Lessons learned from 12 years using the Woven Endobridge for the treatment of cerebral aneurysms in a multi-center series.

Intrasaccular flow disruption with the Woven Endobridge (WEB) has become a well-established endovascular technique for the treatment of intracranial aneurysms. This study presents our 12-year experience with the WEB and evaluates its evolving indications, procedures, and outcomes. A consecutive series of 324 aneurysms treated with WEB between 2011 and 2023 at three neurovascular centers was retrospectively analyzed and the study group was divided into four treatment periods. Uni- and multivariate analyses were performed to evaluate factors associated with technical success, thromboembolic complications, and angiographic outcome. The mean aneurysm size was 7.0 ± 3.6 mm and decreased during the study period, while the proportion of atypical sites for WEB implantation increased. WEB implantation was technically successful in 96.0%, and the ratio of WEB width to dome width increased during the study period, indicating oversizing. The neurological complication rate was 4.9% (1.5% major, 3.4% minor) and the mid-term complete occlusion rate was 60.6% (81.9% adequate occlusion), with no statistical differences in either outcome measure between the study periods. In multivariate analyses, the use of WEB 17 was associated with increased technical success (HR: 7.4, 95%CI: 2.4-23.6, p<0.01), whereas ruptured aneurysm status (HR: 2.5, 95%CI: 1.0-6.0, p=0.04) and the use of additional stents (HR: 4.8, 95%CI: 1.6-14.4, p<0.01) predicted thromboembolic complications. Appropriate oversizing of the WEB favored mid-term complete occlusion (HR: 10.5, 95%CI: 1.3-83.3, p=0.03). The results suggest an expansion of the indications for WEB implantation and highlight the importance of oversizing for treatment efficacy.

Investigating the association between osteopenia and bowel perforation through a multicenter radiologic analysis.

Anecdotal evidence from preliminary observations has noted multiple instances where osteoporosis is present in elderly patients before the clinical detection of bowel disease, even in the absence of overt gastrointestinal symptoms. However, any potential association between these conditions remains to be further investigated. This computed tomography (CT) study investigates whether patients with gastrointestinal (GI) perforation have lower bone mineral density (BMD) than age and sex matched controls. BMD was measured by drawing 3D regions of interest in the bone marrow of the L1-L3 vertebral bodies on CT scans of each of 37 GI perforations and matched controls. Spectrometric calibration of Hounsfield units to the mineral scale was performed with density measurements in the paravertebral muscles (erector spinae) and subcutaneous adipose tissue. The mean BMD of patients with GI perforation (135.9 ± 24.3 mg/ml) was significantly lower than that of controls (96.9 ± 27.5 mg/ml, p < 0.05). The calculated T-and Z-scores of bone mineral density were also significantly different between the two groups (p < 0.05 for each) and were - 2.9 (± 0.90) and - 0.8 (± 0.91) in patients with GI perforation and - 1.6 (± 0.83) and 0 (± 0.96) in the control group, respectively. The results imply that patients with gastrointestinal (GI) perforation have lower bone mineral density (BMD) than age-and sex-matched controls, posing the question whether the screening and aggressive management of osteoporosis is high-risk populations for gastrointestinal perforation can prevent gastrointestinal complications in targeted populations.

Safety and efficacy of coated flow diverters in the treatment of cerebral aneurysms during single antiplatelet therapy: A multicenter study.

OBJECTIVE: This multicenter study evaluates the safety and efficacy of coated flow diverters (cFDs) for the treatment of cerebral aneurysms under single antiplatelet therapy (SAPT). METHODS: This is a retrospective, observational study of 41 patients (median age: 58 years) with 41 aneurysms (median size: 7 mm, 29 [71%] saccular, 9 [22%] ruptured) treated with cFDs at four neurovascular centers between 2020 and 2023. Scheduled cases received continuous SAPT starting seven days before the procedure. Emergency cases were treated with tirofiban followed by SAPT loading. The safety endpoint was ischemic complications occurring during the procedure and within four months of clinical follow-up. RESULTS: The Pipeline Vantage or Flex Shield was used in 26 (63%) procedures, the FRED X in 12 (29%), the p48/64 Hydrophilic Polymer Coating in 2 (5%), and the Derivo Embolization Device 2heal in 1 (2%). Single antiplatelet therapy consisted of prasugrel in 27 (66%) patients, ticagrelor in 9 (22%), and ASA in 5 (12%). There were 2 (5%) early ischemic complications (one minor stroke and one transient ischemic attack). There were no late ischemic complications in the four-month follow-up of 35 patients. The six dropouts included four nontreatment-related deaths after subarachnoid hemorrhage and two patients with a poor outcome after subarachnoid hemorrhage. Complete and favorable occlusion rates (median: 7 months) were 75% (27/36) and 89% (32/36), respectively. CONCLUSIONS: Coated flow diverter implantation in the setting of SAPT was safe and effective and warrants confirmation in a prospective comparative trial.

