Treatment benefit in patients aged 80 years or older with biopsy-proven and non-resected glioblastoma is dependent on MGMT promoter methylation status.

PURPOSE: Glioblastoma is associated with especially poor outcome in the elderly. It is unclear if patients aged ≥80 years benefit from tumor-specific therapy as opposed to receiving best supportive care (BSC) only. METHODS: Patients with IDH-wildtype glioblastoma (WHO 2021), aged ≥80 years, and diagnosed by biopsy between 2010 and 2022 were included. Patient characteristics and clinical parameters were assessed. Uni- and multivariate analyses were performed. RESULTS: 76 patients with a median age of 82 (range 80-89) and a median initial KPS of 80 (range 50-90) were included. Tumor-specific therapy was initiated in 52 patients (68%). 22 patients (29%) received temozolomide monotherapy, 23 patients (30%) were treated with radiotherapy (RT) alone and 7 patients (9%) received combination therapies. In 24 patients (32%), tumor-specific therapy was omitted in lieu of BSC. Overall survival (OS) was longer in patients receiving tumor-specific therapy (5.4 vs. 3.3 months, p < 0.001). Molecular stratification showed that the survival benefit was owed to patients with MGMT promoter methylation (MGMTpos) who received tumor-specific therapy as opposed to BSC (6.2 vs. 2.6 months, p < 0.001), especially to those with better clinical status and no initial polypharmacy. Patients with unmethylated MGMT promoter (MGMTneg) did not benefit from tumor-specific therapy (3.6 vs. 3.7 months, p = 0.18). In multivariate analyses, better clinical status and MGMT promoter methylation were associated with prolonged survival (p < 0.01 and p = 0.01). CONCLUSION: Benefit from tumor-specific treatment in patients with newly diagnosed glioblastoma aged ≥80 years might be restricted to MGMTpos patients, especially to those with good clinical status and no polypharmacy.

Radiation dose and fluoroscopy time of modern endovascular treatment techniques in patients with saccular unruptured intracranial aneurysms.

OBJECTIVES: Modern endovascular treatment of unruptured intracranial aneurysms (UIAs) demands for observance of diagnostic reference levels (DRLs). The national DRL (250 Gy cm2) is only defined for coiling. We provide dosimetric data for the following procedures: coiling, flow diverter (FD), Woven EndoBridge (WEB), combined techniques. METHODS: A retrospective single-centre study of saccular UIAs treated between 2015 and 2019. Regarding dosimetric analysis, the parameters dose area product (DAP) and fluoroscopy time were investigated for the following variables: endovascular technique, aneurysm location, DSA protocol, aneurysm size, and patient age. RESULTS: Eighty-seven patients (59 females, mean age 54 years) were included. Total mean and median DAP (Gy cm2) were 119 ± 73 (89-149) and 94 (73; 130) for coiling, 128 ± 53 (106-151) and 134 (80; 176) for FD, 128 ± 56 (102-153) and 118 (90; 176) for WEB, and 165 ± 102 (110-219) and 131 (98; 209) for combined techniques (p > .05). Regarding the aneurysm location, neither DAP nor fluoroscopy time was significantly different (p > .05). The lowest and highest fluoroscopy times were recorded for WEB and combined techniques, respectively (median 26 and 94 min; p < .001). A low-dose protocol yielded a 43% reduction of DAP (p < .001). Significantly positive correlations were found between DAP and both aneurysm size (r = .320, p = .003) and patient age (r = .214, p = .046). CONCLUSIONS: This UIA study establishes novel local DRLs for modern endovascular techniques such as FD and WEB. A low-dose protocol yielded a significant reduction of radiation dose. KEY POINTS: • This paper establishes local diagnostic reference levels for modern endovascular treatment techniques of unruptured intracranial aneurysms, including flow diverter stenting and Woven EndoBridge device. • Dose area product was not significantly different between endovascular techniques and aneurysm locations, but associated with aneurysm size and patient age. • A low-dose protocol yielded a significant reduction of dose area product and is particularly useful when applying materials with a high radiopacity (e.g. platinum coils).

Radiation dose and image quality in intraoperative CT (iCT) angiography of the brain with stereotactic head frames.

