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.

Behcet disease: A case report on the utilization of T1-weighted black blood fat-suppressed sequences for the detection of venous vasculitis.

T1-weighted black blood FS sequences may provide a useful addition to imaging protocols in detection of subtle changes in venous vasculitides and, therefore, may have an impact on treatment options.

Comparative Analysis of the Low-Profile Acclino Stent and the Enterprise Stent for the Treatment of Unruptured Intracranial Aneurysms.

OBJECTIVE: In preliminary studies, advanced intracranial stents appear to have a favorable safety profile for intracranial aneurysm treatment. This dual-center study is a head-to-head comparison of the low-profile Acandis Acclino stent (a third-generation stent) and the first- and second-generation Enterprise stent. METHODS: Patients who underwent stent-assisted coiling with either the Enterprise or the Acclino stent for unruptured aneurysms during an 8-year period were enrolled and compared for complications, clinical outcomes, and angiographic results. Primary outcome measures were ischemic stroke rate and mid-term complete occlusion rate. Propensity score adjustment was performed to account for small differences between the groups. RESULTS: Enterprise and Acclino stents were used in 48 cases each. The overall rate of thrombotic complications was higher in the Enterprise group than in the Acclino group (20.8% vs. 4.2%, HR: 6.6, 95%CI: 2.2-20.0, P = 0.01, adjusted P < 0.01), which translated into a higher rate of major ischemic stroke after Enterprise treatment (6.3% vs. 0%, HR: 2.1, 95%CI: 1.8-2.4, P = 0.08, adjusted P < 0.01). Mid-term and long-term angiographic follow-up showed complete occlusion rates of 83.3% and 75.0% for Enterprise and 89.2% and 75.9% for Acclino (both P > 0.05). Retreatment rates were 10.4% in the Enterprise group and 4.2% in the Acclino group (P = 0.42, adjusted P = 0.10). CONCLUSIONS: The results indicate a favorable safety profile of the Acclino over the Enterprise, justifying the use of advanced stent systems in clinical practice. However, further comparative studies of the Acclino and other competing stent systems are needed to draw a definitive conclusion on the state of stent-assisted coiling.

Diagnostic Value of Perfusion Parameters for Differentiation of Underlying Etiology in Internal Carotid Artery Occlusions.

PURPOSE: Occlusions of the internal carotid artery (ICA) may be caused by dissection, embolic or macroangiopathic pathogenesis, which partially influences the treatment; however, inferring the underlying etiology in computed tomography angiography can be challenging. In this study, we investigated whether computed tomography perfusion (CT-P) parameters could be used to distinguish between etiologies. METHODS: Patients who received CT­P in acute ischemic stroke due to ICA occlusion between 2012 and 2019 were retrospectively analyzed. Group comparisons between etiologies regarding the ratios of CT­P parameters between both hemispheres for relative cerebral blood volume (rCBV), relative cerebral blood flow (rCBF), time to maximum (Tmax), and mean transit time (MTT) were calculated by one-factorial analysis of variance (ANOVA) and compared by pairwise Bonferroni post hoc tests. An receiver operating characteristics (ROC) analysis was performed if differences in group comparisons were found. Multinomial logistic regression (MLR) including pretherapeutic parameters was calculated for etiologies. RESULTS: In this study 69 patients (age = 70 ± 14 years, dissection = 10, 14.5%, embolic = 19, 27.5% and macroangiopathic = 40, 58.0%) were included. Group differences in ANOVA were only found for MTT ratio (p = 0.003, η2 = 0.164). In the post hoc test, MTT ratio showed a differentiability between embolic and macroangiopathic occlusions (p = 0.002). ROC analysis for differentiating embolic and macroangiopathic ICA occlusions based on MTT ratio showed an AUC of 0.77 (p < 0.001, CI = 0.65-0.89) and a cut-off was yielded at a value of 1.15 for the MTT ratio (sensitivity 73%, specificity 68%). The MLR showed an overall good model performance. CONCLUSION: It was possible to differentiate between patients with embolic and macroangiopathic ICA occlusions based on MTT ratios and to define a corresponding cut-off. Differentiation from patients with dissection versus the other etiologies was not possible by CT­P parameters in our sample.