Non-contrast-enhanced MR-angiography of Extracranial Arteries in Acute Ischemic Stroke at 1.5 Tesla Using Relaxation-Enhanced Angiography Without Contrast and Triggering (REACT).

PURPOSE: To evaluate a novel flow-independent sequence (Relaxation-Enhanced Angiography without Contrast and Triggering (REACT)) for imaging of the extracranial arteries in acute ischemic stroke (AIS) at 1.5 T. METHODS: This retrospective single-center study included 47 AIS patients who received REACT (scan time: 3:01 min) and contrast-enhanced MRA (CE-MRA) of the extracranial arteries at 1.5 T in clinical routine. Two radiologists assessed scans for proximal internal carotid artery (ICA) stenosis, stated their diagnostic confidence and rated the image quality of cervical arteries, impact of artifacts and image noise. Apparent signal- and contrast-to-noise ratios (aSNR/aCNR) were measured for the common carotid artery and ICA. RESULTS: REACT achieved a sensitivity of 95.0% and a specificity of 97.3% for ICA stenoses in high agreement with CE-MRA (κ = 0.83) with equal diagnostic confidence (p = 0.22). Image quality was rated higher for CE-MRA at the aortic arch (p = 0.002) and vertebral arteries (p < 0.001), whereas REACT provided superior results for the extracranial ICA (p = 0.008). Both sequences were only slightly affected by artifacts (p = 0.60), while image noise was more pronounced in CE-MRA (p < 0.001) in line with higher aSNR (p < 0.001) and aCNR (p < 0.001) values in REACT for all vessels. CONCLUSION: Given its good diagnostic performance while yielding comparable image quality and scan time to CE-MRA, REACT may be suitable for the imaging of the extracranial arteries in acute ischemic stroke at 1.5 T.

Impact of imaging biomarkers from body composition analysis on outcome of endovascularly treated acute ischemic stroke patients.

BACKGROUND: We investigate the association of imaging biomarkers extracted from fully automated body composition analysis (BCA) of computed tomography (CT) angiography images of endovascularly treated acute ischemic stroke (AIS) patients regarding angiographic and clinical outcome. METHODS: Retrospective analysis of AIS patients treated with mechanical thrombectomy (MT) at three tertiary care-centers between March 2019-January 2022. Baseline demographics, angiographic outcome and clinical outcome evaluated by the modified Rankin Scale (mRS) at discharge were noted. Multiple tissues, such as muscle, bone, and adipose tissue were acquired with a deep-learning-based, fully automated BCA from CT images of the supra-aortic angiography. RESULTS: A total of 290 stroke patients who underwent MT due to cerebral vessel occlusion in the anterior circulation were included in the study. In the univariate analyses, among all BCA markers, only the lower sarcopenia marker was associated with a poor outcome (P=0.007). It remained an independent predictor for an unfavorable outcome in a logistic regression analysis (OR 0.6, 95% CI 0.3 to 0.9, P=0.044). Fat index (total adipose tissue/bone) and myosteatosis index (inter- and intramuscular adipose tissue/total adipose tissue*100) did not affect clinical outcomes. CONCLUSION: Acute ischemic stroke patients with a lower sarcopenia marker are at risk for an unfavorable outcome. Imaging biomarkers extracted from BCA can be easily obtained from existing CT images, making it readily available at the beginning of treatment. However, further research is necessary to determine whether sarcopenia provides additional value beyond established outcome predictors. Understanding its role could lead to optimized, individualized treatment plans for post-stroke patients, potentially improving recovery outcomes.

Endovascular treatment of aneurysm remnants with the Contour Neurovascular System after previous treatment.