OBJECTIVES: Intraoperative CT (iCT) angiography of the brain with stereotactic frames is an integral part of navigated neurosurgery. Validated data regarding radiation dose and image quality in these special examinations are not available. We therefore investigated two iCT protocols in this IRB-approved study. METHODS: Retrospective analysis of patients, who received a cerebral stereotactic iCT angiography on a 128 slice CT scanner between February 2016 and December 2017. In group A, automated tube current modulation (ATCM; reference value 410 mAs) and automated tube voltage selection (reference value 120 kV) were enabled, and only examinations with a selected voltage of 120 kV were included. In group B, fixed parameters were applied (300 mAs, 120 kV). Radiation dose was measured by assessing the volumetric CT dose index (CTDIvol), dose length product (DLP) and effective dose (ED). Signal-to-noise ratio (SNR) and image noise were assessed for objective image quality, visibility of arteries and grey-white differentiation for subjective image quality. RESULTS: Two hundred patients (n = 100 in each group) were included. In group A, median selected tube current was 643 mAs (group B, 300 mAs; p < 0.001). Median values of CTDIvol, DLP and ED were 91.54 mGy, 1561 mGy cm and 2.97 mSv in group A, and 43.15 mGy, 769 mGy cm and 1.46 mSv in group B (p < 0.001). Image quality did not significantly differ between groups (p > 0.05). CONCLUSIONS: ATCM yielded disproportionally high radiation dose due to substantial tube current increase at the frame level, while image quality did not improve. Thus, ATCM should preferentially be disabled. KEY POINTS: • Automated tube current modulation (ATCM) yields disproportionally high radiation dose in intraoperative CT angiography of the brain with stereotactic head frames. • ATCM does not improve overall image quality in these special examinations. • ATCM is not yet optimised for CT angiography of the brain with major extracorporeal foreign materials within the scan range.

Percutaneous CT fluoroscopy-guided core biopsy of pancreatic lesions: technical and clinical outcome of 104 procedures during a 10-year period.

Background In unclear pancreatic lesions, a tissue sample can confirm or exclude the suspected diagnosis and help to provide an optimal treatment strategy to each patient. To date only one small study reported on the outcome of computed tomography (CT) fluoroscopy-guided biopsies of the pancreas. Purpose To evaluate technical success and diagnostic rate of all CT fluoroscopy-guided core biopsies of the pancreas performed in a single university center during a 10-year period. Material and Methods In this retrospective study we included all patients who underwent a CT fluoroscopy-guided biopsy of a pancreatic mass at our comprehensive cancer center between 2005 and 2014. All interventions were performed under local anesthesia on a 16-row or 128-row CT scanner. Technical success and diagnostic rates as well as complications and effective patient radiation dose were analyzed. Results One hundred and one patients (54 women; mean age, 63.9 ± 12.6 years) underwent a total of 104 CT fluoroscopy-guided biopsies of the pancreas. Ninety-eight of 104 interventions (94.2%) could be performed with technical success and at least one tissue sample could be obtained. In 88 of these 98 samples, a definitive pathological diagnosis, consistent with clinical success could be achieved (89.8%). Overall 19 minor and three major complications occurred during the intra- or 30-day post-interventional period and all other interventions could be performed without complications; there was no death attributable to the intervention. Conclusion CT fluoroscopy-guided biopsy of pancreatic lesions is an effective procedure characterized by a low major complication and a high diagnostic rate.

CT fluoroscopy-guided closed-tip catheter placement before regional hyperthermia treatment of soft tissue sarcomas: 5-Year experience in 35 consecutive patients.

PURPOSE: This study was designed to assess technical success and complications in patients with high-risk soft tissue sarcomas undergoing CT fluoroscopy-guided closed-tip catheter placement before treatment with combined chemotherapy and regional hyperthermia. MATERIALS AND METHODS: This retrospective study comprised all patients referred for insertion of closed-tip catheters for the introduction of thermometry probes before regional hyperthermia treatment at a single university centre from 2010 to 2015. Catheter placements were performed under local anaesthesia and intermittent CT fluoroscopy guidance. Technical success, complication rate, duration of catheter insertion and dose-length product (DLP) were analysed. Technical success was defined as intratumoural catheter placement suitable for subsequent thermometry. RESULTS: A total of 35 procedures were performed on 35 patients (22 men, 13 women). In 34 out of 35 interventions catheters were inserted successfully; in one patient catheter placement was not feasible. No intra-interventional complications occurred. In six patients post-interventional complications were observed - two major (one abscess formation and one severe catheter dislocation) and four minor complications. Technical failure was observed in 11.4% of patients, especially catheter kinking. A total of 55 catheters were placed, with a mean number of 1.7 ± 0.7 per patient. Mean total DLP was 723.2 ± 355.9 mGy*cm. CONCLUSION: CT fluoroscopy-guided closed-tip catheter placement into high-risk soft tissue sarcomas was characterised by high technical success and relatively low complication rate. While major complications were rarely observed, catheter-kinking preventing successful thermometry represented the most frequent technical failure.

