
- From the Divisions of Neuroradiology (K.D.B., H.L., H.K., J.K., W.G., T.K., V.M.P.)
| | - J Klostranec
- From the Divisions of Neuroradiology (K.D.B., H.L., H.K., J.K., W.G., T.K., V.M.P.)
| | - W Guest
- From the Divisions of Neuroradiology (K.D.B., H.L., H.K., J.K., W.G., T.K., V.M.P.)
| | - T Wälchli
- Neurosurgery (T.W., I.R., T.K., V.M.P.), Toronto Western Hospital, Toronto, Ontario, Canada
| | - I Radovanovic
- Neurosurgery (T.W., I.R., T.K., V.M.P.), Toronto Western Hospital, Toronto, Ontario, Canada
| | - T Krings
- From the Divisions of Neuroradiology (K.D.B., H.L., H.K., J.K., W.G., T.K., V.M.P.).,Neurosurgery (T.W., I.R., T.K., V.M.P.), Toronto Western Hospital, Toronto, Ontario, Canada
| | - V M Pereira
- From the Divisions of Neuroradiology (K.D.B., H.L., H.K., J.K., W.G., T.K., V.M.P.).,Neurosurgery (T.W., I.R., T.K., V.M.P.), Toronto Western Hospital, Toronto, Ontario, Canada
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Park KY, Ozaki T, Kostynskyy A, Kortman H, Hilario A, Nicholson P, Agid R, Krings T, Pereira VM. Ticagrelor versus Clopidogrel in the Dual Antiplatelet Regimen for Intracranial Stenting or Flow-Diverter Treatment for Unruptured Cerebral Aneurysms: A Single-Center Cohort Study. AJNR Am J Neuroradiol 2021; 42:1638-1644. [PMID: 34244132 DOI: 10.3174/ajnr.a7216] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 04/25/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND PURPOSE Ticagrelor is a novel P2Y12 antagonist, and little is known about its efficacy and safety in the endovascular treatment of aneurysms. This study evaluated the efficacy and safety of ticagrelor versus clopidogrel for stent-assisted coiling or flow-diversion treatment in patients with unruptured cerebral aneurysms. MATERIALS AND METHODS From November 2003 to February 2019, two hundred one patients (mean age, 57.5 years; 156 women) with 233 unruptured aneurysms underwent stent-assisted coiling or flow-diversion treatment. All patients received antiplatelet therapy of aspirin plus clopidogrel (clopidogrel group, 121 patients with 140 aneurysms) or aspirin plus ticagrelor (ticagrelor group, 80 patients with 93 aneurysms). The clinical and radiologic data in each group were retrospectively reviewed and compared. RESULTS Two hundred thirty-six procedures were performed, including stent-assisted coiling (n = 101) and flow diversion (n = 135). At 90 days, the primary outcome-a composite of any stroke and death-occurred in 9.9% of the clopidogrel group and 8.6% of the ticagrelor group (P = .822). Ischemic stroke occurred in 10 (7.0%) of the clopidogrel group and 7 (7.5%) of the ticagrelor group (P > .999). Disabling stroke occurred in 4 (2.8%) in the clopidogrel group and in 4 (4.3%) in the ticagrelor group (P = .716). Ninety-day death occurred in 3 (2.1%) in the clopidogrel group and 1 (1.1%) in the ticagrelor group (P > .999). Any bleeding at 90 days occurred in 13 (9.2%) in the clopidogrel group and 6 (6.5%) in the ticagrelor group (P = .479). CONCLUSIONS Ticagrelor appears to be as effective and safe as clopidogrel in stent-assisted coiling or flow-diversion treatment for unruptured cerebral aneurysms.
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Affiliation(s)
- K Y Park
- From the Division of Neuroradiology (K.Y.P., T.O., A.K., H.K., A.H., P.N., R.A., T.K., V.M.P.), Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Department of Neurosurgery (K.Y.P.), Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - T Ozaki
- From the Division of Neuroradiology (K.Y.P., T.O., A.K., H.K., A.H., P.N., R.A., T.K., V.M.P.), Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - A Kostynskyy
- From the Division of Neuroradiology (K.Y.P., T.O., A.K., H.K., A.H., P.N., R.A., T.K., V.M.P.), Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - H Kortman
- From the Division of Neuroradiology (K.Y.P., T.O., A.K., H.K., A.H., P.N., R.A., T.K., V.M.P.), Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Department of Radiology (H.K.), Elisabeth-TweeSteden Ziekenhuis St. Elisabeth Hospital, Tilburg, the Netherlands
| | - A Hilario
- From the Division of Neuroradiology (K.Y.P., T.O., A.K., H.K., A.H., P.N., R.A., T.K., V.M.P.), Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - P Nicholson
- From the Division of Neuroradiology (K.Y.P., T.O., A.K., H.K., A.H., P.N., R.A., T.K., V.M.P.), Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - R Agid
- From the Division of Neuroradiology (K.Y.P., T.O., A.K., H.K., A.H., P.N., R.A., T.K., V.M.P.), Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - T Krings
- From the Division of Neuroradiology (K.Y.P., T.O., A.K., H.K., A.H., P.N., R.A., T.K., V.M.P.), Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - V M Pereira
- From the Division of Neuroradiology (K.Y.P., T.O., A.K., H.K., A.H., P.N., R.A., T.K., V.M.P.), Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
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Oliveira Filho RV, Cooke RF, de Mello GA, Pereira VM, Vasconcelos JLM, Pohler KG. The effect of clitoral stimulation post artificial insemination on pregnancy rates of multiparous Bos indicus beef cows submitted to estradiol/progesterone-based estrus synchronization protocol. J Anim Sci 2020; 98:5856330. [PMID: 32529208 DOI: 10.1093/jas/skaa195] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 06/08/2020] [Indexed: 11/14/2022] Open
Abstract
Clitoral stimulation after artificial insemination (AI) in beef cattle is a common practice utilized by AI technicians; however, the effect of clitoral stimulation during fixed-time AI (TAI) is still unknown. The objective of the present experiment was to evaluate the effect of clitoral stimulation on temperament responses and pregnancy rates to TAI in Bos indicus beef cows. A total of 1,186 multiparous Nellore cows across three different locations were assigned to an estradiol/progesterone-based estrus synchronization + TAI protocol (day -11 to 0). Cows were randomly assigned to receive either 3 s of clitoral stimulation (n = 602) or no clitoral stimulation (n = 584) immediately after TAI (day 0). Cow body condition score (BCS) was recorded on day -11. Estrus expression was evaluated based on estrus detection visual aid patch activation on day 0 (estrus, ≥50% activated; no estrus, <50% activated). Temperament was assessed by individual chute score based on a 5-point scale before TAI, and individual exit velocity was measured after clitoral stimulation. Pregnancy diagnosis was performed 30 d after TAI via transrectal ultrasonography. Pregnancy rate to TAI was positively affected by BCS (P < 0.01) and estrus expression (P = 0.03). Pregnancy rates of cows receiving clitoral stimulation did not differ (P = 0.39) from cows non-stimulated (47.5 ± 4.6% vs. 44.3 ± 4.6%, respectively). No interaction of clitoral stimulation and estrus expression was observed (P = 0.26). Chute score was positively correlated to exit velocity (P < 0.01; r = 0.29); however, clitoral stimulation did not affect exit velocity (P = 0.86). In summary, pregnancy rates to TAI are influenced by various factors and multiple strategies have the potential to increase the fertility of beef cows submitted to TAI; however, clitoral stimulation of Bos indicus beef cows did not improve TAI pregnancy rate.
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Affiliation(s)
- Ramiro V Oliveira Filho
- Department of Animal Science, Pregnancy and Developmental Programming Area of Excellence, Texas A&M University, College Station, TX
| | - Reinaldo F Cooke
- Department of Animal Science, Pregnancy and Developmental Programming Area of Excellence, Texas A&M University, College Station, TX
| | - Gustavo A de Mello
- Pontifical Catholic University of Minas Gerais, Poços de Caldas, MG, Brazil
| | | | | | - Ky G Pohler
- Department of Animal Science, Pregnancy and Developmental Programming Area of Excellence, Texas A&M University, College Station, TX
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Bhatia KD, Kortman H, Lee H, Waelchli T, Radovanovic I, Schaafsma JD, Pereira VM, Krings T. Facial Nerve Arterial Arcade Supply in Dural Arteriovenous Fistulas: Anatomy and Treatment Strategies. AJNR Am J Neuroradiol 2020; 41:687-692. [PMID: 32193191 DOI: 10.3174/ajnr.a6449] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Accepted: 01/14/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Endovascular treatment of petrous dural AVFs may carry a risk of iatrogenic facial nerve palsy if the facial nerve arterial arcade, an anastomotic arterial arch that supplies the geniculate ganglion, is not respected or recognized. Our purpose was to demonstrate that the use of a treatment strategy algorithm incorporating detailed angiographic anatomic assessment allows identification of the facial nerve arterial arcade and therefore safe endovascular treatment. MATERIALS AND METHODS This was a retrospective cohort study of consecutive petrous dural AVF cases managed at Toronto Western Hospital between 2006 and 2018. Our standard of care consists of detailed angiographic assessment followed by multidisciplinary discussion on management. Arterial supply, primary and secondary treatments undertaken, angiographic outcomes, and clinical outcomes were assessed by 2 independent fellowship-trained interventional neuroradiologists. RESULTS Fifteen patients had 15 fistulas localized over the petrous temporal bone. Fistulas in all 15 patients had direct cortical venous drainage and received at least partial supply from the facial nerve arterial arcade. Following multidisciplinary evaluation, treatment was performed by endovascular embolization in 8 patients (53%) and microsurgical disconnection in 7 patients (47%). All patients had long-term angiographic cure, and none developed iatrogenic facial nerve palsy. CONCLUSIONS By means of our treatment strategy based on detailed angiographic assessment and multidisciplinary discussion, approximately half of our patients with petrous AVFs were cured by endovascular treatment, half were cured by an operation, and all had preserved facial nerve function.