OBJECTIVE: The Contour Neurovascular System (CNS) is a novel intrasaccular flow disrupting device with a semi-3D cup-like shape for the treatment of intracranial aneurysms. This study investigates the potential and limitations of the CNS for embolization of aneurysm remnants after previous treatment. METHODS: Ten cases of aneurysm recurrence treatment with the CNS were analyzed from a single-center database. Technical success, procedural aspects, complications, and angiographic results were evaluated. RESULTS: The aneurysms (median width: 5.3 mm, median neck width: 3.8 mm) were located in the anterior communicating artery (4), basilar tip (3), internal carotid artery (1), middle cerebral artery (1), and superior cerebellar artery (1). The aneurysms were initially treated endovascularly (9) and by clipping (1). Retreatment failed in one case where the smallest available CNS proved to be too small and had to be removed. Adjunctive coiling was performed in two large remnants of partially thrombosed basilar tip aneurysms. There were no procedural complications or morbidity. At a median follow-up of nine months, 4/8 (50%) aneurysms were completely occluded, 2/8 (25%) had neck remnants, and 2/8 (25%) had aneurysm remnants. The two aneurysm remnants were retreated with coiling and stent-assisted coiling, respectively. CONCLUSIONS: CNS treatment of aneurysm remnants may be feasible, especially for shallow, wide-necked aneurysm geometries. Further studies are needed to identify aneurysm subsets that benefit from CNS retreatment and to define mid- and long-term occlusion rates.

Safety and efficacy of the Contour Neurovascular System for intracranial aneurysm treatment: a retrospective analysis of 76 patients.

OBJECTIVE: The Contour Neurovascular System (CNS) is a novel intrasaccular flow-disrupting device for the treatment of intracranial aneurysms. This study presents the authors' institutional experience and midterm follow-up results with this device. METHODS: Seventy-six consecutive patients (mean ± SD age 58.9 ± 12.4 years) were treated with the CNS for 76 aneurysms (63 unruptured, 10 recurrent, and 3 ruptured). Aneurysm characteristics, procedural details, and clinical/angiographic outcomes were retrospectively evaluated. RESULTS: The most common aneurysm locations were the basilar tip in 25 (32.9%) cases and the anterior communicating artery in 22 (28.9%). There were 18 (23.7%) sidewall aneurysms. The mean ± SD aneurysm width was 5.6 ± 2.5 mm, and 68 (89.5%) aneurysms were wide-necked. The CNS was successfully implanted in 68 (89.5%) aneurysms, with 11 cases of additional coiling and 1 case each of additional stent and balloon. There were 3 (3.9%) thromboembolic events, of which 1 (1.3%) was symptomatic (a major ischemic stroke) and resulted in morbidity. There were no hemorrhagic events or deaths. At last available follow-up (mean 12 months), 32/56 (57.1%) aneurysms were completely occluded, 16/56 (28.6%) had neck remnants, and 8/56 (14.3%) had an aneurysm remnant. Three (5.4%) aneurysms were retreated. CONCLUSIONS: The use of the CNS was safe and feasible but proper aneurysm selection appears to be required, which may be facilitated with increasing operator experience and further study of this device. Similar to other intrasaccular flow disrupters, midterm complete occlusion rates are moderate but may increase with longer follow-up.

The DERIVO 2 Heal Embolization Device in the Treatment of Ruptured and Unruptured Intracranial Aneurysms: a Retrospective Multicenter Study.

BACKROUND: The use of flow diverting stents in the treatment of intracranial aneurysms is associated with a risk of neurological morbidity due to their thrombogenicity. To reduce this risk different surface modifications have been developed. The Derivo 2 Embolization Device (Acandis, Pforzheim, Germany) has proven to be a safe and effective flow diverter. To overcome the risk of thrombo-embolism, the device was modified by adding an anti-thrombogenic fibrin-heparin coating. We aimed to assess the safety and effectiveness of the Derivo 2 heal Embolization Device. METHODS: Retrospective multicenter data from nine German neurovascular centers between February 2022 until December 2023 were used. Patients treated with the Derivo 2 heal Embolization Device for unruptured or ruptured intracranial aneurysms were included. Peri- and postprocedural adverse events, clinical outcomes, and angiographic follow-up results were evaluated. RESULTS: 84 patients (73.8% female; mean age 58.7 years) with 89 aneurysms (mean size 9.8 mm) were included. 87.6% were located in the anterior circulation. Most of them were sidewall aneurysms (88.8%). 96 flow diverters were used. 99.0% were successfully implanted. An in-stent balloon angioplasty was performed in 6.0% of the cases. An additional coiling was performed in 28.6%. Technical difficulties were present in 12.0% of the cases. Thrombotic events occurred in 4.8% with no neurological sequelae. Mortality and morbidity were 0 and 1.2% respectively. Adequate aneurysm occlusion was achieved in 80.7% with a mean follow-up time of 6.6 months. CONCLUSION: The Derivo 2 heal Embolization Device showed a satisfying aneurysm occlusion and safety with a low rate of neurological morbidity.