Pilot randomized trial of selective internal radiation therapy vs. chemoembolization in unresectable hepatocellular carcinoma.

BACKGROUND & AIMS: To compare selective internal radiation therapy (SIRT) with transarterial chemoembolization (TACE), the standard-of-care for intermediate-stage unresectable, hepatocellular carcinoma (HCC), as first-line treatment. METHODS: SIRTACE was an open-label multicenter randomized-controlled pilot study, which prospectively compared primarily safety and health-related quality of life (HRQoL) changes following TACE and SIRT. Patients with unresectable HCC, Child-Pugh ≤B7, ECOG performance status ≤2 and ≤5 liver lesions (≤20 cm total maximum diameter) without extrahepatic spread were randomized to receive either TACE (at 6-weekly intervals until tumour enhancement was not observed on MRI or disease progression) or single-session SIRT (yttrium-90 resin microspheres). RESULTS: Twenty-eight patients with BCLC stage A (32.1%), B (46.4%) or C (21.4%) received either a mean of 3.4 (median 2) TACE interventions (N = 15) or single SIRT (N = 13). Both treatments were well tolerated. Despite SIRT patients having significantly worse physical functioning at baseline, at week-12, neither treatment had a significantly different impact on HRQoL as measured by Functional Assessment of Cancer Therapy-Hepatobiliary total or its subscales. Both TACE and SIRT were effective for the local control of liver tumours. Best overall response-rate (RECIST 1.0) of target lesions were 13.3% and 30.8%, disease control rates were 73.3% and 76.9% for TACE and SIRT, respectively. Two patients in each group were down-staged for liver transplantation (N = 3) or radiofrequency ablation (N = 1). CONCLUSIONS: Single-session SIRT appeared to be as safe and had a similar impact on HRQoL as multiple sessions of TACE, suggesting that SIRT might be an alternative option for patients eligible for TACE.

MRI predictors of clinical success in MR-guided focused ultrasound (MRgFUS) treatments of uterine fibroids: results from a single centre.

OBJECTIVES: To assess the technical and clinical results of MRgFUS treatment and factors affecting clinical treatment success. MATERIALS AND METHODS: A total of 252 women (mean age, 42.1 ± 6.9 years) with uterine fibroids underwent MRgFUS. All patients underwent MRI before treatment. Results were evaluated with respect to post-treatment nonperfused volume (NPV), symptom severity score (SSS), reintervention rate, pregnancy and safety data. RESULTS: NPV ratio was significantly higher in fibroids characterized by low signal intensity in contrast-enhanced T1-weighted fat saturated MR images and in fibroids distant from the spine (>3 cm). NPV ratio was lower in fibroids with septations, with subserosal component and in skin-distant fibroids (p < 0.001). NPV ratio was highly correlated with clinical success: NPV of more than 80 % resulted in clinical success in more than 80 % of patients. Reintervention rate was 12.7 % (mean follow-up time, 19.4 ± 8 months; range, 3-38). Expulsion of fibroids (21 %) was significantly correlated with a high clinical success rate. No severe adverse events were reported. CONCLUSIONS: Adequate patient selection and correct treatment techniques, based on the learning curve of this technology, combined with technical advances of the system, lead to higher clinical success rates with low complications rate, comparable to other uterine-sparing treatment options. KEY POINTS: • MRgFUS appears to be a valid alternative to other uterus-preserving therapies • Patient selection is a significant factor in achieving high NPV ratios • MRI screening parameters correlate with the amount of fibroid ablation in MRgFUS • NPV results of more than 80 % correlate with higher clinical success rates.

CT fluoroscopy-guided percutaneous fiducial marker placement for CyberKnife stereotactic radiosurgery: technical results and complications in 222 consecutive procedures.