Application of novel PACS-based informatics platform to identify imaging based predictors of CDKN2A allelic status in glioblastomas.

Gliomas with CDKN2A mutations are known to have worse prognosis but imaging features of these gliomas are unknown. Our goal is to identify CDKN2A specific qualitative imaging biomarkers in glioblastomas using a new informatics workflow that enables rapid analysis of qualitative imaging features with Visually AcceSAble Rembrandtr Images (VASARI) for large datasets in PACS. Sixty nine patients undergoing GBM resection with CDKN2A status determined by whole-exome sequencing were included. GBMs on magnetic resonance images were automatically 3D segmented using deep learning algorithms incorporated within PACS. VASARI features were assessed using FHIR forms integrated within PACS. GBMs without CDKN2A alterations were significantly larger (64 vs. 30%, p = 0.007) compared to tumors with homozygous deletion (HOMDEL) and heterozygous loss (HETLOSS). Lesions larger than 8 cm were four times more likely to have no CDKN2A alteration (OR: 4.3; 95% CI 1.5-12.1; p < 0.001). We developed a novel integrated PACS informatics platform for the assessment of GBM molecular subtypes and show that tumors with HOMDEL are more likely to have radiographic evidence of pial invasion and less likely to have deep white matter invasion or subependymal invasion. These imaging features may allow noninvasive identification of CDKN2A allele status.

Novel Insights into Pathophysiology of Delayed Cerebral Ischemia: Effects of Current Rescue Therapy on Microvascular Perfusion Heterogeneity.

General microvascular perfusion and its heterogeneity are pathophysiological features of delayed cerebral ischemia (DCI) that are gaining increasing attention. Recently, CT perfusion (CTP) imaging has made it possible to evaluate them radiologically using mean transit time (MTT) and its heterogeneity (measured by cvMTT). This study evaluates the effect of multimodal rescue therapy (intra-arterial nimodipine administration and elevation of blood pressure) on MTT and cvMTT during DCI in aneurysmal subarachnoid haemorrhage (aSAH) patients. A total of seventy-nine aSAH patients who underwent multimodal rescue therapy between May 2012 and December 2019 were retrospectively included in this study. CTP-based perfusion impairment (MTT and cvMTT) on the day of DCI diagnosis was compared with follow-up CTP after initiation of combined multimodal therapy. The mean MTT was significantly reduced in the follow-up CTP compared to the first CTP (3.7 ± 0.7 s vs. 3.3 ± 0.6 s; p < 0.0001). However, no significant reduction of cvMTT was observed (0.16 ± 0.06 vs. 0.15 ± 0.06; p = 0.44). Mean arterial pressure was significantly increased between follow-up and first CTP (98 ± 17 mmHg vs. 104 ± 15 mmHg; p < 0.0001). The combined multimodal rescue therapy was effective in addressing the general microvascular perfusion impairment but did not affect the mechanisms underlying microvascular perfusion heterogeneity. This highlights the need for research into new therapeutic approaches that also target these pathophysiological mechanisms of DCI.

Evaluation of MTT Heterogeneity of Perfusion CT Imaging in the Early Brain Injury Phase: An Insight into aSAH Pathopysiology.

The concept of early brain injury (EBI) is based on the assumption of a global reduction in brain perfusion following aneurysmal subarachnoid hemorrhage (aSAH). However, the heterogeneity of computed tomography perfusion (CTP) imaging in EBI has not yet been investigated. In contrast, increased mean transit time (MTT) heterogeneity, a possible marker of microvascular perfusion heterogeneity, in the delayed cerebral ischemia (DCI) phase has recently been associated with a poor neurological outcome after aSAH. Therefore, in this study, we investigated whether the heterogeneity of early CTP imaging in the EBI phase is an independent predictor of the neurological outcome after aSAH. We retrospectively analyzed the heterogeneity of the MTT using the coefficient of variation (cvMTT) in early CTP scans (within 24 h after ictus) of 124 aSAH patients. Both linear and logistic regression were used to model the mRS outcome, which were treated as numerical and dichotomized values, respectively. Linear regression was used to investigate the linear dependency between the variables. No significant difference in cvMTT between the patients with and those without EVD could be observed (p = 0.69). We found no correlation between cvMTT in early CTP imaging and initial modified Fisher (p = 0.07) and WFNS grades (p = 0.23). The cvMTT in early perfusion imaging did not correlate significantly with the 6-month mRS for the entire study population (p = 0.15) or for any of the subgroups (without EVD: p = 0.21; with EVD: p = 0.3). In conclusion, microvascular perfusion heterogeneity, assessed by the heterogeneity of MTT in early CTP imaging, does not appear to be an independent predictor of the neurological outcome 6 months after aSAH.