Multicenter Experience with the Pipeline Flex and Vantage with Shield Technology for Intracranial Aneurysm Treatment.

BACKGROUND AND PURPOSE: The Pipeline Embolization Device is a safe and effective treatment option for intracranial aneurysms. The newer Pipeline generations have received structural refinements and a surface modification to improve deliverability, procedural safety, and angiographic outcomes. This multicenter study evaluated the clinical safety and efficacy of the 2 surface-modified Pipeline iterations, Pipeline Vantage and Pipeline Flex with Shield Technology (PFS). MATERIALS AND METHODS: Consecutive patients treated between 2017 and 2023 were retrospectively reviewed for aneurysm characteristics, procedural details, complications, and angiographic outcomes. The safety end point was the rate of procedural and postprocedural major neurologic events occurring during the hospital stay. The efficacy end point was the rate of complete occlusion at last follow-up. RESULTS: One hundred forty-one patients underwent 112 Pipeline Vantage procedures and 32 PFS procedures for 147 aneurysms with a mean size of 8.0 (SD, 5.9) mm (11% ruptured, 16% posterior circulation, 18% nonsaccular morphology). All procedures were technically successful with a mean of 1.2 devices implanted. Balloon angioplasty was required in 20/144 (13.9%) procedures. Major neurologic adverse events occurred in 6/144 (4.2%) procedures (all ischemic stroke), resulting in death in 2 (1.4%) patients. There were no hemorrhagic complications. At a mean of 11 months, complete occlusion was achieved in 85/112 (75.9%) aneurysms, 15/112 (13.4%) had an entry remnant, and 12/112 (10.7%) had an aneurysm remnant. CONCLUSIONS: The results demonstrate high feasibility, procedural safety, and efficacy of the surface-modified Pipeline flow diverters.

Pipeline Vantage Embolization Device for the treatment of intracranial aneurysms: A systematic review and meta-analysis.

OBJECTIVE: The Pipeline Vantage Embolization Device (PVED) is a novel coated flow diverter with reduced wire diameters to improve neoendothelialization and stent porosity. This systematic review evaluates the safety and efficacy of the PVED based on the current literature. METHODS: Following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, a thorough literature search was conducted using PubMed, EMBASE, and Cochrane. The random effects model was used to calculate estimates with major neurological complications within 30 days of treatment as the primary safety endpoint and ≤1-year complete occlusion rate as the primary efficacy endpoint. RESULTS: Six single-arm studies (5 retrospective, 1 prospective) with 392 patients and 439 aneurysms (6.8% ruptured) were included. Antiplatelet regimens varied, but dual antiplatelet therapy was administered in the majority. The pooled technical success rate was 99.0% (95%CI, 98.0%-100%) with an average of 1.2 devices implanted per procedure. Balloon angioplasty was performed in 17.0% (95%CI, 6.4-27.6%) and adjunctive coiling in 28.0% (95%CI, 17.8-38.2%), with significant heterogeneity for both variables. Pooled estimates for major neurological complications were 3.5% (95%CI, 1.7%-5.2%) with total ischemic events in 4.1% (95% CI, 1.6%-6.6%) and hemorrhagic events in 1.0% (95% CI, 0.0%-1.9%). The rate of complete angiographic occlusion was 75.7% (95%CI, 70.7%-80.6%) at a mean follow-up of 7 months, with in-stent stenoses in 8.1% (95%CI, 4.5%-11.8%). CONCLUSIONS: The safety and efficacy profile of the PVED appears comparable to competing devices, with potentially fewer complications than first-generation flow diverters. Long-term and comparative studies are needed to further confirm these results.