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Affiliation(s)
- K D Bhatia
- From the Division of Neuroradiology (K.D.B., H.K., H.L., V.M.P., T.K.), Joint Department of Medical Imaging
| | - H Kortman
- From the Division of Neuroradiology (K.D.B., H.K., H.L., V.M.P., T.K.), Joint Department of Medical Imaging
| | - H Lee
- From the Division of Neuroradiology (K.D.B., H.K., H.L., V.M.P., T.K.), Joint Department of Medical Imaging
| | - T Waelchli
- Division of Neurosurgery (T.W., I.R., V.M.P., T.K.), Department of Surgery
| | - I Radovanovic
- Division of Neurosurgery (T.W., I.R., V.M.P., T.K.), Department of Surgery
| | - J D Schaafsma
- Division of Neurology (J.D.S.), Department of Medicine, Toronto Western Hospital, Toronto, Ontario, Canada
| | - V M Pereira
- From the Division of Neuroradiology (K.D.B., H.K., H.L., V.M.P., T.K.), Joint Department of Medical Imaging.,Division of Neurosurgery (T.W., I.R., V.M.P., T.K.), Department of Surgery
| | - T Krings
- From the Division of Neuroradiology (K.D.B., H.K., H.L., V.M.P., T.K.), Joint Department of Medical Imaging.,Division of Neurosurgery (T.W., I.R., V.M.P., T.K.), Department of Surgery
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Bhatia KD, Kortman H, Wälchli T, Radovanovic I, Pereira VM, Krings T. Artery of Davidoff and Schechter Supply in Dural Arteriovenous Fistulas. AJNR Am J Neuroradiol 2020; 41:300-304. [PMID: 31974076 DOI: 10.3174/ajnr.a6380] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 11/20/2019] [Indexed: 01/06/2023]
Abstract
The artery of Davidoff and Schechter is a dural branch of the posterior cerebral artery that can supply the meninges close to the falcotentorial junction. It is usually not identified on angiography except when enlarged in the setting of a dural AVF or meningioma. The impact on treatment of the artery of Davidoff and Schechter supply to a fistula is not well-described in the literature. Our retrospective analysis of patients with dural AVFs treated at the Toronto Western Hospital between 2006 and 2018 identified 6 patients with dural AVFs receiving supply from artery of Davidoff and Schechter (of a total of 173 patients with dural AVFs). All patients were initially treated by transarterial embolization using liquid embolic agents. Three patients required a second endovascular procedure partly due to residual supply from artery of Davidoff and Schechter, and in all cases, angiographic cure was obtained. The treatment approach, challenges encountered, and potential complications of treating such fistulas are described.
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Affiliation(s)
- K D Bhatia
- From the Division of Neuroradiology (K.D.B., H.K., V.M.P., T.K.)
| | - H Kortman
- From the Division of Neuroradiology (K.D.B., H.K., V.M.P., T.K.)
| | - T Wälchli
- Joint Department of Medical Imaging, and Division of Neurosurgery (T.W., I.R., V.M.P., T.K.), Department of Surgery, Toronto Western Hospital, Toronto, Ontario, Canada.,Department of Fundamental Neurobiology (T.W., I.R.), Krembil Research Institute, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.,Group of CNS Angiogenesis and Neurovascular Link, and Physician-Scientist Program (T.W.), Institute for Regenerative Medicine, Neuroscience Center Zurich, Zurich, Switzerland.,Department of Health Sciences and Technology (T.W.), Swiss Federal Institute of Technology, Zurich, Zurich, Switzerland.,Division of Neurosurgery Program (T.W.), University Hospital Zurich, Zurich, Switzerland
| | - I Radovanovic
- Joint Department of Medical Imaging, and Division of Neurosurgery (T.W., I.R., V.M.P., T.K.), Department of Surgery, Toronto Western Hospital, Toronto, Ontario, Canada.,Department of Fundamental Neurobiology (T.W., I.R.), Krembil Research Institute, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - V M Pereira
- From the Division of Neuroradiology (K.D.B., H.K., V.M.P., T.K.).,Joint Department of Medical Imaging, and Division of Neurosurgery (T.W., I.R., V.M.P., T.K.), Department of Surgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - T Krings
- From the Division of Neuroradiology (K.D.B., H.K., V.M.P., T.K.).,Joint Department of Medical Imaging, and Division of Neurosurgery (T.W., I.R., V.M.P., T.K.), Department of Surgery, Toronto Western Hospital, Toronto, Ontario, Canada
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Brina O, Bouillot P, Reymond P, Luthman AS, Santarosa C, Fahrat M, Lovblad KO, Machi P, Delattre BMA, Pereira VM, Vargas MI. How Flow Reduction Influences the Intracranial Aneurysm Occlusion: A Prospective 4D Phase-Contrast MRI Study. AJNR Am J Neuroradiol 2019; 40:2117-2123. [PMID: 31727755 DOI: 10.3174/ajnr.a6312] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 09/20/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND PURPOSE Flow-diverter stents are widely used for the treatment of wide-neck intracranial aneurysms. Various parameters may influence intracranial aneurysm thrombosis, including the flow reduction induced by flow-diverter stent implantation, which is assumed to play a leading role. However, its actual impact remains unclear due to the lack of detailed intra-aneurysmal flow measurements. This study aimed to clarify this relationship by quantitatively measuring the intra-aneurysmal flow using 4D phase-contrast MR imaging. MATERIALS AND METHODS We acquired prospective pre- and post-stent implantation 4D phase-contrast MR imaging data of a consecutive series of 23 patients treated with flow-diverter stents. Velocity field data were combined with the intraprocedural 3D angiogram vessel geometries for precise intracranial aneurysm extraction and partial volume correction. Intra-aneurysmal hemodynamic modifications were compared with occlusion outcomes at 6 and 12 months. RESULTS The averaged velocities at systole were lower after flow-diverter stent implantation for all patients and ranged from 21.7 ± 7.1 cm/s before to 7.2 ± 2.9 cm/s after stent placement. The velocity reduction was more important for the group of patients with aneurysm thrombosis at 6 months (68.8%) and decreased gradually from 66.2% to 55% for 12-month thrombosis and no thrombosis, respectively (P = .08). CONCLUSIONS We propose an innovative approach to measure intracranial flow changes after flow-diverter stent implantation. We identified a trend between flow reduction and thrombosis outcome that brings a new insight into current understanding of the flow-diversion treatment response.
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Affiliation(s)
- O Brina
- From the Divisions of Neuroradiology (O.B., P.R., A.S.L., C.S., K.O.L., P.M., V.M.P., M.I.V.)
| | - P Bouillot
- Department of Quantum Matter Physics (P.B.), University of Geneva, Geneva, Switzerland
| | - P Reymond
- From the Divisions of Neuroradiology (O.B., P.R., A.S.L., C.S., K.O.L., P.M., V.M.P., M.I.V.)
| | - A S Luthman
- From the Divisions of Neuroradiology (O.B., P.R., A.S.L., C.S., K.O.L., P.M., V.M.P., M.I.V.)
| | - C Santarosa
- From the Divisions of Neuroradiology (O.B., P.R., A.S.L., C.S., K.O.L., P.M., V.M.P., M.I.V.)
| | - M Fahrat
- Laboratory for Hydraulic Machines (M.F.), Ecole Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - K O Lovblad
- From the Divisions of Neuroradiology (O.B., P.R., A.S.L., C.S., K.O.L., P.M., V.M.P., M.I.V.)
| | - P Machi
- From the Divisions of Neuroradiology (O.B., P.R., A.S.L., C.S., K.O.L., P.M., V.M.P., M.I.V.)
| | - B M A Delattre
- Radiology (B.M.A.D.), Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - V M Pereira
- From the Divisions of Neuroradiology (O.B., P.R., A.S.L., C.S., K.O.L., P.M., V.M.P., M.I.V.).,Division of Neuroradiology (V.M.P.).,Department of Medical Imaging (V.M.P.).,Division of Neurosurgery (V.M.P.), Department of Surgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - M I Vargas
- From the Divisions of Neuroradiology (O.B., P.R., A.S.L., C.S., K.O.L., P.M., V.M.P., M.I.V.)
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9
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Jhaveri A, Amirabadi A, Dirks P, Kulkarni AV, Shroff MM, Shkumat N, Krings T, Pereira VM, Rea V, Muthusami P. Predictive Value of MRI in Diagnosing Brain AVM Recurrence after Angiographically Documented Exclusion in Children. AJNR Am J Neuroradiol 2019; 40:1227-1235. [PMID: 31248861 DOI: 10.3174/ajnr.a6093] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 04/18/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND PURPOSE MRI is routinely performed following brain AVM after treatment in children. Our aim was to determine the predictive values of contrast-enhanced MR imaging and TOF-MRA for brain AVM recurrence in children, compared with conventional angiography and the role of 3D rotational angiography-MR imaging fusion in these cases. MATERIALS AND METHODS We included all pediatric patients with brain AVMs during an 18-year period with angiographically documented obliteration after treatment. Patients underwent 3T MR imaging, including contrast-enhanced MR imaging, TOF-MRA, and conventional angiography, with a subset undergoing 3D rotational angiography. The predictive values of contrast-enhanced MR imaging and TOF-MRA for brain AVM recurrence were determined. CTA sections reconstructed from 3D rotational angiography were coregistered with and fused to 3D-T1WI for analysis. RESULTS Thirty-nine children (10.8 ± 3.9 years of age; range, 2-17 years; male/female ratio, 19:20; mean Spetzler-Martin grade, 1.9 ± 0.6) met the inclusion criteria. Of these, 13 had angiographically confirmed brain AVM recurrence, 8 following surgery and 5 following embolization. Sensitivity, specificity, and positive and negative predictive values for recurrence were the following: contrast-enhanced MR imaging: 84.6%, 38.5%, 40.7%, 81.8%; TOF-MRA: 50.0%, 96.1%, 85.7%, 79.3%; both: 75.0%, 90.9%, 85.7%, 83.3%. 3D rotational angiography-MR imaging fused images confirmed or excluded recurrence in all available cases (13/13). Embolization-only treatment was a significant predictor of recurrence (OR = 32.4, P = .006). MR imaging features predictive of recurrence included a tuft of vessels on TOF-MRA and nodular juxtamural/linear enhancement with a draining vein on contrast-enhanced MR imaging. CONCLUSIONS MR imaging is useful for surveillance after brain AVM treatment in children, but conventional angiography is required for definitive diagnosis of recurrence. TOF-MRA and contrast-enhanced MR imaging provide complementary information for determining brain AVM recurrence and should be interpreted in conjunction. 3D rotational angiography-MR imaging fusion increases the diagnostic confidence regarding brain AVM recurrence and is therefore suited for intraoperative neuronavigation.
