Blood-Brain Barrier Disruption (BBBD)-Based Immunochemotherapy for Primary Central Nervous System Lymphoma (PCNSL), Early Results of a Phase II Study.

Primary central nervous system lymphoma is a rare but aggressive brain malignancy. It is associated with poor prognosis even with the current standard of care. The aim of this study was to evaluate the effect and tolerability of blood-brain barrier disruption treatment combined with high-dose treatment with autologous stem cell transplantation as consolidation on primary central nervous system lymphoma patients. We performed a prospective phase II study for 25 patients with previously untreated primary central nervous system lymphoma. The blood-brain barrier disruption treatment was initiated 3-4 weeks after the MATRix regimen using the previously optimized therapy protocol. Briefly, each chemotherapy cycle included two subsequent intra-arterial blood-brain barrier disruption treatments on days 1 and 2 via either one of the internal carotid arteries or vertebral arteries. Patients received the therapy in 3-week intervals. The treatment was continued for two more courses after achieving a maximal radiological response to the maximum of six courses. The complete treatment response was observed in 88.0% of the patients. At the median follow-up time of 30 months, median progression-free and overall survivals were not reached. The 2-year overall and progression-free survival rates were 67.1% and 70.3%, respectively. Blood-brain barrier disruption treatment is a promising option for primary central nervous system lymphoma with an acceptable toxicity profile.

Long-term mortality after endovascular thrombectomy for stroke.

OBJECTIVES: Endovascular thrombectomy (EVT) has become the standard treatment for large vessel occlusion (LVO) in acute ischemic stroke. Stroke trials typically report clinical outcome at the three-month time point but there is a lack of studies focusing on the long-term outcome after EVT. The aim of this study is to assess the long-term mortality after EVT for stroke and to determine the factors that are associated with mortality. METHODS: Retrospective single-center analysis of 323 patients who underwent EVT for stroke between the years 2015-2019 and survived at least 30 days. Patients were followed up until the end of the year 2020. Cox regression analysis was used to identify the factors associated with mortality. RESULTS: A total of 53 (16.4%) of the 30-day survivors died during the follow-up. According to the Cox regression analysis, mortality was associated with functional dependence (modified Rankin Scale (mRS) >2, HR 2.7 (95% CI 1.2-5.9), p=0.013), comorbidity (Charlson Comorbidity Index (CCI) ≥3, HR 2.7 (95% CI 1.4-5.5), p=0.004), stroke severity at baseline (National Institutes of Health Stroke Scale (NIHSS) >8, HR 1.9 (95% CI 1.1-3.3), p=0.026), and medical complications (HR 2.4 (95% CI 1.2-4.8), p=0.011). Procedural variables did not have an impact on mortality. CONCLUSIONS: Functional dependence, stroke severity, comorbidity, and medical complications during the hospital stay were associated with the long-term mortality after EVT for stroke.

Physiological instability is linked to mortality in primary central nervous system lymphoma: A case-control fMRI study.

Primary central nervous system lymphoma (PCNSL) is an aggressive brain disease where lymphocytes invade along perivascular spaces of arteries and veins. The invasion markedly changes (peri)vascular structures but its effect on physiological brain pulsations has not been previously studied. Using physiological magnetic resonance encephalography (MREGBOLD ) scanning, this study aims to quantify the extent to which (peri)vascular PCNSL involvement alters the stability of physiological brain pulsations mediated by cerebral vasculature. Clinical implications and relevance were explored. In this study, 21 PCNSL patients (median 67y; 38% females) and 30 healthy age-matched controls (median 63y; 73% females) were scanned for MREGBOLD signal during 2018-2021. Motion effects were removed. Voxel-by-voxel Coefficient of Variation (CV) maps of MREGBOLD signal was calculated to examine the stability of physiological brain pulsations. Group-level differences in CV were examined using nonparametric covariate-adjusted tests. Subject-level CV alterations were examined against control population Z-score maps wherein clusters of increased CV values were detected. Spatial distributions of clusters and findings from routine clinical neuroimaging were compared [contrast-enhanced, diffusion-weighted, fluid-attenuated inversion recovery (FLAIR) data]. Whole-brain mean CV was linked to short-term mortality with 100% sensitivity and 100% specificity, as all deceased patients revealed higher values (n = 5, median 0.055) than surviving patients (n = 16, median 0.028) (p < .0001). After adjusting for medication, head motion, and age, patients revealed higher CV values (group median 0.035) than healthy controls (group median 0.024) around arterial territories (p ≤ .001). Abnormal clusters (median 1.10 × 105 mm3 ) extended spatially beyond FLAIR lesions (median 0.62 × 105 mm3 ) with differences in volumes (p = .0055).