Generative Pre-trained Transformer 4 analysis of cardiovascular magnetic resonance reports in suspected myocarditis: A multicenter study.

BACKGROUND: Diagnosing myocarditis relies on multimodal data, including cardiovascular magnetic resonance (CMR), clinical symptoms, and blood values. The correct interpretation and integration of CMR findings require radiological expertise and knowledge. We aimed to investigate the performance of Generative Pre-trained Transformer 4 (GPT-4), a large language model, for report-based medical decision-making in the context of cardiac MRI for suspected myocarditis. METHODS: This retrospective study includes CMR reports from 396 patients with suspected myocarditis and eight centers, respectively. CMR reports and patient data including blood values, age, and further clinical information were provided to GPT-4 and radiologists with 1 (resident 1), 2 (resident 2), and 4 years (resident 3) of experience in CMR and knowledge of the 2018 Lake Louise Criteria. The final impression of the report regarding the radiological assessment of whether myocarditis is present or not was not provided. The performance of Generative pre-trained transformer 4 (GPT-4) and the human readers were compared to a consensus reading (two board-certified radiologists with 8 and 10 years of experience in CMR). Sensitivity, specificity, and accuracy were calculated. RESULTS: GPT-4 yielded an accuracy of 83%, sensitivity of 90%, and specificity of 78%, which was comparable to the physician with 1 year of experience (R1: 86%, 90%, 84%, p = 0.14) and lower than that of more experienced physicians (R2: 89%, 86%, 91%, p = 0.007 and R3: 91%, 85%, 96%, p < 0.001). GPT-4 and human readers showed a higher diagnostic performance when results from T1- and T2-mapping sequences were part of the reports, for residents 1 and 3 with statistical significance (p = 0.004 and p = 0.02, respectively). CONCLUSION: GPT-4 yielded good accuracy for diagnosing myocarditis based on CMR reports in a large dataset from multiple centers and therefore holds the potential to serve as a diagnostic decision-supporting tool in this capacity, particularly for less experienced physicians. Further studies are required to explore the full potential and elucidate educational aspects of the integration of large language models in medical decision-making.

Feasibility, Safety, and Efficacy of Endovascular vs. Surgical Treatment of Unruptured Multi-Sac Intracranial Aneurysms in a Single-Center Retrospective Series.

PURPOSE: Multi-sac aneurysms (MSAs) are not uncommon, but studies on their management are scarce. This study aims to evaluate and compare the feasibility, safety, and efficacy of MSAs treated with either clipping or coiling after interdisciplinary case discussion at our center. MATERIALS AND METHODS: We retrospectively analyzed MSAs treated by microsurgical clipping, coiling, or stent-assisted coiling (SAC). Treatment modalities, complications, angiographic results, and clinical outcomes were evaluated. Major neurological events were defined as a safety endpoint and complete occlusion as an efficacy endpoint. RESULTS: Ninety patients (mean age, 53.2±11.0 years; 73 [81.1%] females) with MSAs met our inclusion criteria (clipping, 50; coiling, 19; SAC, 21). Most aneurysms were located in the middle cerebral artery (48.9%). All clipping procedures were technically successful, but endovascular treatment failed in 1 coiling case, and a switch from coiling to SAC was required in 2 cases. The major event rates were 4.0% after clipping (1 major stroke and 1 intracranial hemorrhage) and 0% after endovascular therapy (P=0.667). At mid-term angiographic follow-up (mean 12.0±8.9 months), all 37 followed clipped aneurysms were completely occluded, compared to 8/17 (41.7%) after coiling and 11/15 (73.3%) after SAC (P<0.001). Coiling was significantly associated with incomplete occlusion in the adjusted analysis (odds ratio, 11.7; 95% confidence interval, 2.7-52.6; P=0.001). CONCLUSION: Both endovascular and surgical treatment were feasible and safe for MSAs. As coiling was associated with comparatively high recanalization rates, endovascular treatment may be preferred with stent support.

Propensity Score-matched Comparison of WEB 17 and WEB 21 with 4-7 mm Device Sizes for the Treatment of Unruptured Intracranial Aneurysms.