PURPOSE: To evaluate technical outcome and safety of computed tomographic (CT) fluoroscopy-guided percutaneous fiducial marker placement before CyberKnife stereotactic radiosurgery. MATERIALS AND METHODS: Retrospective analysis was performed of 196 patients (106 men) undergoing CT fluoroscopy-guided fiducial marker placement in 222 consecutive procedures under local anesthesia from March 2006 to February 2012. Technical success was defined as fiducial marker location in the tumor or vicinity suitable for CyberKnife radiosurgery evaluated on postinterventional planning CT. Complications were classified per Society of Interventional Radiology (SIR). RESULTS: One hundred ninety-six patients (age, 61.5 y ± 13.1) underwent percutaneous placement of 321 fiducial markers (mean per tumor, 1.2 ± 0.5; range, 1-4) in 37 primary tumors and 227 metastases in the thorax (n = 121), abdomen (n = 122), and bone (n = 21). Fiducial marker placement was technically successful in all procedures: intratumoral localization in 193 (60.1%), at tumor margin in 50 (15.6%), and outside of tumor in 78 cases (24.3%; mean distance to marker, 0.4 cm ± 0.6; range, 0-2.9 cm). Complications were observed in 63 placement procedures (28.4%), including minor self-limiting pneumothorax (n = 21; SIR class B) and self-limiting pulmonary hemorrhage (n = 35; SIR class A), and major pneumothorax requiring thoracostomy/drainage insertion (n = 14; SIR class D) and systemic toxicity of local anesthetic drug (n = 1; SIR class D). CONCLUSIONS: CT fluoroscopy-guided percutaneous fiducial marker placement can be performed with high technical success under local anesthesia in various anatomic regions. Although self-limiting in most cases, pneumothorax and pulmonary hemorrhage are frequently observed during fiducial marker implantation into lung tumors.

Technical and clinical outcome of percutaneous CT fluoroscopy-guided screw placement in unstable injuries of the posterior pelvic ring.

PURPOSE: To evaluate technical success, complications, and effective dose in patients undergoing CT fluoroscopy-guided iliosacral screw placement for the fixation of unstable posterior pelvic ring injuries. MATERIALS AND METHODS: Our retrospective analysis includes all consecutive patients with vertical sacral fractures and/or injury of the iliosacral joint treated with CT fluoroscopy-guided screw placement in our department from 11/2005 to 03/2013. Interventions were carried out under general anesthesia and CT fluoroscopy (10-20 mAs; 120 kV; 16- or 128-row scanner, Siemens Healthcare, Erlangen, Germany). Technical outcome, major and minor complications, and effective patient dose were analyzed. RESULTS: We treated 99 consecutive patients (mean age 53.1 ± 21.7 years, 50 male, 49 female) with posterior pelvic ring instability with CT fluoroscopy-guided screw placement. Intervention was technically successful in all patients (n = 99). No major and one minor local complication occurred (1 %, secondary screw dislocation). General complications included three cases of death (3 %) due to pulmonary embolism (n = 1), hemorrhagic shock (n = 1), or cardiac event (n = 1) during a follow-up period of 30 days. General complications were not related to the intervention. Mean effective patient radiation dose per intervention was 12.28 mSv ± 7.25 mSv. Mean procedural time was 72.1 ± 37.4 min. CONCLUSIONS: CT fluoroscopy-guided screw placement for the treatment of posterior pelvic ring instabilities can be performed with high technical success and a low complication rate. This method provides excellent intrainterventional visualization of iliac and sacral bones, as well as the sacral neuroforamina for precise screw placement by applying an acceptable effective patient dose.

Diagnostic value of protein S100b as predictor of traumatic intracranial haemorrhage in elderly adults with low-energy falls: results from a retrospective observational study.