Treatment of Unique Bilateral Distal Fusiform Superior Cerebellar Artery Aneurysms with Mini-Flow Diverter Device Implantation: Case Report.

Currently, surgical revascularization procedures using intracranial-intracranial (IC-IC) or extracranial-intracranial (EC-IC) bypass and distal clipping or trapping are the valid and rescue treatment modality for extremely rare unilateral distal fusiform superior cerebellar artery (SCA) aneurysms. Yet, in case of bilateral fusiform SCA aneurysms, surgical therapy reaches its limit. Mini-flow diverter devices (FDDs) have only recently become available for treating fusiform aneurysms of such small vessels. We report the unique case of bilateral distal fusiform SCA aneurysms in a 43-year-old man with subarachnoid hemorrhage (Fisher grade IV and World Federation of Neurosurgical Societies [WFNS] grade II) treated with endovascular implantation of bilateral mini-FDDs with excellent outcome and no radiographic signs of infarction. Yet, occlusion of one of the FDDs was found in the follow-up, which again shows the eminent danger of occlusion in case of an implantation of FDDs in such small-caliber vessels, which leaves the discussion about the optimal therapy method open.

Safety and efficacy of the eCLIPs bifurcation remodelling system for the treatment of wide necked bifurcation aneurysms: 1 year results from the European eCLIPs Safety, Feasibility, and Efficacy Study (EESIS).

BACKGROUND: The eCLIPs bifurcation remodelling system is a non-circumferential implant that bridges the neck from outside of a bifurcation aneurysm. The goal of the multicenter, post-marketing European eCLIPs Safety, FeasIbility, and Efficacy Study (EESIS), was to present the efficacy and safety results of the eCLIPs device after 365 days of follow-up. METHODS: All patients were to receive an eCLIPs in conjunction with coils. The study was conducted according to good clinical practices and included independent adjudication of safety and efficacy outcomes. RESULTS: Twenty patients were enrolled at four European centers. Mean age was 60 years (range 41-74) and aneurysms were located at the basilar tip (n=19) and carotid tip (n=1). Average aneurysm dome height was 6.0 mm (range 2.0-15.0). Mean neck length was 5.1 mm (range 2.6-8.5). The technical success rate was 90% (18 of 20). No major territorial strokes or deaths occurred between the index procedure and after 365 days of follow-up. Complete occlusion was achieved in 60% of patients (12 of 20 patients) and 67% of patients with an eCLIPs device (12 of 18) after 365 days of follow-up. Adequate occlusion (complete occlusion and neck remnant) was achieved in 80% of patients (16 of 20 patients) and 89% of patients with an eCLIPs device (16 of 18 patients) after 365 days of follow-up. CONCLUSION: In this small series, treatment with eCLIPs was feasible, safe, and efficacious, considering the challenging nature of the aneurysms. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov NCT02607501.

The impact of preoperative MRI-based apparent diffusion coefficients on local recurrence and outcome in patients with cerebral metastases.