PURPOSE: The WEB 17 system represents the fifth generation of Woven Endobridge (WEB) flow disruptors and features a low profile with fewer wires than its predecessor, the WEB 21. The present study compares the safety and efficacy of the WEB 17 and WEB 21 for the treatment of unruptured cerebral aneurysms with 4-7 mm device sizes, which were available for both systems. METHODS: Patient and aneurysm characteristics, complications, clinical outcome and angiographic results were retrospectively analysed. 1:1 propensity score matching was performed to adjust for minor baseline differences between the groups. RESULTS: Sixty aneurysms treated with WEB 21 and 90 with WEB 17 were included. The overall failure rate (deployment failure and adjunctive stent) was significantly higher with WEB 21 (16.7%) than with WEB 17 (3.3%, p < 0.01). The rates of neurological events between WEB 21 (6.7%) and WEB 17 treatment (1.1%) were not significantly different (p = 0.08). Also, procedural morbidity was comparably low in both groups (WEB 21: 3.3%, WEB 17: 0%, p = 0.16). The rates of complete/adequate occlusion at follow up were 69.7%/86.4% for WEB 17 vs. 80.4%/91.3% for WEB 21 at short-term (p = 0.27), and 64.5%/83.9% vs. 75.9%/86.2% at mid-term (p = 0.41), respectively. Propensity score matching confirmed the results of the unmatched series. CONCLUSION: WEB 17 and WEB 21 had a similar safety and efficacy profile, but WEB 17 was associated with an improved feasibility. Prospective studies with long-term follow-up will define the full potential of the WEB 17 system.

Long-term Safety and Efficacy of the Derivo Embolization Device in a Single-center Series.

PURPOSE: This study analyzes the long-term clinical and angiographic outcomes of the Derivo Embolization Device (DED), an advanced flow diverter device with an electropolished surface, for the treatment of intracranial aneurysms. METHODS: A consecutive series of 101 patients (mean age: 58 years, 72% female) treated with the DED for 122 aneurysms at a single center between 2017 and 2023 was retrospectively analyzed for major (change in National Institutes of Health Stroke Scale [NIHSS] score ≥ 4 points) and minor (change in NIHSS score < 4 points) neurological events, procedural morbidity (increase of at least one point on the modified Rankin Scale), and angiographic results. RESULTS: There were 14 (11%) recurrent aneurysms, 15 (12%) ruptured aneurysms, 26 (21%) posterior circulation aneurysms and 16 (13%) fusiform or dissecting aneurysms. Device deployment failed in 1 case (1%). Procedure-related symptomatic procedural complications consisted of 2 (2%) major events (1 major stroke and 1 vessel perforation with intracranial hemorrhage and infarction) and 6 minor events (6 minor strokes). Procedural morbidity was 5%. There were no late ischemic or hemorrhagic events during follow-up. Complete and favorable aneurysm occlusion was achieved in 54% (40/74) and 62% (46/74) at a mean of 5 months, 71% (27/38) and 87% (33/38) at a mean of 12 months, and 76% (25/33) and 97% (32/33) at a mean of 35 months, respectively. CONCLUSION: The results demonstrate progressive aneurysm occlusion beyond 12 months after DED implantation with an almost 100% favorable occlusion rate. Procedural morbidity was low and there were no late complications.

Treatment of intracranial aneurysms with large-diameter (≥5.5 mm) Derivo Embolization Devices, with particular focus on 7 and 8 mm diameter devices.

OBJECTIVE: There are few studies on flow diverters with diameters >5 mm. We present our preliminary experience with the 5.5-8 mm Derivo Embolization Device (DED) implants for the treatment of cerebral aneurysms. METHODS: A consecutive series of 26 patients (median age: 60 years) treated for 32 aneurysms in 26 procedures was retrospectively analyzed for procedural characteristics, complications, and mid-term angiographic results. RESULTS: The median aneurysm size was 10.5 mm, 2 of 30 (6%) aneurysms were ruptured and 9 (28%) had a fusiform or dissecting morphology. DED implantation was performed in the internal carotid artery in 18 of 26 (69%) procedures and in the vertebrobasilar artery in 8 (31%). Device deployment failed in 1 (4%) procedure. The 7 and 8 mm implants were successfully deployed in 5 cases. Additional balloon angioplasty or stent implantation was performed in 3 (12%) cases to improve wall apposition. Complications included 1 (4%) major stroke and 2 (8%) minor strokes. Angiographic follow up at a mean of 6 months showed complete occlusion in 8 of30 (27%) aneurysms and favorable occlusion in 14 (47%). CONCLUSIONS: The use of large diameter DEDs was safe and feasible. The mid-term occlusion rates are acceptable considering the complex subset of aneurysms studied. Further studies are warranted to define the indications for large-diameter DEDs and to evaluate their long-term efficacy.

