Is aspiration an effective acute stroke treatment in older adults?

Introduction: Clinical outcomes after interventional stroke treatment rely on several factors, with older age being associated with poorer results, which are mainly attributed to patient's comorbidities and medications. The delivery of an aspiration catheter could be hindered by carotid tortuosity, which is more prevalent in elderly patients with increasing age. In this study, we aimed to compare the clinical and angiographic outcomes of a direct aspiration first-pass technique in interventional stroke treatment for elderly patients compared with younger patients. Materials and methods: A total of 162 patients (92 women and 70 men, aged between 35 and 94 years +/- 12.4 years) were included in this study. Patients who were treated in a comprehensive stroke center due to a large-vessel occlusion stroke using aspiration as the first-choice treatment were included in this study. To evaluate carotid arteries, the tortuosity index (TI) was calculated for each segment of each carotid pathway. Results: Age correlated significantly with the presence of carotid tortuosity (R = 0.408, p = 0.000), extracranial length ratio (R = 0.487, p = 0.000), and overall length ratio (R = 0.467, p = 0.000). No significant associations were found with coiling, kinking, or intracranial length ratio. Successful aspiration-based recanalization rate decreased with increasing age, and the differences between the age subgroups were not statistically significant. A comparison of the extreme subgroups, i.e., <60 years old vs. ≥80 years old, did not yield a statistically significant change (p = 0.068). Conclusion: Successful aspiration-based recanalization rate decreased with increasing age; however, these differences were not significant. Clinical outcomes did not significantly differ with regard to carotid tortuosity, regardless of the time of assessment. Neither intracranial nor extracranial tortuosity was significantly associated with reperfusion-related complications in either of the age subgroups.

A new in vitro model applied 90Y microspheres to study the effects of low dose beta radiation on colorectal cancer cell line in various oxygenation conditions.

We propose a new in vitro model to assess the impact of 90Y-microspheres derived low-dose beta radiation on colorectal cancer cell line under various oxygenation conditions that mimic the tumor environment. Cancer cells (HCT116) proliferation was assessed using Alamar Blue (AB) assay after 48, 72, and 96 h. FLUKA code assessed changes in cancer cell populations relative to the absorbed dose. In normoxia, mitochondrial activity measured by Alamar Blue after 48-72 h was significantly correlated with the number of microspheres (48 h: r = 0.87 and 72 h: r = 0.89, p < 0.05) and absorbed dose (48 h: r = 0.87 and 72 h: r = 0.7, p < 0.05). In hypoxia, the coefficients were r = 0.43 for both the number of spheres and absorbed dose and r = 0.45, r = 0.47, respectively. Impediment of cancer cell proliferation depended on the absorbed dose. Doses below 70 Gy could reduce colorectal cancer cell proliferation in vitro. Hypoxia induced a higher resistance to radiation than that observed under normoxic conditions. Hypoxia and radiation induced senescence in cultured cells. The new in vitro model is useful for the assessment of 90Y radioembolization effects at the micro-scale.

Intra-aneurysmal pressure changes during stent-assisted coiling.

We aimed to examine aneurysm hemodynamics with intra-saccular pressure measurement, and compare the effects of coiling, stenting and stent-assisted coiling in proximal segments of intracranial circulation. A cohort of 45 patients underwent elective endovascular coil embolization (with or without stent) for intracranial aneurysm at our department. Arterial pressure transducer was used for all measurements. It was attached to proximal end of the microcatheter. Measurements were taken in the parent artery before and after embolization, at the aneurysm dome before embolization, after stent implantation, and after embolization. Stent-assisted coiling was performed with 4 different stents: LVIS and LVIS Jr (Microvention, Tustin, CA, USA), Leo (Balt, Montmorency, France), Barrel VRD (Medtronic/ Covidien, Irvine, CA, USA). Presence of the stent showed significant reverse correlation with intra-aneurysmal pressure-both systolic and diastolic-after its implantation (r = -0.70 and r = -0.75, respectively), which was further supported by correlations with stent cell size-r = 0.72 and r = 0.71, respectively (P<0.05). Stent implantation resulted in significant decrease in diastolic intra-aneurysmal pressure (p = 0.046). Systolic or mean intra-aneurysmal pressure did not differ significantly. Embolization did not significantly change the intra-aneurysmal pressure in matched pairs, regardless of the use of stent (p>0.05). In conclusion, low-profile braided stents show a potential to divert blood flow, there was significant decrease in diastolic pressure after stent placement. Flow-diverting properties were related to stent porosity. Coiling does not significantly change the intra-aneurysmal pressure, regardless of packing density.

Gallbladder Radiation Protection in SIRT-Quantitative Anatomical Study of Hepatic Vasculature.