BACKGROUND: Surgery of single cerebral metastases is standard but frequently fails to achieve local tumour control. Reliable predictors for local tumour progression and overall survival are unknown. MRI-based apparent diffusion coefficients (ADC) correlate with tumour cellularity and invasion. The present study analysed a potential relation between the MRI based apparent diffusion coefficients local recurrence and outcome in patients with brain metastases. METHODS: A retrospective analysis was performed for patients with cerebral metastases and complete surgical resection evaluated by an early postoperative MRI < 72h. Minimal ADC and mean ADC were assessed in preoperative 1,5T-MRI scans by placing regions of interests in the tumour and the peritumoural tissue. RESULTS: Analysis of the relation between ADC values, local progression and outcome was performed in 86 patients with a mean age of 59 years (range 33-83 years). Primary site was NSCLC in 37.2% of all cases. Despite complete resection 33.7% of all patients suffered from local in-brain-progression. There were no significant differences in ADC values in groups based on histology. In the present cohort, the mean ADCmin and the mean ADCmean within the metastasis did not differ significantly between patients with and without a later local in-brain progression (634 × 10-6 vs. 661 × 10-6 mm2/s and 1324 × 10-6 vs. 1361 × 10-6 mm2/s; 1100 × 10-6 vs. 1054 × 10-6 mm2/s; each p > 0.05). Mean ADC values did not correlate significantly with PFS and OAS. CONCLUSION: In the present study analysed ADC values had no significant impact on local in brain progression and survival parameters.

[Diagnostics and treatment of organic intraorbital foreign bodies]. / Diagnostik und Therapie organischer intraorbitaler Fremdkörper.

BACKGROUND: Orbital injuries with organic foreign bodies are a clinical challenge as they can cause a variety of complications and sometimes lead to irreversible visual impairment. MATERIAL AND METHODS: We report five consecutive cases of patients with organic orbital foreign bodies who presented between 2012 and 2022. Documented parameters include age, gender, time of injury, mechanism of injury, best-corrected visual acuity (BCVA), presence of pain, restriction of motility, performed imaging, location and type of foreign body, treatment and complications. RESULTS: The mean patient age was 61.8 ± 32.3 years and the gender ratio was 4:1 (female:male). In 4 cases the injury had been reported on average 4.6 days (0/14 days min/max) previously. Best corrected visual acuity at first presentation was 0.5 ± 0.2 decimal and after a mean follow-up of 12.7 months (0.5/38 months min/max) at last presentation 0.67 ± 0.3 decimal (p = 0.2). The reason for initial presentation was pain (n = 3) and/or double vision (n = 2). All patients underwent computer tomography (CT). The diagnosis was confirmed in two cases by means of CT. In all five cases the foreign body material could be completely surgically removed, while one patient needed repeated surgery due to retained foreign body material. The organic foreign body material included wood (4) and wax (1). In two cases, a foreign body-induced infection was successfully treated with systemic antibiotics. There were no other complications. CONCLUSION: In orbital trauma a thorough wound exploration must be performed, especially if the mechanism of injury is uncertain and residual foreign bodies or a perforation injury cannot be excluded. The imaging of choice is CT, which may have to be performed again in the postoperative course.

Mothership vs. drip-and-ship: evaluation of initial treatment strategies for acute ischemic stroke in a well-developed network of specialized hospitals.

PURPOSE: Two strategies of initial patient care exist in endovascular thrombectomy (ET) depending on the site of initial admission: the mothership (MS) and drip-and-ship (DnS) principles. This study compares both strategies in regard to patient outcome in a local network of specialized hospitals. METHODS: Two-hundred-and-two patients undergoing ET in anterior circulation ischemic stroke between June 2016 and May 2018 were enrolled. Ninety two patients were directly admitted to our local facility (MS), One-hundred-and-ten were secondarily referred to our facility. Group comparisons between admission strategies in three-months modified Rankin Scale (mRS), Maas Score and Alberta-Stroke-Program-Early-computed-tomography-score (ASPECTS), National-Institutes-of-Health-Stroke-Scale (NIHSS), age and onset-to-recanalization-time were performed. Correlation between admission strategy and mRS was calculated. A binary logistic regression model was computed including mRS as dependent variable. RESULTS: There were neither significant group differences in three-months mRS between MS and DnS nor significant correlations. Patients tended to achieve a better outcome with DnS. Collateralization status differed between MS and DnS (p = 0.003) with better collateralization in DnS. There were no significant group differences in NIHSS or ASPECTS but in onset-to-recanalization-time (p < 0.001) between MS and DnS. Binary logistic regression showed a high explanation of variance of mRS but no significant results for admission strategy. CONCLUSIONS: Functional outcome in patients treated with ET is comparable between the MS and DnS principles. Tendentially better outcome in the DnS subgroup may be explained by selection bias due to a higher willingness to apply ET in patients with worse baseline conditions (e.g. worse collateralization), if patients undergoing MS are already on site.