PURPOSE: The objectives of this study were to analyse the clinical value of protein S100b (S100b) in association with clinical findings and anticoagulation therapy in predicting traumatic intracranial haemorrhage (tICH) and unfavourable outcomes in elderly individuals with low-energy falls (LEF). METHODS: We conducted a retrospective study in the emergency department (ED) of the LMU University Hospital, Munich by consecutively including all patients aged ≥ 65 years presenting to the ED following a LEF between September 2014 and December 2016 and receiving an emergency cranial computed tomography (cCT) examination. Primary endpoint was the prevalence of tICH. Multivariate logistic regression models and receiver operating characteristics were used to measure the association between clinical findings, anticoagulation therapy and S100b and tICH. RESULTS: We included 2687 patients, median age was 81 years (60.4% women). Prevalence of tICH was 6.7% (180/2687) and in-hospital mortality was 6.1% (11/180). Skull fractures were highly associated with tICH (odds ratio OR 46.3; 95% confidence interval CI 19.3-123.8, p < 0.001). Neither anticoagulation therapy nor S100b values were significantly associated with tICH (OR 1.14; 95% CI 0.71-1.86; OR 1.08; 95% CI 0.90-1.25, respectively). Sensitivity of S100b (cut-off: 0.1 ng/ml) was 91.6% (CI 95% 85.1-95.9), specificity was 17.8% (CI 95% 16-19.6), and the area under the curve value was 0.59 (95% CI 0.54 - 0.64) for predicting tICH. CONCLUSION: In conclusion, under real ED conditions, neither clinical findings nor protein S100b concentrations or presence of anticoagulation therapy was sufficient to decide with certainty whether a cCT scan can be bypassed in elderly patients with LEF. Further prospective validation is required.

Clinical outcome of rural in-hospital-stroke patients after interhospital transfer for endovascular therapy within a telemedical stroke network in Germany: a registry-based observational study.

OBJECTIVES: Little is known about in-hospital-stroke (IHS) patients with large vessel occlusion and subsequent transfer to referral centres for endovascular therapy (EVT). However, this subgroup is highly relevant given the substantial amount of IHS, the ongoing trend towards greater use of EVT and lack of EVT possibilities in rural hospitals. The study objective is to explore the clinical outcomes of this vulnerable patient group, given that both IHS and interhospital transfer are associated with worse clinical outcomes due to a higher proportion of pre-existing conditions and substantial time delays during transfer. DESIGN AND SETTING: Prospectively collected data of patients receiving EVT after interhospital transfer from 14 rural hospitals of the Telemedical Stroke Network in Southeast Bavaria (TEMPiS) between February 2018 and July 2020 was analysed. PARTICIPANTS: 49 IHS and 274 out-of-hospital-stroke (OHS) patients were included. OUTCOME MEASURES: Baseline characteristics, treatment times and outcomes were compared between IHS and OHS. The primary endpoint was a 3-month modified Rankin Scale (mRS). RESULTS: In IHS patients, atrial fibrillation (55.3% vs 35.9%, p=0.012), diabetes (36.2% vs 21.1%, p=0.024) and use of oral anticoagulants (44.7% vs 20.8%, p<0.001) were more frequent. Stroke severity was similar in both groups. Treatment times from symptom onset to first brain imaging, therapy decision or EVT were shorter for IHS patients. IHS patients displayed worse clinical outcomes: 59.2% of IHS patients died within 3 months compared with 28.5% of OHS patients (p<0.001). They were less likely to achieve moderate outcomes (mRS 0-3) 3 months after stroke (20.4% vs 39.8%, p=0.010). After controlling for possible confounding variables, IHS was associated with worse clinical outcomes (adjusted OR 3.04 (95% CI 1.57 to 6.04), p<0.001). CONCLUSIONS: The mortality of IHS patients after interhospital transfer and EVT was high and functional outcomes were worse compared with those of OHS patients. Further research is needed to ascertain whether IHS patients benefit from this therapeutic approach. A more careful selection of IHS patients for transfer and means to enable faster treatment should be considered. TRIAL REGISTRATION NUMBER: NCT04270513; Post-results.

Technical and Clinical Outcome of Low-Milliampere CT Fluoroscopy-Guided Percutaneous Drainage Placement in Abdominal Fluid Collections after Liver Transplantation: A 16-Year Retrospective Analysis of 50 Consecutive Patients.

