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2.
J Neuroradiol ; 48(1): 10-15, 2021 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-31228539

RESUMEN

BACKGROUND: Asymmetric inferior petrosal sinuses (IPS) are not infrequently encountered during bilateral IPS sampling. There is little data on whether IPS symmetry influences success in predicting the adenoma side in patients with ACTH-dependent Cushing's syndrome (CS). OBJECTIVE: To assess the influence of IPS drainage patterns on detection of an adenoma in CS. METHODS: Retrospective single-center cohort analysis reviewing records of patients with CS and negative MRI findings who subsequently underwent BIPSS. RESULTS: BIPSS was performed in 38 patients with a mean age of 45±15 years. The overall technical success rate was 97% for bilateral cannulation. Asymmetric IPS were observed in 11 (39%) patients with Cushing's disease (CD). A side-to-side ACTH ratio was not significantly different between patients with symmetric outflow and those with asymmetric outflow at baseline (8.6±2.7 versus 16.4±6.0; P=0.45), but ratios were significantly different after ovine corticotropin-releasing hormone (oCRH) stimulation (6.0±2.5 versus 35.7±22.5; P=0.03). BIPSS correctly predicted the side of the adenoma in 25 (96%) patients with CD. Prediction was better when the venous outflow was symmetric (100%) rather than asymmetric (93%), although the difference was not significant (P=0.42). Remission from CS was achieved in 32 patients (87%), independent of the symmetry of IPS. CONCLUSIONS: Bearing in mind the sample size of this audit, asymmetric IPS at least do not seem to diminish the accuracy of diagnosis of ACTH-dependent CS, nor do they influence the clinical outcome.


Asunto(s)
Adenoma , Síndrome de Cushing , Neoplasias Hipofisarias , Adenoma/diagnóstico por imagen , Hormona Adrenocorticotrópica , Adulto , Animales , Hormona Liberadora de Corticotropina , Síndrome de Cushing/diagnóstico por imagen , Drenaje , Humanos , Persona de Mediana Edad , Muestreo de Seno Petroso , Estudios Retrospectivos , Ovinos
4.
Neuroradiology ; 62(1): 7-14, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31676960

RESUMEN

This document sets out standards for training in Interventional Neuroradiology (INR) in Europe. These standards have been developed by a working group of the European Society of Neuroradiology (ESNR) and the European Society of Minimally Invasive Neurological Therapy (ESMINT) on the initiative and under the umbrella of the Division of Neuroradiology/Section of Radiology of the European Union of Medical Specialists (UEMS).


Asunto(s)
Neurorradiografía/normas , Radiología Intervencionista/educación , Radiología Intervencionista/normas , Certificación/normas , Europa (Continente) , Humanos
6.
JAMA Neurol ; 77(3): 318-326, 2020 03 01.
Artículo en Inglés | MEDLINE | ID: mdl-31816018

RESUMEN

Importance: Achieving complete reperfusion is a key determinant of good outcome in patients treated with mechanical thrombectomy (MT). However, data on treatments geared toward improving reperfusion after incomplete MT are sparse. Objective: To determine whether administration of intra-arterial urokinase is safe and improves reperfusion after failed or incomplete MT. Design, Setting, and Participants: This observational cohort study included a consecutive sample of patients treated with second-generation MT from January 1, 2010, through August 4, 2017. Data were collected from the prospective registry of a tertiary care stroke center. Of 1274 patients screened, 69 refused to participate, and 993 met the observational studies inclusion criteria of a large vessel occlusion in the anterior circulation. Data were analyzed from September 1, 2017, through September 20, 2019. Intervention: One hundred patients received intra-arterial urokinase after failed or incomplete MT using manual microcatheter injections. Main Outcomes and Measures: Primary safety outcome was the occurrence of symptomatic intracranial hemorrhage (sICH) according to the Prolyse in Acute Cerebral Thromboembolism II criteria. Secondary end points included 90-day mortality and 90-day functional independence (defined as modified Rankin Scale score of ≤2). Efficacy was evaluated angiographically, applying the Thrombolysis in Cerebral Infarction (TICI) scale. Results: After exclusion of patients with posterior circulation strokes and those treated with intra-arterial thrombolytics only, 993 patients were included in the final analyses (median age, 74.6 [interquartile range, 62.6-82.2] years; 505 [50.9%] women). Additional intra-arterial urokinase was administered in 100 patients (10.1%). The most common reason for administering intra-arterial urokinase was incomplete reperfusion (TICI<3) after MT (53 [53.0%]). After adjusting for baseline characteristics underlying case selection, intra-arterial urokinase was not associated with an increased risk of sICH (adjusted odds ratio [aOR], 0.81; 95% CI, 0.31-2.13) or 90-day mortality (aOR, 0.78; 95% CI, 0.43-1.40). Among 53 cases of partial or near-complete reperfusion and treated with intra-arterial urokinase, 32 (60.4%) had early reperfusion improvement, and 18 of 53 (34.0%) had an improvement in TICI grade. Correspondingly, patients treated with intra-arterial urokinase had higher rates of functional independence after adjusting for the selection bias favoring a priori poor TICI grades in the intra-arterial urokinase group (aOR, 1.93; 95% CI, 1.11-3.37). Conclusions and Relevance: In selected patients, adjunctive treatment with intra-arterial urokinase during or after MT was safe and improved angiographic reperfusion. Systemic evaluation of this approach in a multicenter prospective registry or a randomized clinical trial seems warranted.