Identifying clinically applicable machine learning algorithms for glioma segmentation: recent advances and discoveries.

Background: While there are innumerable machine learning (ML) research algorithms used for segmentation of gliomas, there is yet to be a US FDA cleared product. The aim of this study is to explore the systemic limitations of research algorithms that have prevented translation from concept to product by a review of the current research literature. Methods: We performed a systematic literature review on 4 databases. Of 11 727 articles, 58 articles met the inclusion criteria and were used for data extraction and screening using TRIPOD. Results: We found that while many articles were published on ML-based glioma segmentation and report high accuracy results, there were substantial limitations in the methods and results portions of the papers that result in difficulty reproducing the methods and translation into clinical practice. Conclusions: In addition, we identified that more than a third of the articles used the same publicly available BRaTS and TCIA datasets and are responsible for the majority of patient data on which ML algorithms were trained, which leads to limited generalizability and potential for overfitting and bias.

Case report: First case of neuromelioidosis in Europe: CNS infection caused by Burkholderia pseudomallei.

Neuromelioidosis is a rare CNS infection caused by Burkholderia pseudomallei and is characterized by high morbidity and mortality. Our report presents the diagnostic and therapeutic approach of the first case of neuromelioidosis confirmed in Europe. A 47-year-old man with a medical history of recurrent otitis with otorrhea and fever after tympanoplasty and radical cavity revision operation on the left ear was admitted with headache, decreased level of consciousness, dysarthria, left-sided hemiparesis, and urinary incontinence. After extensive investigations including MRI, microbiological, serological, and CSF analyses, and, ultimately, brain biopsy, a diagnosis of neuromelioidosis was established. Despite antibiotic treatment, the patient showed no clinical improvement and remained in a severely compromised neurological state under mandatory mechanical ventilation. Neuromelioidosis can pose a diagnostic challenge requiring an extensive diagnostic evaluation because of its uncommon clinical and radiological presentations.

A fully radiopaque hybrid stent retriever versus a precursor device: Outcome, efficacy, and safety in large vessel stroke.

BACKGROUND AND PURPOSE: The aim of this multicenter study was to compare the clinical outcome, safety, and efficacy of the full-length radiopaque Aperio Hybrid stent retriever (APH) with the precursor Aperio thrombectomy device (AP). METHODS: Multicentric retrospective analysis of patients with stroke, treated with the APH and AP due to an acute ischemic stroke by large vessel occlusions in the anterior or posterior circulation, was performed. We focused on the comparison of favorable clinical outcome (modified Rankin Scale, 0-2) after 3 months, favorable reperfusion rates (thrombolysis in cerebral infarction scale ≥ 2b), and the complication rate. RESULTS: A total of 51 patients (female: n = 33, 64.7%, mean age 73 ± 16 years) with a median baseline National Institutes of Health Stroke Scale: 15 were treated with the APH or AP. Favorable outcome in patients treated with APH was excellent (44.0%) and comparable to the AP (36.8%). The rate of final favorable reperfusion for both devices was outstanding (APH 31/31 and AP 20/20). The overall complication rate for the APH was slightly higher compared to the AP (32.3%/15.0%). Symptomatic intracranial hemorrhage was recorded in 0 of 51 cases. The all-cause mortality rate at 90 days was 20.0% for the APH and comparable for the AP (21.1%). CONCLUSIONS: Comparable clinical outcome, efficacy, and safety of the AP and the recently introduced APH were demonstrated. Both devices appeared feasible, efficient, and safe with regard to endovascular treatment in large vessel occlusion.

Impact of defacing on automated brain atrophy estimation.