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Affiliation(s)
- A Jhaveri
- From Pediatric Neuroradiology and Image Guided Therapy (A.J., A.A., M.M.S., N.S., V.R., P.M.), Diagnostic Imaging
| | - A Amirabadi
- From Pediatric Neuroradiology and Image Guided Therapy (A.J., A.A., M.M.S., N.S., V.R., P.M.), Diagnostic Imaging
| | - P Dirks
- Division of Neurosurgery (P.D., A.V.K.), Department of Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - A V Kulkarni
- Division of Neurosurgery (P.D., A.V.K.), Department of Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - M M Shroff
- From Pediatric Neuroradiology and Image Guided Therapy (A.J., A.A., M.M.S., N.S., V.R., P.M.), Diagnostic Imaging
| | - N Shkumat
- From Pediatric Neuroradiology and Image Guided Therapy (A.J., A.A., M.M.S., N.S., V.R., P.M.), Diagnostic Imaging
| | - T Krings
- Divisions of Neuroradiology and Neurosurgery (T.K.,V.M.P.), Departments of Medical Imaging and Surgery, University of Toronto, and Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - V M Pereira
- Divisions of Neuroradiology and Neurosurgery (T.K.,V.M.P.), Departments of Medical Imaging and Surgery, University of Toronto, and Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - V Rea
- From Pediatric Neuroradiology and Image Guided Therapy (A.J., A.A., M.M.S., N.S., V.R., P.M.), Diagnostic Imaging
| | - P Muthusami
- From Pediatric Neuroradiology and Image Guided Therapy (A.J., A.A., M.M.S., N.S., V.R., P.M.), Diagnostic Imaging
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10
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Dmytriw AA, Phan K, Moore JM, Pereira VM, Krings T, Thomas AJ. On Flow Diversion: The Changing Landscape of Intracerebral Aneurysm Management. AJNR Am J Neuroradiol 2019; 40:591-600. [PMID: 30894358 DOI: 10.3174/ajnr.a6006] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 01/25/2019] [Indexed: 12/15/2022]
Abstract
Uptake of flow-diverting technology is rapidly outpacing the availability of clinical evidence. Most current usage is off-label, and the endovascular community is nearer the beginning than the end of the learning curve, given the number of devices in development. A comprehensive overview of technical specifications alongside key outcome data is essential both for clinical decision-making and to direct further investigations. Most-studied has been the Pipeline Embolization Device, which has undergone a transition to the Pipeline Flex for which outcome data are sparse or heterogeneous. Alternative endoluminal devices do not appear to be outperforming the Pipeline Embolization Device to date, though prospective studies and long-term data mostly are lacking, and between-study comparisons must be treated with caution. Nominal technical specifications may be unrelated to in situ performance, emphasizing the importance of correct radiologic sizing and device placement. Devices designed specifically for bifurcation aneurysms also lack long-term outcome data or have only recently become available for clinical use. There are no major studies directly comparing a flow-diverting device with standard coiling or microsurgical clipping. Data on flow-diverting stents are too limited in terms of long-term outcomes to reliably inform clinical decision-making. The best available evidence supports using a single endoluminal device for most indications. Recommendations on the suitability and choice of a device for bifurcation or ruptured aneurysms or for anatomically complex lesions cannot be made on the basis of current evidence. The appropriateness of flow-diverting treatment must be decided on a case-by-case basis, considering experience and the relative risks against standard approaches or observation.
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Affiliation(s)
- A A Dmytriw
- From the Department of Medical Imaging (A.A.D., V.M.P., T.K.), Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada .,Neurosurgical Service (A.A.D., K.P., J.M.M., A.J.T.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - K Phan
- Neurosurgical Service (A.A.D., K.P., J.M.M., A.J.T.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,NeuroSpine Surgery Research Group (K.P.), Prince of Wales Private Hospital, Sydney, Australia
| | - J M Moore
- Neurosurgical Service (A.A.D., K.P., J.M.M., A.J.T.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - V M Pereira
- From the Department of Medical Imaging (A.A.D., V.M.P., T.K.), Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - T Krings
- From the Department of Medical Imaging (A.A.D., V.M.P., T.K.), Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - A J Thomas
- Neurosurgical Service (A.A.D., K.P., J.M.M., A.J.T.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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11
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Kim H, Al-Shahi Salman R, Flemming KD, Flint AC, Hess CP, Hetts S, Krings T, Laakso A, Lanzino G, Lawton MT, McCulloch CE, Mohr JP, Morgan MK, Moy CS, Nakaji P, Pereira VM, Sgarabotto Ribeiro D, Stapf C, Stefani MA, Zaroff JG, Zhao Y. Abstract TP585: Long-Term Outcomes in Unruptured Brain Arteriovenous Malformation Patients: The Multicenter Arteriovenous Malformation Research Study (MARS). Stroke 2019. [DOI: 10.1161/str.50.suppl_1.tp585] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Helen Kim
- Anesthesia, Epidemiology & Biostatistics, UCSF, San Francisco, CA
| | | | | | | | | | | | - Timo Krings
- Div of Neuroradiology, Univ of Toronto, Toronto, Canada
| | | | | | | | | | - Jay P Mohr
- Vascular Neurology, Columbia Univ Med Cntr, New York, NY
| | | | | | - Peter Nakaji
- Neurosurgery, Barrow Neurological Institute, Phoenix, AZ
| | | | | | | | - Marco A Stefani
- Universidade Federal do Rio Grande do Sul, Farroupilha, Brazil
| | | | - Yuanli Zhao
- Neurosurgery Cntr of Beijing Tiantan Hosp, Beijing, China
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12
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Adeeb N, Griessenauer CJ, Dmytriw AA, Shallwani H, Gupta R, Foreman PM, Shakir H, Moore J, Limbucci N, Mangiafico S, Kumar A, Michelozzi C, Zhang Y, Pereira VM, Matouk CC, Harrigan MR, Siddiqui AH, Levy EI, Renieri L, Marotta TR, Cognard C, Ogilvy CS, Thomas AJ. Risk of Branch Occlusion and Ischemic Complications with the Pipeline Embolization Device in the Treatment of Posterior Circulation Aneurysms. AJNR Am J Neuroradiol 2018; 39:1303-1309. [PMID: 29880475 DOI: 10.3174/ajnr.a5696] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 04/10/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Flow diversion with the Pipeline Embolization Device is increasingly used for endovascular treatment of intracranial aneurysms due to high reported obliteration rates and low associated morbidity. While obliteration of covered branches in the anterior circulation is generally asymptomatic, this has not been studied within the posterior circulation. The aim of this study was to evaluate the association between branch coverage and occlusion, as well as associated ischemic events in a cohort of patients with posterior circulation aneurysms treated with the Pipeline Embolization Device. MATERIALS AND METHODS A retrospective review of prospectively maintained databases at 8 academic institutions from 2009 to 2016 was performed to identify patients with posterior circulation aneurysms treated with the Pipeline Embolization Device. Branch coverage following placement was evaluated, including the posterior inferior cerebellar artery, anterior inferior cerebellar artery, superior cerebellar artery, and posterior cerebral artery. If the Pipeline Embolization Device crossed the ostia of the contralateral vertebral artery, its long-term patency was assessed as well. RESULTS A cohort of 129 consecutive patients underwent treatment of 131 posterior circulation aneurysms with the Pipeline Embolization Device. Adjunctive coiling was used in 40 (31.0%) procedures. One or more branches were covered in 103 (79.8%) procedures. At a median follow-up of 11 months, 11% were occluded, most frequently the vertebral artery (34.8%). Branch obliteration was most common among asymptomatic aneurysms (P < .001). Ischemic complications occurred in 29 (22.5%) procedures. On multivariable analysis, there was no significant difference in ischemic complications in cases in which a branch was covered (P = .24) or occluded (P = .16). CONCLUSIONS There was a low occlusion incidence in end arteries following branch coverage at last follow-up. The incidence was higher in the posterior cerebral artery and vertebral artery where collateral supply is high. Branch occlusion was not associated with a significant increase in ischemic complications.