Introduction: This study was designed to assess quantitatively a safe position of the microcatheter during the SIRT (Selective Internal Radiation Therapy) procedure, in order to minimize the risk of non-target spheres leaking. Materials and Methods: Retrospective analysis of the distance of the tip of the microcatheter from coiled or patent non-target arteries was measured during 99mTc-MAA work-up procedure. Frequency of extrahepatic leaking during work-up and SIRT procedures was evaluated. Results: There were 85 patients who underwent 98 work-up procedures. There were 64 radioembolizations. There were 44 gastroduodenal, 51 right gastric, and 54 cystic artery embolizations performed. Extrahepatic 99mTc-MAA leaking was observed in 33 cases: 16 to gallbladder, four to a gastric wall, nine to the duodenum, one to the intestinal wall, and three to the abdominal wall. Leak in 99mTc-MAA was also related to the presence of additional arteries (p = 0.009). There were 34 proximal and 31 distal to cystic artery 99mTc-MAA injections resulting in 12 vs. four leaks, respectively (p = 0.039, RR-2.5). Mean distance of the tip of the microcatheter from the origin of the cystic artery was 20 mm (minimum of 2.1 mm and maximum of 53 mm) proximally and 10 mm (minimum 1 mm and maximum 51 mm) distally (ns). Conclusions: Leaking in 99mTc-MAA (99mTc - labelled macroaggregated albumin) was related to the presence of additional arteries. Regardless of cystic artery embolization, it is 2.5 times safer to inject microspheres distal to its origin, compared to proximal injection. Cystic artery origin relative to the right hepatic artery division usually necessitates embolization of the former.

Are type I dural arteriovenous fistulas safe? Single-centre experience of endovascular treatment of dural arteriovenous fistulas.

INTRODUCTION: There are mixed reports on the incidence of intracranial haemorrhage in patients with dural arteriovenous fistulas. We assessed new proposed risk factors (i.a. number of outflows and outflow diameter) of intracerebral haemorrhage due to intracranial dural arteriovenous fistula and presented our personal experience in endovascular treatment of dural arteriovenous fistulas. MATERIAL AND METHODS: The patient database from January 2006 and December 2016 was reviewed, and 25 patients with 28 dural arteriovenous fistulas were identified. RESULTS: 50% of patients presented with intracerebral haemorrhage. Multiple dural fistulas occurred in 12% of patients. Spearman's rank correlation coefficient revealed that there was a strong association between Cognard classification type and time needed to treat (r = 0.59, p < 0.05), as well as the volume of contrast used (r = 0.77, p < 0.05). Infratentorial (r = 0.53, p < 0.05) and right-sided (r = 0.66, p < 0.05) localisation were more challenging to treat. Bleeding was associated with poorer clinical outcome (r = 0.48, p < 0.05). No significant differences were found between the non-haemorrhagic group and the haemorrhagic group regarding the number of outflows (p = 0.459) and largest outflow diameter (p = 0.298). Clinical evaluation at follow-up was as follows: 56% of patients were asymptomatic, 24% had non-significant disability, maintaining independency, 16% had moderate disability, and 8% died - one in the course of intracerebral haemorrhage and one due to other sustained injuries. There were no reported embolisation-related complications. CONCLUSIONS: To conclude, regardless of presentation, both symptomatic and asymptomatic dural arteriovenous fistulas deserve clinical attention, structured evaluation, and follow-up. Type I fistulas were associated with haemorrhage in 1/3 of all cases. Overall our results indicate that the risk of haemorrhage and dire consequences is multifactorial.

Superior ophthalmic vein and ophthalmic artery in immediate evaluation after endovascular treatment of carotid-cavernous fistulas.

PURPOSE: To validate superior ophthalmic vein (SOV) and ophthalmic artery (OA) usefulness in immediate evaluation of new endovascular approaches to treat carotid-cavernous fistulas (CCFs). MATERIAL AND METHODS: A retrospective review of 597 intracerebral malformation embolisations yielded 40 embolisations of CCF in the treatment of 18 patients. Two interventional radiologists performed detailed radiological angiographic assessments. RESULTS: Mean age at initial admission was 58.9 years (SD 18.5 years, range 24-85 years). Patients presented with: chemosis (50%), ocular bruit (50%), exophthalmos (61%), diminished visual acuity (77.8%), headache (16.7%), and intracerebral haemorrhage (5.55%), and 5.55% were asymptomatic. Unilateral fistulas (10-55.5%) showed more diversified venous drainage pattern than bilateral ones (8-44.4%). There were statistically significant differences in post-traumatic and spontaneous CCF regarding age (p = 0.036), type of fistula (p = 0.0008), and presence of pseudoaneurysm (p = 0.036). 77.8% of patients had increased ipsilateral SOV diameter. SOV enlargement was not associated with type of fistula, history of trauma, or degree of exophthalmos. Ipsilateral ophthalmic artery was visible in all patients on both pre- and postprocedural angiography on lateral projection. Pre- and post-procedural SOV diameter was significantly different. Internal carotid artery patency was 100%, while the overall final angiographic or clinical success was 85.7%. We had three cases of peri-procedural complications. CONCLUSIONS: We reported changeable dynamics of SOV and OA after endovascular treatment of CCFs and proved the feasibility of coils and Onyx-18 in the treatment thereof.