BACKGROUND: Defacing has become mandatory for anonymization of brain MRI scans; however, concerns regarding data integrity were raised. Thus, we systematically evaluated the effect of different defacing procedures on automated brain atrophy estimation. METHODS: In total, 268 Alzheimer's disease patients were included from ADNI, which included unaccelerated (n = 154), within-session unaccelerated repeat (n = 67) and accelerated 3D T1 imaging (n = 114). Atrophy maps were computed using the open-source software veganbagel for every original, unmodified scan and after defacing using afni_refacer, fsl_deface, mri_deface, mri_reface, PyDeface or spm_deface, and the root-mean-square error (RMSE) between z-scores was calculated. RMSE values derived from unaccelerated and unaccelerated repeat imaging served as a benchmark. Outliers were defined as RMSE > 75th percentile and by using Grubbs's test. RESULTS: Benchmark RMSE was 0.28 ± 0.1 (range 0.12-0.58, 75th percentile 0.33). Outliers were found for unaccelerated and accelerated T1 imaging using the 75th percentile cutoff: afni_refacer (unaccelerated: 18, accelerated: 16), fsl_deface (unaccelerated: 4, accelerated: 18), mri_deface (unaccelerated: 0, accelerated: 15), mri_reface (unaccelerated: 0, accelerated: 2) and spm_deface (unaccelerated: 0, accelerated: 7). PyDeface performed best with no outliers (unaccelerated mean RMSE 0.08 ± 0.05, accelerated mean RMSE 0.07 ± 0.05). The following outliers were found according to Grubbs's test: afni_refacer (unaccelerated: 16, accelerated: 13), fsl_deface (unaccelerated: 10, accelerated: 21), mri_deface (unaccelerated: 7, accelerated: 20), mri_reface (unaccelerated: 7, accelerated: 6), PyDeface (unaccelerated: 5, accelerated: 8) and spm_deface (unaccelerated: 10, accelerated: 12). CONCLUSION: Most defacing approaches have an impact on atrophy estimation, especially in accelerated 3D T1 imaging. Only PyDeface showed good results with negligible impact on atrophy estimation.

Cost-Effectiveness of Endovascular Thrombectomy in Childhood Stroke: An Analysis of the Save ChildS Study.

BACKGROUND AND PURPOSE: The Save ChildS Study demonstrated that endovascular thrombectomy (EVT) is a safe treatment option for pediatric stroke patients with large vessel occlusions (LVOs) with high recanalization rates. Our aim was to determine the long-term cost, health consequences and cost-effectiveness of EVT in this patient population. METHODS: In this retrospective study, a decision-analytic Markov model estimated lifetime costs and quality-adjusted life years (QALYs). Early outcome parameters were based on the entire Save ChildS Study to model the EVT group. As no randomized data exist, the Save ChildS patient subgroup with unsuccessful recanalization was used to model the standard of care group. For modeling of lifetime estimates, pediatric and adult input parameters were obtained from the current literature. The analysis was conducted in a United States setting applying healthcare and societal perspectives. Probabilistic sensitivity analyses were performed. The willingness-to-pay threshold was set to $100,000 per QALY. RESULTS: The model. RESULTS: yielded EVT as the dominant (cost-effective as well as cost-saving) strategy for pediatric stroke patients. The incremental effectiveness for the average age of 11.3 years at first stroke in the Save ChildS Study was determined as an additional 4.02 lifetime QALYs, with lifetime cost-savings that amounted to $169,982 from a healthcare perspective and $254,110 when applying a societal perspective. Acceptability rates for EVT were 96.60% and 96.66% for the healthcare and societal perspectives. CONCLUSIONS: EVT for pediatric stroke patients with LVOs resulted in added QALY and reduced lifetime costs. Based on the available data in the Save ChildS Study, EVT is very likely to be a cost-effective treatment strategy for childhood stroke.

Mechanical thrombectomy in stroke patients with acute occlusion of the M1- compared to the M2-segment: Safety, efficacy, and clinical outcome.