Asunto(s)
Accidente Cerebrovascular Isquémico/tratamiento farmacológico , Recuperación de la Función/efectos de los fármacos , Activador de Plasminógeno de Tipo Uroquinasa/uso terapéutico , Anciano , Anciano de 80 o más Años , Arteriopatías Oclusivas/tratamiento farmacológico , Arteriopatías Oclusivas/cirugía , Estudios de Cohortes , Femenino , Humanos , Infusiones Intraarteriales , Hemorragias Intracraneales/epidemiología , Accidente Cerebrovascular Isquémico/cirugía , Masculino , Persona de Mediana Edad , Trombectomía , Insuficiencia del Tratamiento
7.
Clin Neuroradiol ; 29(1): 143-151, 2019 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-29098320

RESUMEN

PURPOSE: Knowledge about the localization and outcome of iatrogenic dissection (ID) during endovascular treatment of acute ischemic stroke (AIS) is limited. We aimed to determine the frequency, clinical aspects and morphology of ID in endovascular AIS treatment and to identify predictors of this complication. METHODS: Digital subtraction angiography (DSA) of ID carried out during endovascular treatment between January 2000 and March 2012 have been re-evaluated. The ID localization and morphology were analyzed and related to the interventional techniques. Baseline clinical and radiological findings, treatment modality and outcome were compared with patients without ID. RESULTS: Out of 866 patients 18 (2%) suffered an ID (44% female, median age 64 years). Localization was extracranial in 15 (83%, 14 internal carotid artery and 1 vertebral artery) and intracranial in 3 (17%; 1 vertebrobasilar dissection and 2 in the anterior circulation). Of the IDs 5 (28%) resulted in a high-degree, 3 (17%) in a moderate, 5 (28%) in a mild and 5 (28%) in no stenosis and 8 IDs were stented in the acute phase. At 3 months 7 (42%) patients had a favorable outcome (modified Rankin score mRS ≤ 2) and 6 (33%) patients had died. Patients with ID had a different stroke etiology (p = 0.041), were more likely to be smokers (44% versus 19%, p = 0.015) and were more likely to be treated with mechanical thrombectomy (100% versus 60%, p < 0.001). Although two ID patients had relevant complications, the outcome did not differ between the groups. CONCLUSION: The occurrence of ID is a rare complication of endovascular AIS treatment associated with smoking and mechanical thrombectomy.


Asunto(s)
Angiografía de Substracción Digital , Arteria Basilar/lesiones , Traumatismos de las Arterias Carótidas/diagnóstico por imagen , Accidente Cerebrovascular/terapia , Disección de la Arteria Vertebral/diagnóstico por imagen , Adulto , Anciano , Arteria Basilar/diagnóstico por imagen , Traumatismos de las Arterias Carótidas/terapia , Angiografía por Tomografía Computarizada , Procedimientos Endovasculares/efectos adversos , Femenino , Fibrinolíticos/efectos adversos , Humanos , Enfermedad Iatrogénica , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Stents , Trombectomía/efectos adversos , Terapia Trombolítica/efectos adversos , Activador de Plasminógeno de Tipo Uroquinasa/uso terapéutico , Disección de la Arteria Vertebral/terapia , Insuficiencia Vertebrobasilar/diagnóstico por imagen , Insuficiencia Vertebrobasilar/etiología
8.
PLoS One ; 13(9): e0203535, 2018.
Artículo en Inglés | MEDLINE | ID: mdl-30256814

RESUMEN

BACKGROUND AND PURPOSE: Anemia is associated with worse outcome in stroke, but the impact of anemia with intravenous thrombolysis or endovascular therapy has hardly been delineated. The aim of this study was to analyze the role of anemia on infarct evolution and outcome after acute stroke treatment. METHODS: 1158 patients from Bern and 321 from Los Angeles were included. Baseline data and 3 months outcome assessed with the modified Rankin Scale were recorded prospectively. Baseline DWI lesion volumes were measured in 345 patients and both baseline and final infarct volumes in 180 patients using CT or MRI. Multivariable and linear regression analysis were used to determine predictors of outcome and infarct growth. RESULTS: 712 patients underwent endovascular treatment and 446 intravenous thrombolysis. Lower hemoglobin at baseline, at 24h, and nadir until day 5 predicted poor outcome (OR 1.150-1.279) and higher mortality (OR 1.131-1.237) independently of treatment. Decrease of hemoglobin after hospital arrival, mainly induced by hemodilution, predicted poor outcome and had a linear association with final infarct volumes and the amount and velocity of infarct growth. Infarcts of patients with newly observed anemia were twice as large as infarcts with normal hemoglobin levels. CONCLUSION: Anemia at hospital admission and any hemoglobin decrease during acute stroke treatment affect outcome negatively, probably by enlarging and accelerating infarct growth. Our results indicate that hemodilution has an adverse effect on penumbral evolution. Whether hemoglobin decrease in acute stroke could be avoided and whether this would improve outcome would need to be studied prospectively.