The Predictive Value of SPECT/CT imaging in colorectal liver metastases response after 90Y-radioembolization.

CONCLUSION: The mT/N1 ratio, PAD, and AAD can be used as predictors of tumor response to SIRT treatment, and SPECT/CT imaging can be used for dosimetric assessment of radioembolization.

Interventional radiology treatments for iatrogenic severe bleeding during percutaneous coronary interventions.

PURPOSE: Interventional cardiology and interventional radiology are separate medical disciplines in which intra-arterial contrast media are used. Interventional cardiology has resigned from many types of treatment techniques that are now used and developed in the field of interventional radiology. In the event of iatrogenic bleeding during coronary interventions, there is an urgent need to use safe and efficient rescue procedures that are as efficient as cardiosurgery but use simpler treatment options. Serious perforations require immediate endovascular interventions. Medical history may reveal risk factors for artery perforation. Medicines, location of artery perforation, and extent of bleeding are directly associated with the prognosis. Most often, arterial perforations are due to inappropriate wire manipulation or use of oversized balloons or cutting balloons. Prolonged, artery-occluding balloon inflation, covered stent implantation, and embolisation with different agents are among the available treatment options for artery ruptures. MATERIAL AND METHODS: A retrospective analysis was carried out among selected patients with iatrogenic vascular complications during procedures involving either coronary or non-coronary arteries. RESULTS: Only representative cases were selected and presented in the patient subsection. CONCLUSIONS: Artery perforation during cardiac catheterisation can lead to dire consequences. To manage this complication, clinicians need pre-established procedures, adequate resources, and knowledge. Interventional radiology can be used as a salvage therapy in such cases.

[Treatment of ischemic stroke with mechanical trombectomy systems]. / Leczenie udaru niedokrwiennego mózgu z zastosowaniem systemów do trombektomii mechanicznej.

The implementation of ischemic stroke therapy has created new opportunities for clinical improvement and the reversal of adverse prognosis in patients with ischemic stroke. Mechanical thrombectomy has become the recommended treatment for acute stroke in a select group of patients and in highly specialized centres with experience in endovascular therapy. AIM: The aim of the study was to evaluate of the efficacy and safety of mechanical thrombectomy in patients with acute ischemic stroke within the first six hours of illness was reported. MATERIALS AND METHODS: 34 patients previously hospitalized in the Department of Neurology due to ischemic stroke were included in the study during the first six hours of illness. Short-term efficacy and safety (1 month after surgery) and long-term (3 months) were evaluated based on the assessment of early mortality, functional status and neurological status. Factors that increase the risk of death were also analyzed. RESULTS: In the study group, the recanalization of the vessel was obtained in 52% of patients, which was associated with a significant improvement of functional status. Improvements in functional and neurological status were obtained in most of the patients (63%), including very good functional status (mRS 0-1) in 7 (20%) patients upon discharge from the hospital. CONCLUSIONS: In the study group, the recanalization of the vessel was obtained in 52% of patients, which was associated with a significant improvement of functional status. Improvements in functional and neurological status were obtained in most of the patients (63%), including very good functional status (mRS 0-1) in 7 (20%) patients upon discharge from the hospital.

Superselective renal artery embolization in the treatment of iatrogenic bleeding into the urinary tract.

BACKGROUND: The aim of this study was to evaluate the efficacy of superselective renal artery embolization in patients with bleeding into the urinary system. MATERIAL/METHODS: From 2007 to 2012, 20 patients were treated with superselective renal artery embolization for bleeding after percutaneous nephrolithotomy (PCNL), nephron-sparing surgery (NSS), including 1 patient with AVF after PCNL. During the procedure, embolization material was injected through a microcatheter to stop the bleeding. Embolization materials included a mixture of cyanoacrylate and lipiodol, embolization coils, and Spongostan. Clinical evaluation included remission of hematuria and normalization of blood morphotic elements. RESULTS: The cause of bleeding into the urinary tract was damage to vessels (all cases): with coexisting false aneurism (8 cases); with coexisting arterio-venus fistula (1 case); and with coexisting intrarenal hematoma (3 cases). The bleeding occurred 2-5 days after PCNL and NSS, and 10 days after PCNL with AVF. The mean hematocrit level was 22%-24%. Technical success was achieved in 20 cases. Clinical success was achieved in 19 cases. One patient with hematuria after PCNL with AVF needed a second endovascular treatment to stop bleeding. CONCLUSIONS: Superselective renal artery embolization is an effective procedure in the treatment of iatrogenic bleeding into the urinary tract after PCNL and NSS.