Impact of Vaccination Status on Outcome of Patients With COVID-19 and Acute Ischemic Stroke Undergoing Mechanical Thrombectomy.

BACKGROUND: Data on impact of COVID-19 vaccination and outcomes of patients with COVID-19 and acute ischemic stroke undergoing mechanical thrombectomy are scarce. Addressing this subject, we report our multicenter experience. METHODS AND RESULTS: This was a retrospective analysis of patients with COVID-19 and known vaccination status treated with mechanical thrombectomy for acute ischemic stroke at 20 tertiary care centers between January 2020 and January 2023. Baseline demographics, angiographic outcome, and clinical outcome evaluated by the modified Rankin Scale score at discharge were noted. A multivariate analysis was conducted to test whether these variables were associated with an unfavorable outcome, defined as modified Rankin Scale score >3. A total of 137 patients with acute ischemic stroke (48 vaccinated and 89 unvaccinated) with acute or subsided COVID-19 infection who underwent mechanical thrombectomy attributable to vessel occlusion were included in the study. Angiographic outcomes between vaccinated and unvaccinated patients were similar (modified Thrombolysis in Cerebral Infarction ≥2b: 85.4% in vaccinated patients versus 86.5% in unvaccinated patients; P=0.859). The rate of functional independence (modified Rankin Scale score, ≤2) was 23.3% in the vaccinated group and 20.9% in the unvaccinated group (P=0.763). The mortality rate was 30% in both groups. In the multivariable analysis, vaccination status was not a significant predictor for an unfavorable outcome (P=0.957). However, acute COVID-19 infection remained significant (odds ratio, 1.197 [95% CI, 1.007-1.417]; P=0.041). CONCLUSIONS: Our study demonstrated no impact of COVID-19 vaccination on angiographic or clinical outcome of COVID-19-positive patients with acute ischemic stroke undergoing mechanical thrombectomy, whereas worsening attributable to COVID-19 was confirmed.

Highly compressed SENSE accelerated relaxation-enhanced angiography without contrast and triggering (REACT) for fast non-contrast enhanced magnetic resonance angiography of the neck: Clinical evaluation in patients with acute ischemic stroke at 3 tesla.

BACKGROUND AND PURPOSE: Long acquisition times limit the feasibility of established non-contrast-enhanced MRA (non-CE-MRA) techniques. The purpose of this study was to evaluate a highly accelerated flow-independent sequence (Relaxation-Enhanced Angiography without Contrast and Triggering [REACT]) for imaging of the extracranial arteries in acute ischemic stroke (AIS). MATERIALS AND METHODS: Compressed SENSE (CS) accelerated (factor 7) 3D isotropic REACT (fixed scan time: 01:22 min, reconstructed voxel size 0.625 × 0.625 × 0.75 mm3) and CE-MRA (CS factor 6, scan time: 1:08 min, reconstructed voxel size 0.5 mm3) were acquired in 76 AIS patients (69.4 ± 14.3 years, 33 females) at 3 Tesla. Two radiologists assessed scans for the presence of internal carotid artery (ICA) stenosis and stated their diagnostic confidence using a 5-point scale (5 = excellent). Vessel quality of cervical arteries as well as the impact of artifacts and image noise were scored on 5-point scales (5 = excellent/none). Apparent signal- and contrast-to-noise ratios (aSNR/aCNR) were measured for the common carotid artery (CCA) and ICA (C1-segment). RESULTS: REACT provided a sensitivity of 88.5% and specificity of 100% for clinically relevant (≥50%) ICA stenosis with substantial concordance to CE-MRA regarding stenosis grading (Cohen's kappa 0.778) and similar diagnostic confidence (REACT: mean 4.5 ± 0.4 vs. CE-MRA: 4.5 ± 0.6; P = 0.674). Presence of artifacts (3.6 ± 0.5 vs. 3.5 ± 0.7; P = 0.985) and vessel quality (all segments: 3.6 ± 0.7 vs. 3.8 ± 0.7; P = 0.004) were comparable between both techniques with REACT showing higher scores at the CCA (4.3 ± 0.6 vs. 3.8 ± 0.9; P < 0.001) and CE-MRA at V2- (3.3 ± 0.5 vs. 3.9 ± 0.8; P < 0.001) and V3-segments (3.3 ± 0.5 vs. 4.0 ± 0.8; P < 0.001). For all vessels, REACT showed a lower impact of image noise (3.8 ± 0.6 vs. 3.6 ± 0.7; P = 0.024) while yielding higher aSNR (52.5 ± 15.1 vs. 37.9 ± 12.5; P < 0.001) and aCNR (49.4 ± 15.0 vs. 34.7 ± 12.3; P < 0.001) for all vessels combined. CONCLUSIONS: In patients with acute ischemic stroke, highly accelerated REACT provides an accurate detection of ICA stenosis with vessel quality and scan time comparable to CE-MRA.