Asunto(s)
Anemia/metabolismo , Hemoglobinas/metabolismo , Accidente Cerebrovascular/complicaciones , Accidente Cerebrovascular/metabolismo , Anciano , Anciano de 80 o más Años , Procedimientos Endovasculares/métodos , Femenino , Humanos , Modelos Lineales , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Estudios Retrospectivos , Accidente Cerebrovascular/terapia , Terapia Trombolítica/métodos
9.
Artif Organs ; 42(10): 1001-1009, 2018 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-29726003

RESUMEN

Cerebral oximetry using near-infrared spectroscopy (NIRS) allows for continuous monitoring of cerebral perfusion and immediate treatment of hemodynamic perturbations. In configurations used in current clinical practice, NIRS optodes are placed on the patient`s forehead and cerebral oxygen saturation (ScO2 ) is determined in bilateral frontal cortical samples. However, focal cerebral ischemic lesions outside of the NIRS field of view may remain undetected. The objective of this observational case-series study was to investigate ScO2 measurements in patients with acute iatrogenic stroke not located in the frontal cortical region. Adult patients undergoing cardiac surgery with cardiopulmonary bypass or interventional cardiology procedures and suffering stroke in the early postoperative period were identified from the Bernese Stroke Registry and analyzed for their intraoperative ScO2 values and brain imaging data. Main outcome measures were the ScO2 values, computed tomography and magnetic resonance imaging findings. In six patients, the infarct areas were localized in the vascular territories of the posterior and/or dorsal middle cerebral arteries. One patient had watershed stroke and another one excellent collaterals resulting in normal cerebral blood volume and only subtle decrease of cerebral blood flow in initially critically perfused watershed brain areas. Intraoperative ScO2 values were entirely unremarkable or nonindicative for brain damage. Our results indicate that uneventful intraoperative NIRS monitoring does not exclude severe cerebral ischemia due to the limited field of view of commercially available NIRS devices. False negative NIRS may occur as a consequence of stroke localized outside the frontal cortex.


Asunto(s)
Isquemia Encefálica/diagnóstico , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Monitoreo Intraoperatorio/métodos , Oximetría/métodos , Complicaciones Posoperatorias/diagnóstico , Espectroscopía Infrarroja Corta/métodos , Adulto , Anciano , Anciano de 80 o más Años , Encéfalo/irrigación sanguínea , Isquemia Encefálica/etiología , Puente Cardiopulmonar/métodos , Infarto Cerebral/diagnóstico , Infarto Cerebral/etiología , Circulación Cerebrovascular , Femenino , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología
10.
J Biomed Opt ; 23(1): 1-11, 2018 01.
Artículo en Inglés | MEDLINE | ID: mdl-29359545

RESUMEN

Stroke due to hypoperfusion or emboli is a devastating adverse event of cardiac surgery, but early detection and treatment could protect patients from an unfavorable postoperative course. Hypoperfusion and emboli can be detected with transcranial Doppler of the middle cerebral artery (MCA). The measured blood flow velocity correlates with cerebral oxygenation determined clinically by near-infrared spectroscopy (NIRS) of the frontal cortex. We tested the potential advantage of a spatially extended NIRS in detecting critical events in three cardiac surgery patients with a whole-head fiber holder of the FOIRE-3000 continuous-wave NIRS system. Principle components analysis was performed to differentiate between global and localized hypoperfusion or ischemic territories of the middle and anterior cerebral arteries. In one patient, we detected a critical hypoperfusion of the right MCA, which was not apparent in the frontal channels but was accompanied by intra- and postoperative neurological correlates of ischemia. We conclude that spatially extended NIRS of temporal and parietal vascular territories could improve the detection of critically low cerebral perfusion. Even in severe hemispheric stroke, NIRS of the frontal lobe may remain normal because the anterior cerebral artery can be supplied by the contralateral side directly or via the anterior communicating artery.


Asunto(s)
Encéfalo , Puente Cardiopulmonar/métodos , Monitorización Neurofisiológica Intraoperatoria/métodos , Neuroimagen/métodos , Espectroscopía Infrarroja Corta/métodos , Anciano , Encéfalo/irrigación sanguínea , Encéfalo/diagnóstico por imagen , Circulación Cerebrovascular/fisiología , Humanos , Interpretación de Imagen Asistida por Computador , Masculino
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