PURPOSE: Evaluation of the effectiveness of CT-guided drainage (CTD) placement in managing symptomatic postoperative fluid collections in liver transplant patients. The assessment included technical success, clinical outcomes, and the occurrence of complications during the peri-interventional period. METHODS: Analysis spanned the years 2005 to 2020 and involved 91 drain placement sessions in 50 patients using percutaneous transabdominal or transhepatic access. Criteria for technical success (TS) included (a) achieving adequate drainage of the fluid collection and (b) the absence of peri-interventional complications necessitating minor or prolonged hospitalization. Clinical success (CS) was characterized by (a) a reduction or normalization of inflammatory blood parameters within 30 days after CTD placement and (b) the absence of a need for surgical revision within 60 days after the intervention. Inflammatory markers in terms of C-reactive protein (CRP), leukocyte count and interleukin-6, were evaluated. The dose length product (DLP) for various intervention steps was calculated. RESULTS: The TS rate was 93.4%. CS rates were 64.3% for CRP, 77.8% for leukocytes, and 54.5% for interleukin-6. Median time until successful decrease was 5.0 days for CRP and 3.0 days for leukocytes and interleukin-6. Surgical revision was not necessary in 94.0% of the cases. During the second half of the observation period, there was a trend (p = 0.328) towards a lower DLP for the entire intervention procedure (median: years 2013 to 2020: 623.0 mGy·cm vs. years 2005 to 2012: 811.5 mGy·cm). DLP for the CT fluoroscopy component was significantly (p = 0.001) lower in the later period (median: years 2013 to 2020: 31.0 mGy·cm vs. years 2005 to 2012: 80.5 mGy·cm). CONCLUSIONS: The TS rate of CT-guided drainage (CTD) placement was notably high. The CS rate ranged from fair to good. The reduction in radiation exposure over time can be attributed to advancements in CT technology and the growing expertise of interventional radiologists.

Percutaneous radiofrequency ablation (RFA) or robotic radiosurgery (RRS) for salvage treatment of colorectal liver metastases.

BACKGROUND: Stereotactic radiation therapy is an evolving modality to treat otherwise unresectable liver metastases. In this analysis, two local therapies: 1) single session robotic radiosurgery (RRS) and 2) percutaneous radiofrequency ablation (RFA) were compared in a total of 60 heavily pretreated colorectal cancer patients. METHODS: Thirty patients with a total of 35 colorectal liver metastases not qualifying for surgery that were treated in curative intent with RRS were prospectively followed. To compare efficacy of both treatment modalities, patients treated with RFA during the same period of time were matched according to number and size of the treated lesions. Local tumor control, local disease free survival (DFS), and freedom from distant recurrence (FFDR) were analyzed for efficacy. Treatment-related side effects were recorded for comparison. RESULTS: The median diameter of the treated lesions was 33 mm (7-53 mm). Baseline characteristics did not differ significantly between the groups. One- and two-year local control rates showed no significant difference but favored RRS (85% vs. 65% and 80% vs. 61%, respectively). A significantly longer local DFS of patients treated with RRS compared to RFA (34.4 months vs. 6.0 months; p < 0.001) was found. Both, median FFDR (11.4 months for RRS vs. 7.1 months for RFA p = 0.25) and the recurrence rate (67% for RRS and 63% for RFA, p > 0.99) were comparable. CONCLUSION: Single session RRS is a safe and effective method to treat colorectal liver metastases. In this analysis, a trend towards longer DFS was seen in patients treated with RRS when compared to RFA.

CT fluoroscopy guided percutaneous gastrostomy or jejunostomy without (CT-PG/PJ) or with simultaneous endoscopy (CT-PEG/PEJ) in otherwise untreatable patients.

PURPOSE: Percutaneous endoscopic gastrostomy (PEG) or percutaneous endoscopic jejunostomy (PEJ) are substantial for patients with swallowing disorders to maintain enteral nutrition or to decompress palliatively intractable small bowel obstruction. Endoscopic placement can be impossible due to previous (gastric) operation, obesity, hepato-splenomegaly, peritoneal carcinosis, inadequate transillumination, or obstructed passage. Computed tomography (CT)-fluoroscopic guidance with or without endoscopy can enable placement of CT-PG/CT-PJ or CT-PEG/CT-PEJ if endoscopically guided placement fails. In this retrospective study, we will evaluate the feasibility and safety of this method. METHODS: A total of 101 consecutive patients were referred to our department for feeding support (n = 87) or decompression (n = 14). Reasons were: ENT tumor (n = 51), esophageal cancer (n = 19), mediastinal mass (n = 2), neurological disorder (n = 15). Decompression tubes were placed because of cancer (n = 13) or Crohn's disease (n = 1). The following approaches were chosen: CT fluoroscopy and simultaneous gastroscopy (n = 61), inflation of the stomach via nasogastric tube (n = 29), and direct puncture under CT-fluoroscopic guidance (n = 11). RESULTS: CT fluoroscopy-guided gastrostomy was feasible in 89 of 101 patients. No procedure-related mortality was observed. One tube was misplaced into the colon in a patient with a history of gastrectomy. No complication was seen after removal. Minor complications: dislodgement (n = 17), peristomal leakage (n = 7), wound infection (n = 1), superficial skin infection (n = 6), tube obstruction (n = 2). CONCLUSIONS: CT fluoroscopy-guided PG/PJ or PEG/PEJ is feasible and safe and provides adequate feeding support or decompression. It offers the benefits of minimally invasive therapy even in patients with contraindications to established endoscopic methods, combining the advantages of both techniques. Long-term complications-mainly tube-related problems-are easily treated.