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Affiliation(s)
- N Adeeb
- From the Beth Israel Deaconess Medical Center (N.A., C.J.G., A.A.D., R.G., J.M., C.S.O., A.J.T.), Harvard Medical School, Boston, Massachusetts
| | - C J Griessenauer
- From the Beth Israel Deaconess Medical Center (N.A., C.J.G., A.A.D., R.G., J.M., C.S.O., A.J.T.), Harvard Medical School, Boston, Massachusetts
- Department of Neurosurgery (C.J.G.), Geisinger Medical Center, Geisinger Commonwealth School of Medicine, Danville, Pennsylvania
| | - A A Dmytriw
- From the Beth Israel Deaconess Medical Center (N.A., C.J.G., A.A.D., R.G., J.M., C.S.O., A.J.T.), Harvard Medical School, Boston, Massachusetts
- Department of Medical Imaging (A.A.D., Y.Z., V.M.P.), Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Division of Diagnostic and Therapeutic Neuroradiology (A.A.D., A.K., T.R.M.), St. Michael's Hospital, Toronto, Ontario, Canada
| | - H Shallwani
- Department of Neurosurgery (H. Shallwani, H. Shakir, A.H.S., E.I.L.), State University of New York at Buffalo, Buffalo, New York
| | - R Gupta
- From the Beth Israel Deaconess Medical Center (N.A., C.J.G., A.A.D., R.G., J.M., C.S.O., A.J.T.), Harvard Medical School, Boston, Massachusetts
| | - P M Foreman
- Department of Neurosurgery (P.M.F., M.R.H.), University of Alabama at Birmingham, Birmingham, Alabama
| | - H Shakir
- Department of Neurosurgery (H. Shallwani, H. Shakir, A.H.S., E.I.L.), State University of New York at Buffalo, Buffalo, New York
| | - J Moore
- From the Beth Israel Deaconess Medical Center (N.A., C.J.G., A.A.D., R.G., J.M., C.S.O., A.J.T.), Harvard Medical School, Boston, Massachusetts
| | - N Limbucci
- Department of Interventional Neuroradiology (N.L., S.M., L.R.), University of Florence, Florence, Italy
| | - S Mangiafico
- Department of Interventional Neuroradiology (N.L., S.M., L.R.), University of Florence, Florence, Italy
| | - A Kumar
- Division of Diagnostic and Therapeutic Neuroradiology (A.A.D., A.K., T.R.M.), St. Michael's Hospital, Toronto, Ontario, Canada
| | - C Michelozzi
- Department of Diagnostic and Therapeutic Neuroradiology (C.M., C.C.), Toulouse University Hospital, Toulouse, France
| | - Y Zhang
- Department of Medical Imaging (A.A.D., Y.Z., V.M.P.), Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - V M Pereira
- Department of Medical Imaging (A.A.D., Y.Z., V.M.P.), Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - C C Matouk
- Department of Neurosurgery (C.C.M.), Yale School of Medicine, New Haven, Connecticut
| | - M R Harrigan
- Department of Neurosurgery (P.M.F., M.R.H.), University of Alabama at Birmingham, Birmingham, Alabama
| | - A H Siddiqui
- Department of Neurosurgery (H. Shallwani, H. Shakir, A.H.S., E.I.L.), State University of New York at Buffalo, Buffalo, New York
| | - E I Levy
- Department of Neurosurgery (H. Shallwani, H. Shakir, A.H.S., E.I.L.), State University of New York at Buffalo, Buffalo, New York
| | - L Renieri
- Department of Interventional Neuroradiology (N.L., S.M., L.R.), University of Florence, Florence, Italy
| | - T R Marotta
- Division of Diagnostic and Therapeutic Neuroradiology (A.A.D., A.K., T.R.M.), St. Michael's Hospital, Toronto, Ontario, Canada
| | - C Cognard
- Department of Diagnostic and Therapeutic Neuroradiology (C.M., C.C.), Toulouse University Hospital, Toulouse, France
| | - C S Ogilvy
- From the Beth Israel Deaconess Medical Center (N.A., C.J.G., A.A.D., R.G., J.M., C.S.O., A.J.T.), Harvard Medical School, Boston, Massachusetts
| | - A J Thomas
- From the Beth Israel Deaconess Medical Center (N.A., C.J.G., A.A.D., R.G., J.M., C.S.O., A.J.T.), Harvard Medical School, Boston, Massachusetts
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13
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Hilditch CA, Nicholson P, Murad MH, Rabinstein A, Schaafsma J, Pikula A, Krings T, Pereira VM, Agid R, Brinjikji W. Endovascular Management of Acute Stroke in the Elderly: A Systematic Review and Meta-Analysis. AJNR Am J Neuroradiol 2018; 39:887-891. [PMID: 29567654 DOI: 10.3174/ajnr.a5598] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 01/24/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND Acute ischemic stroke occurs more frequently, presents with more severe symptoms, and has worse outcomes in elderly patients. The safety and efficacy of endovascular therapy for acute stroke in this age group has not been fully established. PURPOSE We present the results of a systematic review and meta-analysis examining clinical, procedural, and radiologic outcomes of endovascular therapy for acute stroke in patients older than 80 years of age. DATA SOURCES We searched PubMed, MEDLINE, and EMBASE from 1992 to week 35 of 2017 for studies evaluating endovascular therapy for acute stroke in the elderly. STUDY SELECTION Two independent reviewers selected studies and abstracted data. The primary end point was good functional outcome at 3 months defined as modified Rankin Scale score of ≤2. DATA ANALYSIS Data were analyzed using random-effects meta-analysis. DATA SYNTHESIS Seventeen studies reporting on 860 patients were included. The rate of good functional outcome at 3 months was 27% (95% CI, 21%-32%). Mortality at 3 months was 34% (95% CI, 23%-44%). Successful recanalization was achieved in 78% of patients (95% CI, 72%-85%). Procedure-related complications occurred in 11% (95% CI, 4%-17%). The incidence of intracranial hemorrhage was 24% (95% CI, 15%-32%), and for symptomatic intracranial hemorrhage, it was 8% (95% CI, 5%-10%). The mean time to groin was 251 minutes (95% CI, 224-278 minutes). Procedure time was 99 minutes (95% CI, 67-131 minutes). LIMITATIONS I2 values were above 50% for all outcomes, indicating substantial heterogeneity. CONCLUSIONS Good functional recovery in octogenarians treated with endovascular therapy for acute stroke can be achieved in a high proportion of patients despite the higher incidence of comorbidity in this cohort. Outcomes are inferior to those reported for younger patients; however, endovascular therapy can allow at least 1 in 4 patients older than 80 years of age to regain independent function at 3 months. More research is required to improve patient selection in the elderly, but age should not be a discriminator when deciding to offer endovascular therapy for patients with acute stroke.
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Affiliation(s)
- C A Hilditch
- From the Division of Neuroradiology (C.A.H., P.N., T.K., V.M.P., R.A., W.B.), Joint Division of Medical Imaging
| | - P Nicholson
- From the Division of Neuroradiology (C.A.H., P.N., T.K., V.M.P., R.A., W.B.), Joint Division of Medical Imaging
| | - M H Murad
- Evidence-Based Practice Center (M.H.M.)
| | - A Rabinstein
- Department of Neurology (A.R.), Mayo Clinic, Rochester, Minnesota
| | - J Schaafsma
- Division of Neurology (J.S., A.P.), Toronto Western Hospital, Toronto, Ontario, Canada
| | - A Pikula
- Division of Neurology (J.S., A.P.), Toronto Western Hospital, Toronto, Ontario, Canada
| | - T Krings
- From the Division of Neuroradiology (C.A.H., P.N., T.K., V.M.P., R.A., W.B.), Joint Division of Medical Imaging.,Division of Neurosurgery (T.K., V.M.P.), Department of Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - V M Pereira
- From the Division of Neuroradiology (C.A.H., P.N., T.K., V.M.P., R.A., W.B.), Joint Division of Medical Imaging.,Division of Neurosurgery (T.K., V.M.P.), Department of Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - R Agid
- From the Division of Neuroradiology (C.A.H., P.N., T.K., V.M.P., R.A., W.B.), Joint Division of Medical Imaging
| | - W Brinjikji
- From the Division of Neuroradiology (C.A.H., P.N., T.K., V.M.P., R.A., W.B.), Joint Division of Medical Imaging
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14
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Chnafa C, Brina O, Pereira VM, Steinman DA. Better Than Nothing: A Rational Approach for Minimizing the Impact of Outflow Strategy on Cerebrovascular Simulations. AJNR Am J Neuroradiol 2018; 39:337-343. [PMID: 29269407 DOI: 10.3174/ajnr.a5484] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 10/13/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Computational fluid dynamics simulations of neurovascular diseases are impacted by various modeling assumptions and uncertainties, including outlet boundary conditions. Many studies of intracranial aneurysms, for example, assume zero pressure at all outlets, often the default ("do-nothing") strategy, with no physiological basis. Others divide outflow according to the outlet diameters cubed, nominally based on the more physiological Murray's law but still susceptible to subjective choices about the segmented model extent. Here we demonstrate the limitations and impact of these outflow strategies, against a novel "splitting" method introduced here. MATERIALS AND METHODS With our method, the segmented lumen is split into its constituent bifurcations, where flow divisions are estimated locally using a power law. Together these provide the global outflow rate boundary conditions. The impact of outflow strategy on flow rates was tested for 70 cases of MCA aneurysm with 0D simulations. The impact on hemodynamic indices used for rupture status assessment was tested for 10 cases with 3D simulations. RESULTS Differences in flow rates among the various strategies were up to 70%, with a non-negligible impact on average and oscillatory wall shear stresses in some cases. Murray-law and splitting methods gave flow rates closest to physiological values reported in the literature; however, only the splitting method was insensitive to arbitrary truncation of the model extent. CONCLUSIONS Cerebrovascular simulations can depend strongly on the outflow strategy. The default zero-pressure method should be avoided in favor of Murray-law or splitting methods, the latter being released as an open-source tool to encourage the standardization of outflow strategies.