PURPOSE: Endovascular treatment (ET) in occlusions of the M1- and proximal M2-segment of the middle cerebral artery (MCA) is an established procedure. In contrast, ET in distal M2-occlusions has not been sufficiently evaluated yet. The purpose of this study was to assess relevant parameters for clinical outcome, efficacy, and safety of patients undergoing ET in M1-, proximal M2-, and distal M2-occlusions. METHODS: One hundred seventy-four patients undergoing ET in acute ischemic stroke with an occlusion of the M1- or M2-segment of the MCA were enrolled prospectively. Non-parametric analysis of variance in 3-month mRS, TICI scale, and complication rates were performed with Kruskal-Wallis test between M1- and proximal and distal M2-occlusions. Subsequent pairwise group comparisons were calculated using Mann-Whitney U-tests. Binary logistic regression models were calculated for each occlusion site. RESULTS: There were no significant group differences in 3-month mRS, mTICI scale, or complication rates between M1- and M2-occlusions nor between proximal and distal M2-occlusions. Binary logistic regression in patients with M1-occlusions showed a substantial explanation of variance (NR2=0.35). NIHSS (p=0.009) and Maas Score as parameter for collateralization (p=0.01) appeared as significant contributing parameters. Binary logistic regression in M2-occlusions showed a high explanation of variance (NR2=0.50) of mRS but no significant factors. CONCLUSIONS: Clinical outcome and procedural safety of patients with M2-occlusions undergoing ET are comparable to those of patients with M1-occlusions. Clinical outcome of patients with M1-occlusions undergoing ET is primarily influenced by the initial neurological deficit and the collateralization of the occlusions. By contrast, clinical outcome in patients with M2-occlusions undergoing ET is more multifactorial.

The rupture of an anterior communicating artery aneurysm does not associate with an asymmetry in the A1 or A2 arteries: a retrospective study of radiological features.

BACKGROUND AND OBJECTIVES: Although the formation and rupture risk of an anterior communicating artery (ACoA) aneurysm has been the subject of many studies, no previous study has primarily searched for the relationship of the parent and daughter vessels and the impact of their size/diameter ratio on the potential rupture risk of an AcoA aneurysm. The objective of this study is to explore this link and to further analyse the surrounding vasculature of the anterior communicating artery aneurysm. MATERIALS AND METHODS: We conducted a retrospective analysis of 434 patients: 284 patients with an ACoA aneurysm (121 unruptured and 162 ruptured) and 150 control patients without an ΑCoA aneurysm. Radiological angiography investigations were used to assess the diameter ratios of the parent vessels in addition to ACoA aneurysm morphology parameters. RESULTS: When comparing the ruptured to the unruptured cases, we observed no significant difference in the parent or daughter vessel diameter ratios. Younger patient age (OR 0.96, p = 0.00) and a higher aneurysm size ratio (OR 1.10, p = 0.02) were of prognostic importance concerning the rupture risk of the aneurysm. The A1 diameter ratio and the A2 diameter were not statistically significant (OR 1.00, p = 0.99, and OR 3.38, p = 0.25 respectively). CONCLUSIONS: In our study, we focused on asymmetry in the parent and daughter vessels as well as traditional ACoA aneurysm morphological characteristics. We were able to label younger patient age and a greater size ratio as independent prognostic factors for ACoA aneurysm rupture. We were unable to label parent and daughter vessel asymmetry as prognostic factors. To validate our findings, parent and daughter vessel asymmetry should be subjected to future prospective studies.

Treatment of recurrent and residual aneurysms with the low-profile Acandis Acclino stent: Multi-center review of 19 patients.

OBJECTIVE: To evaluate the safety and efficacy of the low-profile Acandis Acclino microstent for embolization of recurrent and residual intracranial aneurysms. METHODS: Consecutive patients treated with the Acclino for aneurysm remnants at three German neurovascular centers were enrolled. The technical success, complications, angiographic and clinical outcome were investigated. RESULTS: Nineteen patients (median age: 53 years) with 19 aneurysm remnants (median size: 5 mm, anterior circulation: 14) were included. Initial aneurysm treatment consisted of stand-alone coiling in 14 cases, stent-assisted coiling in 4 and clipping in 1. Acclino stent-assisted coil embolization was performed technically successfully in all patients. Morbidity occurred in one patient (5.3%) due to aneurysm perforation. At the angiographic follow-up with a median follow-up duration of 21 months (range: 5-37 months), complete occlusion was obtained in 76.9%. The retreatment rate was 7.7%. CONCLUSIONS: Retreatment of aneurysm remnants with the Acclino microstent was associated with high aneurysm occlusion rates and acceptable morbidity. Further studies will be necessary to draw a definite conclusion.