Safety and efficacy of coated flow diverters in the treatment of ruptured intracranial aneurysms: a retrospective multicenter study.

BACKGROUND: This multicenter study evaluated the safety and efficacy of coated flow diverters (cFDs) for the treatment of ruptured intracranial aneurysms. METHODS: Consecutive patients treated with different cFDs for ruptured aneurysms under tirofiban at eight neurovascular centers between 2016 and 2023 were retrospectively analyzed. The majority of patients were loaded with dual antiplatelet therapy after the treatment. Aneurysm occlusion was determined using the O'Kelly-Marotta (OKM) grading scale. Primary outcome measures were major procedural complications and aneurysmal rebleeding during hospitalization. RESULTS: The study included 60 aneurysms (posterior circulation: 28 (47%)) with a mean size of 5.8±4.7 mm. Aneurysm morphology was saccular in 28 (47%), blister-like in 12 (20%), dissecting in 13 (22%), and fusiform in 7 (12%). Technical success was 100% with a mean of 1.1 cFDs implanted per aneurysm. Adjunctive coiling was performed in 11 (18%) aneurysms. Immediate contrast retention was observed in 45 (75%) aneurysms. There was 1 (2%) major procedural complication (a major stroke, eventually leading to death) and no aneurysmal rebleeding. A good outcome (modified Rankin Scale 0-2) was achieved in 40 (67%) patients. At a mean follow-up of 6 months, 27/34 (79%) aneurysms were completely occluded (OKM D), 3/34 (9%) had an entry remnant (OKM C), and 4/34 (12%) had residual filling (OKM A or B). There was 1 (3%) severe in-stent stenosis during follow-up that was treated with balloon angioplasty. CONCLUSIONS: Treatment of ruptured aneurysms with cFDs was reasonably safe and efficient and thus represents a valid treatment option, especially for complex cases.

Initial experience with a state-of-the-art mobile head CT scanner for use in neurointensive care units.

OBJECTIVE: Mobile head computed tomography (CT) scanners can reduce transport-related complications in neurointensive care unit (NICU) patients and decrease the burden on NICU staff; however, the initial investment cost and reduced image quality of early mobile scanners have prevented their widespread clinical use. Here, we report our initial experience with a novel 32-row mobile CT scanner for use in NICUs. METHODS: Over a 2-year period, 107 patients received a mobile head CT scan. The technical characteristics of the scanner and the organizational procedures are described in detail. Patient characteristics were retrospectively collected and image quality was subjectively evaluated on a Likert scale ranging from 0 to 5 and compared with a stationary CT scanner. RESULTS: Mobile head CT was used for follow-up of intracranial hemorrhage in 51%, routine postoperative imaging in 28%, evaluation of neurological deterioration in 14%, bedside monitoring after external ventricular drain placement in 4%, and follow-up of ischemic stroke in 3% of cases. Diagnostic imaging quality was achieved in all cases, eliminating the need for stationary CT scanning. The overall image quality of mobile CT (median 4 points) was inferior to that of conventional stationary CT (median 5 points, p < 0.01), but was rated with 4 or 5 points in the majority of cases. CONCLUSIONS: State-of-the-art mobile CT was found to be easy to use and maneuver and has the potential to expedite the diagnosis of NICU patients and reduce staff workload. Image quality was adequate for common NICU issues.