Finnish flow diverter study: 8 years of experience in the treatment of acutely ruptured intracranial aneurysms.

BACKGROUND: Flow diversion of acutely ruptured intracranial aneurysms (IAs) is controversial due to high treatment-related complication rates and a lack of supporting evidence. We present clinical and radiological results of the largest series to date. METHODS: This is a nationwide retrospective study of acutely ruptured IAs treated with flow diverters (FDs). The primary outcome was the modified Rankin Scale (mRS) score at the last available follow-up time. Secondary outcomes were treatment-related complications and the aneurysm occlusion rate. RESULTS: 110 patients (64 females; mean age 55.7 years; range 12-82 years) with acutely ruptured IAs were treated with FDs between 2012 and 2020 in five centers. 70 acutely ruptured IAs (64%) were located in anterior circulation, and 47 acutely ruptured IAs (43%) were blister-like. A favorable functional outcome (mRS 0-2) was seen in 73% of patients (74/102). Treatment-related complications were seen in 45% of patients (n=49). Rebleeding was observed in 3 patients (3%). The data from radiological follow-ups were available for 80% of patients (n=88), and complete occlusion was seen in 90% of aneurysms (79/88). The data from clinical follow-ups were available for 93% of patients (n=102). The overall mortality rate was 18% (18/102). CONCLUSIONS: FD treatment yields high occlusion for acutely ruptured IAs but is associated with a high risk of complications. Considering the high mortality rate of aneurysmal subarachnoid hemorrhage, the prevention of rebleeding is crucial. Thus, FD treatment may be justified as a last resort option.

Medical complications and outcome after endovascular therapy for acute ischemic stroke.

AIM: Endovascular therapy (EVT) in acute stroke is an effective but invasive treatment which is frequently followed by various complications. The aim of the present study was to examine the rate of medical complications and other adverse events following EVT. METHODS: Retrospective single-center study of 380 consecutive stroke patients who received EVT between the years 2015-2019. RESULTS: A total of 234 (61.6%) patients had at least one recorded medical complication. The most common complication was pneumonia in 154 (40.5%) patients, followed by acute cardiac insufficiency in 134 (35.3%), and myocardial infarction in 22 (5.8%) patients. In multivariate analysis, the need for general anesthesia (OR 3.8 (1.9-7.7)), Charlson Comorbidity Index >3 (OR 1.3 (1.1-1.5)), male gender (1.9 (1.1-1.3)) and high National Institutes of Health Stroke Scale (NIHSS) score at admission (1.1 (1.0-1.2)) were associated with medical complications. CONCLUSION: Medical complications are common among unselected stroke patients undergoing EVT. Both comorbidity and stroke severity have an influence on medical complications. Early recognition of complications is essential, because vast majority of patients encountering medical complications have a poor short-term outcome.

Drip-and-ship stroke thrombolysis in the emergency department of a healthcare center - a possibility for those fallen ill in rural settings.

Thrombolysis with tissue plasminogen activator is the mainstay in the treatment of acute stroke. Reducing the delay of thrombolysis treatment improves patient prognosis and reduces the incidence of complications. Variable telestroke regimens have improved the availability of stroke thrombolysis, especially in rural settings, where neurologists are not readily available. In the drip-and-ship strategy, stroke thrombolysis is initiated in a peripheral hospital and the patient is then transferred to a tertiary care unit. We report the first case of drip-and-ship stroke thrombolysis in a rural health care center in Northeastern Finland.