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Affiliation(s)
- C Chnafa
- From the Biomedical Simulation Laboratory (C.C., D.A.S.), Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada
| | - O Brina
- Joint Division of Medical Imaging (O.B., V.M.P.), Department of Medical Imaging and Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, and University of Toronto, Toronto, Ontario, Canada
| | - V M Pereira
- Joint Division of Medical Imaging (O.B., V.M.P.), Department of Medical Imaging and Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, and University of Toronto, Toronto, Ontario, Canada
| | - D A Steinman
- From the Biomedical Simulation Laboratory (C.C., D.A.S.), Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada
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15
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Chnafa C, Bouillot P, Brina O, Delattre BMA, Vargas MI, Lovblad KO, Pereira VM, Steinman DA. Vessel calibre and flow splitting relationships at the internal carotid artery terminal bifurcation. Physiol Meas 2017; 38:2044-2057. [DOI: 10.1088/1361-6579/aa92bf] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Jadhav AP, Diener HC, Bonafe A, Pereira VM, Levy EI, Baxter BW, Jovin TG, Nogueira RG, Yavagal DR, Cognard C, Purcell DD, Menon BK, Jahan R, Saver JL, Goyal M. Correlation between Clinical Outcomes and Baseline CT and CT Angiographic Findings in the SWIFT PRIME Trial. AJNR Am J Neuroradiol 2017; 38:2270-2276. [PMID: 29025724 DOI: 10.3174/ajnr.a5406] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 07/19/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Patient selection for endovascular therapy remains a great challenge in clinic practice. We sought to determine the effect of baseline CT and angiography on outcomes in the Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke (SWIFT PRIME) trial and to identify patients who would benefit from endovascular stroke therapy. MATERIALS AND METHODS The primary end point was a 90-day modified Rankin Scale score of 0-2. Subgroup and classification and regression tree analysis was performed on baseline ASPECTS, site of occlusion, clot length, collateral status, and onset-to-treatment time. RESULTS Smaller baseline infarct (n = 145) (ASPECTS 8-10) was associated with better outcomes in patients treated with thrombectomy versus IV tPA alone (66% versus 41%; rate ratio, 1.62) compared with patients with larger baseline infarcts (n = 44) (ASPECTS 6-7) (42% versus 21%; rate ratio, 1.98). The benefit of thrombectomy over IV tPA alone did not differ significantly by ASPECTS. Stratification by occlusion location also showed benefit with thrombectomy across all groups. Improved outcomes after thrombectomy occurred in patients with clot lengths of ≥8 mm (71% versus 43%; rate ratio, 1.67). Outcomes stratified by collateral status had a benefit with thrombectomy across all groups: none-fair collaterals (33% versus 0%), good collaterals (58% versus 44%), and excellent collaterals (82% versus 28%). Using a 3-level classification and regression tree analysis, we observed optimal outcomes in patients with favorable baseline ASPECTS, complete/near-complete recanalization (TICI 2b/3), and early treatment (mean mRS, 1.35 versus 3.73), while univariate and multivariate logistic regression showed significantly better results in patients with higher ASPECTS. CONCLUSIONS While benefit was seen with endovascular therapy across multiple subgroups, the greatest response was observed in patients with a small baseline core infarct, excellent collaterals, and early treatment.
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Affiliation(s)
- A P Jadhav
- From Department of Neurology and Neurological Surgery (A.P.J., T.G.J.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - H-C Diener
- Department of Neurology (H.-C.D,), University Hospital of University Duisburg-Essen, Essen, Germany
| | - A Bonafe
- Department of Neuroradiology (A.B.), Hôpital Gui-de-Chauliac, Montpellier, France
| | - V M Pereira
- Division of Neuroradiology and Division of Neurosurgery (V.M.P.), Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - E I Levy
- Department of Neurosurgery (E.I.L.), State University of New York at Buffalo, Buffalo, New York
| | - B W Baxter
- Department of Radiology (B.W.B.), Erlanger Hospital at University of Tennessee, Chattanooga, Tennessee
| | - T G Jovin
- From Department of Neurology and Neurological Surgery (A.P.J., T.G.J.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - R G Nogueira
- Department of Neurology (R.G.N.), Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia
| | - D R Yavagal
- Department of Neurology and Neurosurgery (D.R.Y.), University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, Florida
| | - C Cognard
- Department of Diagnostic and Therapeutic Neuroradiology (C.C.), University Hospital of Toulouse, Toulouse, France
| | - D D Purcell
- BioClinica (D.D.P.), Newark, California.,Department of Radiology (D.D.P.), California Pacific Medical Center, San Francisco, California.,Division of Neuroradiology (D.D.P.), University of California San Francisco, San Francisco, California
| | - B K Menon
- Neurology and Neurosurgery (B.K.M.), University of Calgary, Calgary, Alberta, Canada
| | - R Jahan
- Division of Interventional Neuroradiology (R.J.)
| | - J L Saver
- Department of Neurology and Comprehensive Stroke Center (J.L.S.), David Geffen School of Medicine at the University of California Los Angeles, University of California, Los Angeles, Los Angeles, California
| | - M Goyal
- Departments of Radiology and Clinical Neurosciences (M.G.)
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Pereira VM, Costa AL, Feldl J, Maria TMR, Seixas de Melo JS, Martín-Ramos P, Martín-Gil J, Ramos Silva M. Synthesis, structure and physical properties of luminescent Pr(III) β-diketonate complexes. Spectrochim Acta A Mol Biomol Spectrosc 2017; 172:25-33. [PMID: 27345124 DOI: 10.1016/j.saa.2016.06.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Revised: 06/08/2016] [Accepted: 06/16/2016] [Indexed: 06/06/2023]
Affiliation(s)
- V M Pereira
- CFisUC, Department of Physics, University of Coimbra, Rua Larga, P-3004-516 Coimbra, Portugal
| | - A L Costa
- CQC, Department of Chemistry, University of Coimbra, Rua Larga, P-3004-535 Coimbra, Portugal
| | - J Feldl
- CFisUC, Department of Physics, University of Coimbra, Rua Larga, P-3004-516 Coimbra, Portugal; Fakultät für Physik, Ludwig-Maximilians-Universität, Schellingstrasse 4, 80799 München, Germany
| | - T M R Maria
- CQC, Department of Chemistry, University of Coimbra, Rua Larga, P-3004-535 Coimbra, Portugal
| | - J S Seixas de Melo
- CQC, Department of Chemistry, University of Coimbra, Rua Larga, P-3004-535 Coimbra, Portugal
| | - P Martín-Ramos
- CFisUC, Department of Physics, University of Coimbra, Rua Larga, P-3004-516 Coimbra, Portugal; Higher Polytechnic School of Huesca, University of Zaragoza, Carretera de Cuarte s/n, 22071 Huesca, Spain.
| | - J Martín-Gil
- Advanced Materials Laboratory, ETSIIAA, Universidad de Valladolid, Avda. Madrid 44, 34004 Palencia, Spain
| | - M Ramos Silva
- CFisUC, Department of Physics, University of Coimbra, Rua Larga, P-3004-516 Coimbra, Portugal.
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Morales HG, Bonnefous O, Geers AJ, Brina O, Pereira VM, Spelle L, Moret J, Larrabide I. Does Arterial Flow Rate Affect the Assessment of Flow-Diverter Stent Performance? AJNR Am J Neuroradiol 2016; 37:2293-2298. [PMID: 27633810 DOI: 10.3174/ajnr.a4933] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 07/20/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Our aim was to assess the performance of flow-diverter stents. The pre- and end-of-treatment angiographies are commonly compared. However, the arterial flow rate may change between acquisitions; therefore, a better understanding of its influence on the local intra-aneurysmal hemodynamics before and after flow-diverter stent use is required. MATERIALS AND METHODS Twenty-five image-based aneurysm models extracted from 3D rotational angiograms were conditioned for computational fluid dynamics simulations. Pulsatile simulations were performed at different arterial flow rates, covering a wide possible range of physiologic flows among 1-5 mL/s. The effect of flow-diverter stents on intra-aneurysmal hemodynamics was numerically simulated with a porous medium model. Spatiotemporal-averaged intra-aneurysmal flow velocity and flow rate were calculated for each case to quantify the hemodynamics after treatment. The short-term flow-diverter stent performance was characterized by the relative velocity reduction inside the aneurysm. RESULTS Spatiotemporal-averaged intra-aneurysmal flow velocity before and after flow-diverter stent use is linearly proportional to the mean arterial flow rate (minimum R2 > 0.983 of the linear regression models for untreated and stented models). Relative velocity reduction asymptotically decreases with increasing mean arterial flow rate. When the most probable range of arterial flow rate was considered (3-5 mL/s), instead of the wide possible flow range, the mean SD of relative velocity reduction was reduced from 3.6% to 0.48%. CONCLUSIONS Both intra-aneurysmal aneurysm velocity and flow-diverter stent performance depend on the arterial flow rate. The performance could be considered independent of the arterial flow rates within the most probable range of physiologic flows.
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Affiliation(s)
- H G Morales
- From Medisys-Philips Research (H.G.M., O.Bonnefous), Paris, France
| | - O Bonnefous
- From Medisys-Philips Research (H.G.M., O.Bonnefous), Paris, France
| | - A J Geers
- Centre for Cardiovascular Science (A.J.G.), University of Edinburgh, Edinburgh, Scotland.,Department of Information and Communication Technologies (A.J.G.), Universitat Pompeu Fabra, Barcelona, Spain
| | - O Brina
- Department of Information Neuroradiology (O.Brina), University Hospital of Geneva, Geneva, Switzerland
| | - V M Pereira
- Department of Medical Imaging and Department of Surgery (V.M.P.), University Health Network, Toronto, Ontario, Canada
| | - L Spelle
- Interventional Neuroradiology (L.S., J.M.), Beaujon University Hospital, Clichy, France.,Paris Diderot University (L.S.), Paris, France
| | - J Moret
- Interventional Neuroradiology (L.S., J.M.), Beaujon University Hospital, Clichy, France
| | - I Larrabide
- PLADEMA-CONICET (I.L.), Universidad Nacional del Centro de la Provincia de Buenos Aires, Tandil, Argentina
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Bouillot P, Brina O, Yilmaz H, Farhat M, Erceg G, Lovblad KO, Vargas MI, Kulcsar Z, Pereira VM. Virtual-versus-Real Implantation of Flow Diverters: Clinical Potential and Influence of Vascular Geometry. AJNR Am J Neuroradiol 2016; 37:2079-2086. [PMID: 27365325 DOI: 10.3174/ajnr.a4845] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 04/24/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Intracranial stents have become extremely important in the endovascular management of complex intracranial aneurysms. Sizing and landing zone predictions are still very challenging steps in the procedure. Virtual stent deployment may help therapeutic planning, device choice, and hemodynamic simulations. We aimed to assess the predictability of our recently developed virtual deployment model by comparing in vivo and virtual stents implanted in a consecutive series of patients presenting with intracranial aneurysms. MATERIALS AND METHODS Virtual stents were implanted in patient-specific geometries of intracranial aneurysms treated with the Pipeline Embolization Device. The length and cross-section of virtual and real stents measured with conebeam CT were compared. The influence of vessel geometry modifications occurring during the intervention was analyzed. RESULTS The virtual deployment based on pre- and poststent implantation 3D rotational angiography overestimated (underestimated) the device length by 13% ± 11% (-9% ± 5%). These differences were highly correlated (R2 = 0.67) with the virtual-versus-real stent radius differences of -6% ± 7% (5% ± 4%) for predictions based on pre- and poststent implantation 3D rotational angiography. These mismatches were due principally to implantation concerns and vessel-shape modifications. CONCLUSIONS The recently proposed geometric model was shown to predict accurately the deployment of Pipeline Embolization Devices when the stent radius was well-assessed. However, unpredictable delivery manipulations and variations of vessel geometry occurring during the intervention might impact the stent implantation.