CT fluoroscopy-guided vertebral augmentation with a radiofrequency-induced, high-viscosity bone cement (StabiliT(®)): technical results and polymethylmethacrylate leakages in 25 patients.

OBJECTIVE: To assess the technical results of CT fluoroscopy-guided, radiofrequency-induced vertebral augmentation (StabiliT®) in terms of vertebral height restoration and polymethylmethacrylate (PMMA) leakages, occurring in 25 individual patients with vertebral compression fractures and osteolysis. MATERIALS AND METHODS: From 07/2010 to 08/2011, 25 patients (16 women, nine men; age 71 ± 14; range 41-89) with painful vertebral compression fractures due to osteoporosis (n = 19), metastases (n = 2) or multiple myeloma (n = 4) underwent vertebral augmentation with a radiofrequency-activated, high-viscosity polymethylmethacrylate (PMMA) bone cement (StabiliT® Vertebral Augmentation system; DFINE Europe GmbH, Mannheim) under local anesthesia. Thirty-four vertebrae (Th5-L5) were treated in 27 sessions under CT fluoroscopy guidance (128-row CT, Somatom Definition AS, Siemens, Erlangen) using a unilateral access and a cavity-creating osteotome prior to remote-controlled, hydraulically driven cement injection. 1/2/3 levels were treated in 21/5/1 session(s). Vertebral height change in the midsagittal plane (anterior, midvertebral, posterior endplate distance) and PMMA leaks were retrospectively evaluated using the postinterventional CT. RESULTS: All patients were successfully treated in the first session. Mean (MV ± SD) procedure time and amount of injected PMMA were 56 ± 14 min and 4.5 ± 1.4 ml, respectively. Mean anterior/midvertebral/posterior height gain was +7.1/+9.7/+0.4%. Small local vertebral leaks were observed in 18/34 vertebrae (53%) without any clinical sequelae. No major complications occurred. CONCLUSIONS: CT fluoroscopy-guided, RF-induced vertebral augmentation with a high-viscosity bone cement (StabiliT®) was safe and technically successful in all patients. Using a hydraulic cement injection technique, a moderate restoration of anterior and midvertebral height was seen while the system was not markedly superior to standard vertebroplasty regarding the frequency of minor asymptomatic PMMA leaks.

Radiation Dose and Fluoroscopy Time of Extracranial Carotid Artery Stenting : Elective vs. Emergency Treatment Including Combined Mechanical Thrombectomy in Tandem Occlusion.

PURPOSE: Fluoroscopically guided endovascular carotid artery stenting (CAS) of extracranial carotid stenosis (ECS) is a reasonable alternative to carotid endarterectomy in selected patients. Diagnostic reference levels (DRL) for this common neurointervention have not yet been defined and respective literature data are sparse. We provide detailed dosimetrics for useful expansion of the DRL catalogue. METHODS: A retrospective single-center study of patients undergoing CAS between 2013 and 2021. We analyzed dose area product (DAP) and fluoroscopy time considering the following parameters: indications for CAS, semielective/elective versus emergency including additional mechanical thrombectomy (MT) in extracranial/intracranial tandem occlusion, etiology of ECS (atherosclerotic vs. radiation-induced), periprocedural features, e.g., number of applied stents, percutaneous transluminal angioplasty (PTA) and MT maneuvers, and dose protocol. Local DRL was defined as 75% percentile of the DAP distribution. RESULTS: A total of 102 patients were included (semielective/elective CAS n = 75, emergency CAS n = 8, CAS + MT n = 19). Total median DAP was 78.2 Gy cm2 (DRL 117 Gy cm2). Lowest and highest median dosimetry values were documented for semielective/elective CAS and CAS + MT (DAP 49.1 vs. 146.8 Gy cm2, fluoroscopy time 27.1 vs. 43.8 min; p < 0.005), respectively. Dosimetrics were significantly lower in patients undergoing 0-1 PTA maneuvers compared to ≥ 2 maneuvers (p < 0.05). Etiology of ECS, number of stents and MT maneuvers had no significant impact on dosimetry values (p > 0.05). A low-dose protocol yielded a 33% reduction of DAP. CONCLUSION: This CAS study suggests novel local DRLs for both elective and emergency cases with or without intracranial MT. A dedicated low-dose protocol was suitable for substantial reduction of radiation dose.