Early rebleeding after coiling of ruptured intracranial aneurysms.

BACKGROUND: Early rebleeding after coiling of a ruptured intracranial aneurysm (IA) may cause disability or death. The incidence and predictors of early rebleeding have previously been sparsely investigated. PURPOSE: To assess the incidence and risk factors of early rebleeding after coiling of a ruptured IA and to analyze the outcome of the patients suffering early rehemorrhage. MATERIAL AND METHODS: The data of 194 consecutive acutely (within 3 days) coiled patients with saccular ruptured IAs were analyzed. Age, gender, hypertension, aneurysm multiplicity, Hunt et Hess (HH) grade, intracerebral hematoma (ICH), intraventricular hematoma (IVH), external ventricular drainage (EVD), aneurysm location and size, and the grade of the initial aneurysm occlusion were tested to find the risk factors for early rebleeding. The outcome of the patients suffering rehemorrhage was verified. RESULTS: Early rebleeding after coiling occurred in 7 patients out of 194 (3.6%). The presence of an ICH at admission and HH grade 3­5 before coiling were significant risk factors for rebleeding. An early rehemorrhage appeared as an enlargement of the initial ICH in all of these patients. Six of seven patients had good outcome (Glasgow Outcome Scale, GOS, 3­5). Logistic regression analysis did not find any other statistically significant risk factors. CONCLUSION: The incidence of early rebleeding after acutely coiled ruptured IA was 3.6%. Risk factors for post-procedural rehemorrhage were the presence of ICH on the initial CT and HH grade 3­5 before coiling. Early rebleeding appeared exclusively as an enlargement of the initial ICH and not an increased amount of blood in the subarachnoid space.

Endovascular embolization of spontaneous retroperitoneal hemorrhage secondary to anticoagulant treatment.

The purpose of this study was to report a single hospital's experience of endovascular treatment of patients with retroperitoneal hemorrhage (RPH) secondary to anticoagulant treatment. Ten consecutive patients treated in an intensive care unit and needing blood transfusions due to RPH secondary to anticoagulation were referred for digital subtraction angiography (DSA) to detect the bleeding site(s) and to evaluate the possibilities of treating them by transcatheter embolization. DSA revealed bleeding site(s) in all 10 patients: 1 lumbar artery in 4 patients, 1 branch of internal iliac artery in 3 patients and multiple bleeding sites in 3 patients. Embolization could be performed in 9 of them. Coils, gelatin and/or polyvinyl alcohol were used as embolic agents. Bleeding stopped or markedly decreased after embolization in 8 of the 9 (89%) patients. Four patients were operated on prior to embolization, but surgery failed to control the bleeding in any of these cases. Abdominal compartment syndrome requiring surgical or radiological intervention after embolization developed in 5 patients. One patient died, and 2 had sequelae due to RPH. All 7 patients whose bleeding stopped after embolization had a good clinical outcome. Embolization seems to be an effective and safe method to control the bleeding in patients with RPH secondary to anticoagulant treatment when conservative treatment is insufficient.

Accuracy of computer-aided measurements in endovascular stent-graft planning: an experimental study with two phantoms.

RATIONALE AND OBJECTIVES: The aim of this study was to evaluate the accuracy of the new measurement software, created for aortic stent-graft planning. The software finds semiautomatically the centerline of the vessel from computer tomographic angiography data and calculates semiautomatically diameters and lengths. MATERIALS AND METHODS: Two phantoms were constructed, scanned by CT and measured with the measurement software. Results were compared with the known dimensions of the phantoms and mean fractional errors were calculated. Linear regression analysis was also made between measured and known diameters. RESULTS: The mean fractional error (+/- SD) for all diameter measurements combined was 0.017 +/- 0.011. In the linear regression analysis, was 1.000. For length measurements, the mean fractional error (+/- SD) was 0.009 +/- 0.0006. CONCLUSIONS: The software enables accurate measurements perpendicular or parallel to the semiautomatically created centerline path.