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Affiliation(s)
- P Bouillot
- From the Division of Neuroradiology (P.B., O.B., H.Y., G.E., K.-O.L., M.I.V., Z.K.), University Hospitals of Geneva, Geneva, Switzerland.,Laboratory for Hydraulic Machines (P.B., M.F.), École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - O Brina
- From the Division of Neuroradiology (P.B., O.B., H.Y., G.E., K.-O.L., M.I.V., Z.K.), University Hospitals of Geneva, Geneva, Switzerland
| | - H Yilmaz
- From the Division of Neuroradiology (P.B., O.B., H.Y., G.E., K.-O.L., M.I.V., Z.K.), University Hospitals of Geneva, Geneva, Switzerland
| | - M Farhat
- Laboratory for Hydraulic Machines (P.B., M.F.), École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - G Erceg
- From the Division of Neuroradiology (P.B., O.B., H.Y., G.E., K.-O.L., M.I.V., Z.K.), University Hospitals of Geneva, Geneva, Switzerland
| | - K-O Lovblad
- From the Division of Neuroradiology (P.B., O.B., H.Y., G.E., K.-O.L., M.I.V., Z.K.), University Hospitals of Geneva, Geneva, Switzerland
| | - M I Vargas
- From the Division of Neuroradiology (P.B., O.B., H.Y., G.E., K.-O.L., M.I.V., Z.K.), University Hospitals of Geneva, Geneva, Switzerland
| | - Z Kulcsar
- From the Division of Neuroradiology (P.B., O.B., H.Y., G.E., K.-O.L., M.I.V., Z.K.), University Hospitals of Geneva, Geneva, Switzerland
| | - V M Pereira
- Division of Neuroradiology (V.M.P.), Department of Medical Imaging .,Division of Neurosurgery (V.M.P.), Department of Surgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
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Slater LA, Coutinho JM, Gralla J, Nogueira RG, Bonafé A, Dávalos A, Jahan R, Levy E, Baxter BJ, Saver JL, Pereira VM. TICI and Age: What's the Score? AJNR Am J Neuroradiol 2015; 37:838-43. [PMID: 26611995 DOI: 10.3174/ajnr.a4618] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 09/07/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND PURPOSE Previous studies have suggested that advanced age predicts worse outcome following mechanical thrombectomy. We assessed outcomes from 2 recent large prospective studies to determine the association among TICI, age, and outcome. MATERIALS AND METHODS Data from the Solitaire FR Thrombectomy for Acute Revascularization (STAR) trial, an international multicenter prospective single-arm thrombectomy study and the Solitaire arm of the Solitaire FR With the Intention For Thrombectomy (SWIFT) trial were pooled. TICI was determined by core laboratory review. Good outcome was defined as an mRS score of 0-2 at 90 days. We analyzed the association among clinical outcome, successful-versus-unsuccessful reperfusion (TICI 2b-3 versus TICI 0-2a), and age (dichotomized across the median). RESULTS Two hundred sixty-nine of 291 patients treated with Solitaire in the STAR and SWIFT data bases for whom TICI and 90-day outcome data were available were included. The median age was 70 years (interquartile range, 60-76 years) with an age range of 25-88 years. The mean age of patients 70 years of age or younger was 59 years, and it was 77 years for patients older than 70 years. There was no significant difference between baseline NIHSS scores or procedure time metrics. Hemorrhage and device-related complications were more common in the younger age group but did not reach statistical significance. In absolute terms, the rate of good outcome was higher in the younger population (64% versus 44%, P < .001). However, the magnitude of benefit from successful reperfusion was higher in the 70 years of age and older group (OR, 4.82; 95% CI, 1.32-17.63 versus OR 7.32; 95% CI, 1.73-30.99). CONCLUSIONS Successful reperfusion is the strongest predictor of good outcome following mechanical thrombectomy, and the magnitude of benefit is highest in the patient population older than 70 years of age.
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Affiliation(s)
- L A Slater
- From the Division of Neuroradiology (L.A.S., J.M.C., V.M.P.), Joint Department of Medical Imaging, Department of Medical Imaging
| | - J M Coutinho
- From the Division of Neuroradiology (L.A.S., J.M.C., V.M.P.), Joint Department of Medical Imaging, Department of Medical Imaging
| | - J Gralla
- Service of Neuroradiology (J.G.), Inselspital, University of Bern, Bern, Switzerland
| | - R G Nogueira
- Marcus Stroke and Neuroscience Center (R.G.N.), Department of Neurology, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia
| | - A Bonafé
- Department of Neuroradiology (A.B.), Hôpital Gui-de-Chauliac, Montpellier, France
| | - A Dávalos
- Department of Neurosciences (A.D.), Hospital Universitario Germans Trias i Pujol, Barcelona, Spain
| | - R Jahan
- Division of Interventional Neuroradiology (R.J.)
| | - E Levy
- Toshiba Stroke and Vascular Research Center (E.L.), State University of New York at Buffalo, Buffalo, New York
| | - B J Baxter
- Department of Radiology (B.J.B.), Erlanger Hospital at the University of Tennessee, Chattanooga, Tennessee
| | - J L Saver
- Department of Neurology and Comprehensive Stroke Center (J.L.S.), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - V M Pereira
- From the Division of Neuroradiology (L.A.S., J.M.C., V.M.P.), Joint Department of Medical Imaging, Department of Medical Imaging Division of Neurosurgery (V.M.P.), Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Coutinho JM, Liebeskind DS, Slater LA, Nogueira RG, Baxter BW, Levy EI, Siddiqui AH, Goyal M, Zaidat OO, Davalos A, Bonafé A, Jahan R, Gralla J, Saver JL, Pereira VM. Mechanical Thrombectomy for Isolated M2 Occlusions: A Post Hoc Analysis of the STAR, SWIFT, and SWIFT PRIME Studies. AJNR Am J Neuroradiol 2015; 37:667-72. [PMID: 26564442 DOI: 10.3174/ajnr.a4591] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 08/11/2015] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND PURPOSE Mechanical thrombectomy is beneficial for patients with acute ischemic stroke and a proximal anterior occlusion, but it is unclear if these results can be extrapolated to patients with an M2 occlusion. The purpose of this study was to examine the technical aspects, safety, and outcomes of mechanical thrombectomy with a stent retriever in patients with an isolated M2 occlusion who were included in 3 large multicenter prospective studies. MATERIALS AND METHODS We included patients from the Solitaire Flow Restoration Thrombectomy for Acute Revascularization (STAR), Solitaire With the Intention For Thrombectomy (SWIFT), and Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment (SWIFT PRIME) studies, 3 large multicenter prospective studies on thrombectomy for ischemic stroke. We compared outcomes and technical details of patients with an M2 with those with an M1 occlusion. All patients were treated with a stent retriever. Imaging data and outcomes were scored by an independent core laboratory. Successful reperfusion was defined as modified Thrombolysis in Cerebral Infarction score of 2b/3. RESULTS We included 50 patients with an M2 and 249 patients with an M1 occlusion. Patients with an M2 occlusion were older (mean age, 71 versus 67 years; P = .04) and had a lower NIHSS score (median, 13 versus 17; P < .001) compared with those with an M1 occlusion. Procedural time was nonsignificantly shorter in patients with an M2 occlusion (median, 29 versus 35 minutes; P = .41). The average number of passes with a stent retriever was also nonsignificantly lower in patients with an M2 occlusion (mean, 1.4 versus 1.7; P = .07). There were no significant differences in successful reperfusion (85% versus 82%, P = .82), symptomatic intracerebral hemorrhages (2% versus 2%, P = 1.0), device-related serious adverse events (6% versus 4%, P = .46), or modified Rankin Scale score 0-2 at follow-up (60% versus 56%, P = .64). CONCLUSIONS Endovascular reperfusion therapy appears to be feasible in selected patients with ischemic stroke and an M2 occlusion.