The calcium-phosphate balance, modulation of thyroid autoimmune processes and other adverse effects connected with thyroid arterial embolization.

In search of new treatment options for thyroid diseases, when conventional procedures are ineffective, contraindicated or associated with serious side effects, safety of thyroid arteries embolization in the treatment of particular thyroid diseases was evaluated. The study included eight subjects with retrosternal toxic goiter, six patients affected by Graves' disease, five cases of retrosternal non-toxic goiter, two subjects with post-amiodarone hyperthyroidism, and one patient with severe thyroid-related orbitopathy, who underwent selective embolization of thyroid arteries. The study assessed and compared calcium-phosphate balance, modulation of thyroid autoimmunity and the presence of different side effects in patients who underwent the procedure. In addition, the serum concentrations of thyroid hormones, anti-thyroid autoantibodies and thyroid volume have been measured. Five of all enrolled subjects (22.7 %) experienced transient, not clinically relevant hypocalcaemia with no need for calcium supplementation. There were no significant changes in serum calcium levels in patients after embolization of both inferior thyroid arteries. The transient side effects associated with the treatment were neck pain and a slight increase in body temperature. Noted high concentration of free thyroid hormones immediately after the procedure was not accompanied by worsening of symptoms or signs of thyrotoxicosis. In patients with Graves' disease, a significant decrease in thyrotropin receptor antibodies level was observed. Thyroid arterial embolization does not disturb permanently calcium-phosphate balance, modulates positively thyroid autoimmune processes and is associated with no serious post-procedure side effects. Hence, it may be considered as a safe and effective treatment modality for selected thyroid disorders.

Partial thyroid arterial embolization for the treatment of hyperthyroidism.

BACKGROUND: Hyperactive thyroid gland in patients that are unable to tolerate or accept standard therapy is a common clinical problem. Aim of the study was to evaluate effectiveness of partial thyroid arterial embolization in patients with hyperthyroidism. MATERIAL/METHODS: From May 2004 to November 2005 partial thyroid gland embolization was performed in 15 patients. Mean thyroid gland volume was 162 ml. Embolization of one to three thyroid arteries was performed with the mixture of Histoacryl and Lipiodol. Selective angiography was performed after embolization to ensure that the targeted arteries were completely occluded. Follow-up study covered 12 patients. RESULTS: The embolization procedure was well tolerated by all patients. Three days after embolization fT3 and fT4 levels were higher than before the procedure. Further laboratory tests showed quick reversal to near-normal or normal levels of thyroid hormones. 12 weeks follow-up showed: normal serum levels of fT3, fT4 and TSH in 9 of 12 patients (75%), hyperthyroidism in 3 of 12 patients (25%), goiter volume reduction of approximately 32% of its original volume (from 13 to 76.3%), mean thyroid gland volume of 94ml. One year after embolization 7 of 12 patients required thyreostatic drugs. At two and four years follow-up thyreostatics doses were significantly lower and thyroid tissue was fibrotic. CONCLUSIONS: Based on our results the treatment of the thyroid gland goiters using arterial thyroid gland partial embolization may be offered as an effective alternative for patients who will not or cannot accept standard therapy.

The use of routine imaging data in diagnosis of cerebral pseudoaneurysm prior to angiography.

PURPOSE: A false aneurysm is rare and underdiagnosed complication of intracranial hemorrhage. Objective of the study was to point out diagnostic imaging signs of false aneurysm and to determine frequency and diagnostic significance of these signs. MATERIALS AND METHODS: Cerebral arteriography performed in our center from November 2007 to September 2010 revealed the false aneurysm in 8 patients (4 male, 4 female, mean age was 38 years). During the same angiographic procedure 6 patients were treated by endovascular embolization using coils, mixture of Histoacryl and Lipiodol or Onyx (liquid embolic material). Authors retrospectively analyzed preprocedural studies (computed tomography, magnetic resonance imaging) and angiographic findings to identify signs specific to false aneurysm. RESULTS: Computed tomographic findings that are not specific but should raise suspicion of the false aneurysm include: enlargement of parenchymal hematoma dimensions, unusual or delayed evolution of hematoma and spot sign associated with acute hematoma expansion. More specific signs can be revealed in digital subtraction angiography that shows a globular shaped neckless aneurysmal sac, delayed filling and emptying of contrast agent and stagnation of contrast with regard to the head position. CONCLUSION: Although preangiographic imaging studies findings in patients with false aneurysms are not specific, they should lead to angiographic validation, especially enlarging parenchymal hematoma and atypical hematoma evolution. Digital subtraction angiography makes it possible to diagnose the lesion and to use endovascular embolization techniques, which are currently the method of choice for treatment of pseudoaneurysms.