Accuracy, Hemorrhagic Complications and CT Radiation Dose of Emergency External Ventricular Drain (EVD) Placement in Pediatric Patients: A 15-Year Retrospective Analysis.

PURPOSE: To assess accuracy, the frequency of hemorrhagic complications and computed tomography (CT) radiation dose parameters in pediatric patients undergoing landmark-guided external ventricular drain (EVD) placement in an emergency setting. METHODS: Retrospective analysis comprised 36 EVD placements with subsequent CT control scans in 29 patients (aged 0 to 17 years) in our university hospital from 2008 to 2022. The position of the EVD as well as the presence and extension of bleeding were classified according to previously established grading schemes. Dose length product (DLP), volume-weighted CT dose index (CTDIvol) and scan length were extracted from the radiation dose reports and compared to the diagnostic reference values (DRLs) issued by the German Federal Office for Radiation Protection. RESULTS: After the initial EVD placement, optimal positioning of the catheter tip into the ipsilateral frontal horn or third ventricle (Grade I), or a functional positioning in the contralateral lateral ventricle or the non-eloquent cortex (Grade II), was achieved in 28 and 8 cases, respectively. In 32 of 36 procedures, no evidence of hemorrhage was present in the control CT scan. Grade 1 (<1 mL) and Grade 2 (≥1 to 15 mL) bleedings were detected after 3 and 1 placement(s), respectively. For control scans after EVD placements, CTDIvol (median [25%; 75% quartile]) was 39.92 [30.80; 45.55] mGy, DLP yielded 475.50 [375.00; 624.75] mGy*cm and the scan length result was 136 [120; 166] mm. Exceedances of the DRL values were observed in 14.5% for CTDIvol, 12.7% for DLP and 65.6% for the scan length. None of these values was in the range requiring a report to the national authorities. CONCLUSION: Landmark-based emergency EVD placement in pediatric patients yielded an optimal position in most cases already after the initial insertion. Complications in terms of secondary hemorrhages are rare. CT dose levels associated with the intervention are below the reportable threshold of the national DRLs in Germany.

Periprocedural unfractionated heparin bolus during endovascular treatment in acute ischemic stroke does more harm than good.

BACKGROUND: Unfractionated heparin (UFH) bolus is occasionally administered during endovascular treatment (EVT) to reduce thrombotic complications in acute ischemic stroke patients. However, the MR CLEAN-MED trial showed an increase in symptomatic intracranial hemorrhages (sICH) and a non-significant shift towards worse functional outcome with UFH administration. We aimed to analyze the impact of periprocedural UFH bolus in a real-world setting in anterior (ACS) and posterior circulation stroke (PCS) patients. METHODS: We analyzed data from the German Stroke Registry-Endovascular Treatment using propensity score matching. Primary outcome was the modified Rankin Scale at 3 months, and secondary outcome measures included mortality, angiographic outcomes, post-EVT National Institute of Health Stroke Scale scores and ICH at 24 hours. RESULTS: Among 13,082 patients, 7948 with ACS (UFH bolus use in 15%) and 841 with PCS (UFH bolus use in 16.3%) were included in the propensity score matching analysis. Applying MR CLEAN-MED study criteria, UFH bolus was associated with worse functional outcomes (odds ratio [OR] 1.44; 95% CI 1.06-1.96). Analyzing all ACS and PCS patients, UFH bolus did not provide any net benefit. In ACS patients treated with intravenous thrombolysis (IVT), UFH bolus use was associated with worse functional outcomes (OR 2.40; 95% CI 1.34 to 5.06). CONCLUSION: Our findings show transferability of the MR CLEAN-MED results into a real-world setting, confirming a negative effect of periprocedural UFH on functional outcome in this subgroup of patients. Considering all ACS and PCS patients, periprocedural UFH did not provide a net benefit and appears to be harmful, particularly in IVT-treated patients.