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Affiliation(s)
- J M Coutinho
- From the Divisions of Neuroradiology (J.M.C., L.-A.S., V.M.P.)
| | - D S Liebeskind
- Neurovascular Imaging Research Core and the University of California, Los Angeles Stroke Center (D.S.L.), Los Angeles, California
| | - L-A Slater
- From the Divisions of Neuroradiology (J.M.C., L.-A.S., V.M.P.)
| | - R G Nogueira
- Marcus Stroke and Neuroscience Center (R.G.N.), Department of Neurology, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia
| | - B W Baxter
- Department of Radiology (B.W.B.), Erlanger Hospital at University of Tennessee, Chattanooga, Tennessee
| | - E I Levy
- Department of Neurosurgery (E.I.L., A.H.S.)
| | - A H Siddiqui
- Department of Neurosurgery (E.I.L., A.H.S.) Toshiba Stroke and Vascular Research Center (A.H.S.), State University of New York at Buffalo, Buffalo, New York
| | - M Goyal
- Departments of Radiology and Clinical Neurosciences (M.G.), University of Calgary, Calgary, Alberta, Canada
| | - O O Zaidat
- Department of Neurology (O.O.Z.), Medical College of Wisconsin, Milwaukee, Wisconsin
| | - A Davalos
- Department of Neurosciences (A.D.), Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Barcelona, Spain
| | - A Bonafé
- Department of Neuroradiology (A.B.), Hôpital Gui-de-Chauliac, Montpellier, France
| | - R Jahan
- Division of Interventional Neuroradiology (R.J.)
| | - J Gralla
- Departments of Diagnostic and Interventional Neuroradiology (J.G.), Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - J L Saver
- Department of Neurology and Comprehensive Stroke Center (J.L.S.), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - V M Pereira
- From the Divisions of Neuroradiology (J.M.C., L.-A.S., V.M.P.) Neurosurgery (V.M.P.), Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
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Perhac J, Spaltenstein J, Pereira VM, Schaller K, Brina O, Cabrilo I, Ratib O. Improving workflows of neuro-interventional procedures with autostereoscopic 3D visualization of multi-modality imaging in hybrid interventional suites. Int J Comput Assist Radiol Surg 2015; 11:189-96. [PMID: 26233622 DOI: 10.1007/s11548-015-1268-0] [Citation(s) in RCA: 3] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2015] [Accepted: 07/14/2015] [Indexed: 11/30/2022]
Abstract
PURPOSE Recent developments in interventional neuroradiology techniques, medical imaging modalities, endovascular stenting and embolization materials lead to an increasing number of patients with cerebral aneurysms and arteriovenous malformations that are eligible for endovascular treatment and have opened new perspectives for novel ways for patient treatment in general. In this paper, we describe a software tool for 3D image fusion of multi-modal acquisitions to assist endovascular treatment of cerebral malformations. The software and an autostereoscopic 3D display were implemented and tested in clinical applications in a hybrid interventional suite that is used for radio-interventional as well as neurosurgical procedures. Our hypothesis is that fusion of image data acquired prior to intervention procedures with images acquired during those procedures should allow better visualizing and navigating through complex cerebral vasculature. This should also improve workflows of neuro-interventional procedures. METHODS Preoperative and intra-operative acquisitions of vascular images of the brain were performed and transferred to a dedicated imaging workstation to be processed with our image fusion and visualization software tool. The tool was developed as a plugin extension to the open-source DICOM viewer OsiriX and is based on a modular and scalable architecture. Several processing modules were implemented to allow spatial co-registration and fusion of preoperative and intra-operative modalities. A special extension was also implemented for interactive autostereosopic, glass-free 3D visualization of fused results. RESULTS The software platform was validated and evaluated in nine in vivo procedures by expert users. All patient cases were related to interventional treatment of neuro-vascular diseases. The emphasis was laid on the added value of spatial co-registration and fusion of preoperative and intra-operative modalities, as well as the overall impact on workflow during the intervention. The co-registered and fused images were visualized on an autostereoscopic 3D monitor installed in hybrid interventional suite. All experiments were evaluated and scored by interventional physicians and technicians. CONCLUSIONS Displaying 3D-4D representations of brain vascular anomalies based on multi-modal acquisitions on a 3D autostereoscopic display is beneficial for the workflow and efficiency of interventional radiologists. The implemented software tool fulfills the premise of applicability of an open-source platform for more advanced, multi-modal visualization and processing of brain vascular structures for image-guided therapeutic interventions.
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Affiliation(s)
- J Perhac
- University Hospitals of Geneva, Geneva, Switzerland.
| | | | - V M Pereira
- University Hospitals of Geneva, Geneva, Switzerland
| | - K Schaller
- University Hospitals of Geneva, Geneva, Switzerland
| | - O Brina
- University Hospitals of Geneva, Geneva, Switzerland
| | - I Cabrilo
- University Hospitals of Geneva, Geneva, Switzerland
| | - O Ratib
- University Hospitals of Geneva, Geneva, Switzerland
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Almekhlafi MA, Davalos A, Bonafe A, Chapot R, Gralla J, Pereira VM, Goyal M. Impact of age and baseline NIHSS scores on clinical outcomes in the mechanical thrombectomy using solitaire FR in acute ischemic stroke study. AJNR Am J Neuroradiol 2014; 35:1337-40. [PMID: 24557701 DOI: 10.3174/ajnr.a3855] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND PURPOSE Age and stroke severity are inversely correlated with the odds of favorable outcome after ischemic stroke. A previously proposed score for Stroke Prognostication Using Age and NIHSS Stroke Scale (SPAN) indicated that SPAN-100-positive patients (ie, age + NIHSS score = 100 or more) do not benefit from IV-tPA. If this finding holds true for endovascular therapy, this score can impact patient selection for such interventions. This study investigated whether a score combining age and NIHSS score can improve patients' selection for endovascular stroke therapy. MATERIALS AND METHODS The SPAN index was calculated for patients in the prospective Solitaire FR Thrombectomy for Acute Revascularization study: an international single-arm multicenter cohort for anterior circulation stroke treatment by using the Solitaire FR. The proportion with favorable outcome (90-day mRS score ≤2) was compared between SPAN-100-positive versus-negative patients. RESULTS Of the 202 patients enrolled, 196 had baseline NIHSS scores. Fifteen (7.7%) patients were SPAN-100-positive. There was no difference in the rate of successful reperfusion (Thrombolysis In Cerebral Infarction 2b or 3) between SPAN-100-positive versus -negative groups (93.3% versus 82.8%, respectively; P = .3). Stroke SPAN-100-positive patients had a significantly lower proportion of favorable clinical outcomes (26.7% versus 60.8% in SPAN-100-negative, P = .01). In a multivariable analysis, SPAN-100-positive status was associated with lower odds of favorable outcome (OR, 0.3; 95% CI, 0.1-0.9; P = .04). A higher baseline Alberta Stroke Program Early CT Score and a short onset to revascularization time also predicted favorable outcome in the multivariable analysis. CONCLUSIONS A significantly lower proportion of patients with a positive SPAN-100 achieved favorable outcome in this cohort. SPAN-100 was an independent predictor of favorable outcome after adjusting for time to treatment and the extent of preintervention tissue damage according to the Alberta Stroke Program Early CT Score.
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Affiliation(s)
- M A Almekhlafi
- From the Departments of Clinical Neurosciences (M.A.A.)Radiology (M.A.A., M.G.), University of Calgary, Calgary, Alberta, CanadaFaculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia
| | - A Davalos
- Department of Neurology (A.D.), University Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - A Bonafe
- Department of Neuroradiology (A.B.), Centre Hospitalier Universitaire de Montpellie-Guy de Chauliac, Montpellier, France
| | - R Chapot
- Department of Neuroradiology (R.C.), Alfred Krupp Krankenhaus, Essen, Germany
| | - J Gralla
- Department of Diagnostic and Interventional Neuroradiology (J.G.), Inselspital, University of Bern, Bern, Switzerland
| | - V M Pereira
- Department of Neuroradiology (V.M.P.), University Hospital of Geneva, Geneva, Switzerland
| | - M Goyal
- Radiology (M.A.A., M.G.), University of Calgary, Calgary, Alberta, CanadaDepartment for Radiology (M.G.), Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.
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Brandão LP, Souza CPF, Pereira VM, Silva SO, Santos-Serejo JA, Ledo CAS, Amorim EP. Descriptor selection for banana accessions based on univariate and multivariate analysis. Genet Mol Res 2013; 12:1603-20. [PMID: 23765967 DOI: 10.4238/2013.may.14.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Our objective was to establish a minimum number of morphological descriptors for the characterization of banana germplasm and evaluate the efficiency of removal of redundant characters, based on univariate and multivariate statistical analyses. Phenotypic characterization was made of 77 accessions from Bahia, Brazil, using 92 descriptors. The selection of the descriptors was carried out by principal components analysis (quantitative) and by entropy (multi-category). Efficiency of elimination was analyzed by a comparative study between the clusters formed, taking into consideration all 92 descriptors and smaller groups. The selected descriptors were analyzed with the Ward-MLM procedure and a combined matrix formed by the Gower algorithm. We were able to reduce the number of descriptors used for characterizing the banana germplasm (42%). The correlation between the matrices considering the 92 descriptors and the selected ones was 0.82, showing that the reduction in the number of descriptors did not influence estimation of genetic variability between the banana accessions. We conclude that removing these descriptors caused no loss of information, considering the groups formed from pre-established criteria, including subgroup/subspecies.
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Affiliation(s)
- L P Brandão
- Universidade Federal do Recôncavo da Bahia, Cruz das Almas, BA, Brasil
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Pereira VM, Marcos-Gonzalez A, Radovanovic I, Bijlenga P, Narata AP, Moret J, Schaller K, Lovblad KO. Transvenous embolization of a ruptured deep cerebral arteriovenous malformation. A technical note. Interv Neuroradiol 2013; 19:27-34. [PMID: 23472720 DOI: 10.1177/159101991301900104] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2012] [Accepted: 10/10/2012] [Indexed: 01/09/2023] Open
Abstract
Ruptured cerebral arteriovenous malformations (AVMs) usually require treatment to avoid re-bleeding. Depending on the angioarchitecture and center strategy, the treatment can be surgical, endovascular, radiosurgical or combined methods. The classic endovascular approach is transarterial, but sometimes it is not always applicable. The transvenous approach has been described as an alternative for the endovascular treatment of small AVMs when arterial access or another therapeutic method is not possible. This approach can be considered when the nidus is small and if there is a single draining vein. We present a technical note on a transvenous approach for the treatment of a ruptured AVM in a young patient.
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Affiliation(s)
- V M Pereira
- Interventional Neuroradiology Unit, Neuroradiology Service, University Hospital of Geneva, Geneva, Switzerland.
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Lövblad KO, Pereira VM. Molecular imaging changes with cognition. AJNR Am J Neuroradiol 2012. [PMID: 23179655 DOI: 10.3174/ajnr.a3343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- K-O Lövblad
- Geneva University Hospitals, Geneva, Switzerland
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Pereira VM, Bonnefous O, Ouared R, Brina O, Stawiaski J, Aerts H, Ruijters D, Narata AP, Bijlenga P, Schaller K, Lovblad KO. A DSA-based method using contrast-motion estimation for the assessment of the intra-aneurysmal flow changes induced by flow-diverter stents. AJNR Am J Neuroradiol 2012; 34:808-15. [PMID: 23124641 DOI: 10.3174/ajnr.a3322] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Flow-diverter stents modify intra-aneurysmal blood flow and induce the progressive thrombosis of intracranial aneurysms followed by stable vascular reconstruction. The aim of this study was to report a new method for the appraisal of intracranial blood flow from DSA performed during endovascular treatment procedures. MATERIALS AND METHODS A cohort of 24 patients with unruptured IAs who underwent FDS implantation was prospectively recruited. Pre- and post-DSA sequences in combination with 3D rotational angiography were acquired. The quantification of arterial and intra-aneurysmal flow was accomplished by using an optical flow approach. Flow reduction was assessed by using a new metric termed the mean aneurysm flow amplitude ratio. The correlation between the MAFA ratio and the incidence of aneurysm thrombosis was assessed by using receiver operating characteristic analysis and the Fisher exact test when the optimum Youden index was found. RESULTS The quantification of flow was successfully achieved in 21 of 24 patients (87.5%). On the imaging follow-up, 18 aneurysms developed complete thrombosis (87.5%) and 3 displayed residual circulation (12.5%). The threshold analysis of the MAFA ratio significantly predicted thrombosis at 12 months below a threshold of 1.03 (P=.035). There was no significant correlation between the time for complete occlusion of the aneurysm and contrast stagnation inside the aneurysm after treatment (P>.05). CONCLUSIONS The MAFA ratio based on DSA flow quantification appears to be a reliable predictor for the assessment of stent treatment outcomes in this small study. These results open the door for perioperative flow quantification and provide indices that may help clinicians make appropriate intraprocedural decisions.
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Affiliation(s)
- V M Pereira
- Interventional Neuroradiology Unit, Service of Neuroradiology, University Hospital of Geneva, Geneva, Switzerland.
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Kulcsár Z, Bonvin C, Pereira VM, Altrichter S, Yilmaz H, Lövblad KO, Sztajzel R, Rüfenacht DA. Penumbra system: a novel mechanical thrombectomy device for large-vessel occlusions in acute stroke. AJNR Am J Neuroradiol 2009; 31:628-33. [PMID: 20019113 DOI: 10.3174/ajnr.a1924] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Large IC artery occlusion is often resistant to recanalization. We present our initial experience with the PS. MATERIALS AND METHODS Presenting with a severe acute ischemic stroke, the first 27 consecutive patients were considered for thromboaspiration therapy and retrospective data base analysis. All patients received standard thrombectomy treatment as monotherapy or in combination with thrombolysis or IC stent placement. The primary end point was revascularization of the target vessel to grade 2 or 3 on the TICI scale. Secondary end points were improvement of >4 points on the NIHSS score at discharge and favorable outcome, and improvement in overall mortality at 3 months and in sICH- and procedure-related adverse events. RESULTS At baseline, the mean age was 66 +/- 14 years and the mean NIHSS score was 14 +/- 7. The anterior circulation was affected in 23 patients, and there were 4 basilar artery occlusions. Intracranial stent placement was performed in 4 patients. A recanalization to TICI 2 or 3 was achieved in 25 patients (93%). None of the patients developed sICH. At hospital discharge, 15 patients (56%) had an NIHSS improvement of >4 and 13 patients (48%) had an mRS score of <2 at 3 months. There was a significant correlation between complete vessel recanalization and favorable outcome. The all-cause mortality at 3 months was 11%. CONCLUSIONS The PS showed a high potential for recanalization of acute thromboembolic occlusions of the large cerebral arteries. Complete recanalization was strongly correlated with good clinical outcome.
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Affiliation(s)
- Z Kulcsár
- Department of Radiology, Geneva University Hospital, Switzerland.
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Wissmeyer M, Altrichter S, Pereira VM, Viallon M, Federspiel A, Seeck M, Schaller K, Lövblad KO. Arterial spin-labeling MRI perfusion in tuberous sclerosis: correlation with PET. J Neuroradiol 2009; 37:127-30. [PMID: 19577299 DOI: 10.1016/j.neurad.2009.05.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2009] [Accepted: 05/22/2009] [Indexed: 10/20/2022]
Abstract
Neuroimaging using magnetic resonance imaging (MRI) is required for the investigation of surgically intractable epilepsy. In addition to the standard MRI techniques, perfusion sequences can be added to improve visualization of the underlying pathological changes. Also, as arterial spin-labeling (ASL) MRI perfusion does not require contrast administration, it may even be advantageous in these patients. We report here on three patients with epilepsy and tuberous sclerosis who underwent brain MRI with ASL and positron emission tomography (PET), both of which were found to correlate with each other and with electrophysiological data.
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Affiliation(s)
- M Wissmeyer
- Department of Nuclear Medicine, Geneva University Hospital, Switzerland
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Pereira VM, Geiprasert S, Krings T, Caldas JGMP, Toulgoat F, Ozanne A, Mercier P, Lasjaunias PL. Extracranial vertebral artery involvement in neurofibromatosis type I. Report of four cases and literature review. Interv Neuroradiol 2007; 13:315-28. [PMID: 20566100 PMCID: PMC3329237 DOI: 10.1177/159101990701300402] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [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: 11/06/2007] [Accepted: 11/12/2007] [Indexed: 11/17/2022] Open
Abstract
SUMMARY Neurofibromatosis type 1 (NF-1) is one of the most common inherited diseases and as an autosomal dominant genetic disorder results from NF-1 gene mutation with 100% penetration and wide phenotypic variability. The disease can involve a wide variety of tissues derived from all three embryonic layers. NF-1 vasculopathy has been described primarily in peripheral arteries, but arteries supplying the CNS may also be involved. Of those, extracranial vertebral involvement is the commonest and most important. A series of four patients with NF-1 and vascular disease of the vertebral artery is described with a review of the pathophysiology, vascular phenotypes, their management and the pertinent literature.
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Affiliation(s)
- V M Pereira
- Service de Neuroradiologie Diagnostique et Thérapeutique, Hôpital de Bicetre, Le Kremlin-Bicetre, Paris, France - Department of Neuroradiology, University of Sao Paulo, Brasil -
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Caimi G, Perucchi A, Degiorgi L, Ott HR, Pereira VM, Neto AHC, Bianchi AD, Fisk Z. Magneto-optical evidence of double exchange in a percolating lattice. Phys Rev Lett 2006; 96:016403. [PMID: 16486488 DOI: 10.1103/physrevlett.96.016403] [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] [Subscribe] [Scholar Register] [Received: 10/06/2005] [Indexed: 05/06/2023]
Abstract
Substituting Eu by Ca in ferromagnetic EuB6 leads to a percolation limited magnetic ordering. We present and discuss magneto-optical data of the Eu(1-x)Ca(x)B6 series, based on measurements of the reflectivity R(omega) from the far infrared up to the ultraviolet, as a function of temperature and magnetic field. Via the Kramers-Kronig transformation of R(omega) we extract the complete absorption spectra of samples with different values of x. The change of the spectral weight in the Drude component by increasing the magnetic field agrees with a scenario based on the double-exchange model, and suggests a crossover from a ferromagnetic metal to a ferromagnetic Anderson insulator upon increasing Ca content at low temperatures.
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Affiliation(s)
- G Caimi
- Laboratorium für Festkörperphysik, ETH Zürich, CH-8093 Zürich, Switzerland
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Abstract
The main purpose of this work is to formulate benzathine penicillin G nanoemulsion and nanocapsules, to evaluate their physicochemical and stabilising characteristics, and to determine their antimicrobial activity and penicillin in vitro release kinetics. Nanoemulsions were produced by the spontaneous emulsification approach and nanocapsules of poly (D,L-lactic acid-co-glycolic acid) polymer (PLGA) were prepared by the method of interfacial deposition of a pre-formed polymer. A 207+/-8 nm mean diameter nanoemulsion formulation maintained stability for more than 5 months at 4 degrees C. Stable nanocapsules with 224+/-58 nm mean diameter were obtained, which remained stabilised over 120 days at 4 degrees C. The penicillin encapsulation ratio in the nanocapsules was 85%. The in vitro release profiles indicated that penicillin released from the nanoemulsion was similar to the one observed from nanocapsules. However it can be clearly deduced from the in vitro kinetic analysis that the antibiotic cannot be protected in colloidal delivery systems. Nevertheless, stable formulations obtained in this investigation supply a potential dosage form to encapsulate more easily soluble drugs.
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Affiliation(s)
- N S Santos-Magalhães
- Laboratório de Tecnologia Químico-Farmacêutica (LTQF), Departamento de Farmácia, Universidade Federal de Pernambuco, Av Prof. Artur Sá, s/n, Cidade Universitária, 50740-520, PE, Recife, Brazil.
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De Sampaio LF, Pereira VM, Prapas A, Ribeiro Lima C, Abreu Sousa FM. [Modification in the contraceptive behavior in Sorocaba in a period of 11 years (1968-1979) (author's transl)]. J Bras Ginecol 1980; 90:223-35. [PMID: 12336597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
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de Sampaio Júnior LF, Dib JE, Pereira VM, Neme B. [Evaluation of the efficacy and side effects of the contraceptive containing 0.5 mg of norethindrone and 0.1 mg of mestranol in a family planning clinic]. Matern Infanc (Sao Paulo) 1971; 30:65-9. [PMID: 5135370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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