Multivessel Occlusion in Patients Subjected to Thrombectomy: Prevalence, Associated Factors, and Clinical Implications.

BACKGROUND AND PURPOSE: Patients with embolic large-vessel occlusion may present with additional coincidental acute occlusions within or distant from the involved territory, referred to as multivessel occlusion (MVO). Purpose of this study was to assess prevalence of MVO, associated factors, and clinical relevance in patients undergoing endovascular stroke treatment. METHODS: Image data of consecutive endovascular candidates (n=720) with direct access to angiography were extracted from a prospective registry. Prevalence of MVO was assessed with multimodal magnetic resonance imaging/computed tomography and confirmed by intra-arterial angiography. Explorative analysis of associated factors and clinical relevance was evaluated using multivariable logistic regression including variables with P<0.15 in univariate comparison. Good functional outcome was defined as modified Rankin Scale score ≤2 at day 90. RESULTS: MVO was present in 10.7% of patients (95% confidence interval [CI], 6.4%-13.0%). Two, 3, and 4 concomitant occlusions were found in 80.5%, 16.9%, and 2.6% of MVO cases, respectively. Detection rate on initial radiological report was 54.5%. Downstream MVO was present in around one third of MVO (n=27/77, 35.1%), whereas all other MVO (n=50/77, 64.9%) occurred in different territories. Independent factors related to MVO were statin treatment (adjusted odds ratio [aOR], 0.477; 95% CI, 0.276-0.827), higher systolic blood pressure (aOR per mm Hg increase, 1.014; 95% CI, 1.005-1.023), and primary occlusion site M2 (aOR, 1.870; 95% CI, 1.103-3.170). MVO was related to lower rates of successful reperfusion (aOR, 0.549; 95% CI, 0.316-0.953) and lower rates of good functional outcome (aOR, 0.437; 95% CI, 0.207-0.923). CONCLUSIONS: Every tenth patient subjected to angiography for endovascular stroke treatment experienced MVO in our series, and only half were prospectively identified on preinterventional diagnostic imaging. Patients with MVO had higher baseline systolic blood pressure and were less often medicated with statins, an observation that warrants external validation and evaluation regarding causality. Occurrence of MVO has implication for treatment decisions, negatively affects endovascular treatment success, and is predictive of worse clinical outcome.

Rates and Quality of Preinterventional Reperfusion in Patients With Direct Access to Endovascular Treatment.

Background and Purpose- Preinterventional reperfusion before endovascular treatment (ET) is a benefit of bridging with intravenous tPA (tissue-type plasminogen activator). However, detailed data on reperfusion quality and rates of obviating ET in a cohort of patients with immediate access to ET is lacking. Purpose of this analysis was to evaluate prevalence and quality of preinterventional reperfusion in mothership patients. Methods- All mothership patients (n=627) from a prospective registry subjected to angiography with an intention to perform ET were reviewed. Preinterventional change of occlusion site (COS) was categorized into COS with Thrombolysis in Cerebral Infarction (TICI) 0/1, COS with TICI ≥2a, COS with TICI ≥2b, and COS with perfusion worsening. Predictors and clinical relevance were evaluated using multivariable logistic regression and results are displayed as adjusted odds ratios (aOR) and corresponding 95% confidence intervals (95% CI). Results- Prevalence of COS in all patients was 10.7% (95% CI, 8.3%-13.1%), subdividing into 2.7% COS with TICI 0/1, 6.2% COS with ≥TICI 2a (including 2.9% with TICI ≥2b), and 1.8% COS with perfusion worsening. Factors related to COS with ≥TICI 2a were intravenous tPA (aOR, 11.98; 95% CI, 4.5-31.6), cardiogenic thrombus origin (aOR, 2.3; 95% CI, 1.1-4.6), and thrombus length (aOR per 1 mm increase 0.926; 95% CI, 0.87-0.99). Additional ET was performed despite COS with ≥TICI 2a in 51.3%. COS with ≥TICI 2a showed a tendency for favorable outcomes (modified Rankin Scale, ≤2; aOR, 2.65; 95% CI, 0.98-7.17). Rates of COS with ≥TICI 2a were particularly low in internal carotid artery and proximal M1 occlusions (2.2%; 95% CI, 0.9%-5%), where intravenous tPA was associated with perfusion worsening (aOR, 4.33; 95% CI, 1.12-16.80). Conclusions- Prevalence of preinterventional reperfusion is non-negligible in patients with direct access to ET and is clearly favored by intravenous tPA treatment. However, it is often incomplete and often requires additional ET. Preinterventional reperfusion of internal carotid artery and proximal M1 occlusions is rare and usually of low quality, where intravenous tPA may also promote perfusion worsening.

Predictors of Unexpected Early Reocclusion After Successful Mechanical Thrombectomy in Acute Ischemic Stroke Patients.

Background and Purpose- Sustained successful reperfusion is an important prognostic factor for good clinical outcome in acute ischemic stroke. We aimed to identify the prevalence, clinical impact, and predictors of early reocclusion after initially successful thrombectomies within a prospective cohort. Methods- A total of 711 stroke patients with successful reperfusion (modified Thrombolysis in Cerebral Infarction, 2b/3) followed with magnetic resonance or computed tomographic angiography at 24 to 48 hours were included. Multivariable logistic regression analysis was used to evaluate associated factors and clinical impact. Results are displayed as adjusted odds ratio (aOR) and 95% CI. Improvement in accuracy of additional imaging findings on angiography control runs after the intervention was evaluated by area under the curve. Results- Early reocclusion was observed in 16 of 711 successfully reperfused patients (2.3%; 95% CI, 1.1-3.3; median delay: 20 hours). Suggestive predictors were higher platelets on admission (aOR, 1.01; 95% CI, 1.01-1.02), prestroke functional dependence (aOR, 7.12; 95% CI, 1.49-34.03), and stroke of undetermined or other specified pathogenesis in the TOAST classification (aOR, 7.19; 95% CI, 1.10-47.05 and aOR, 36.50; 95% CI, 4.47-298.11, respectively). When implementing residual embolic fragments or stenosis at the thrombectomy site into the logistic regression model, discrimination between patients with and without reocclusion improved significantly (area under the curve, 0.955 versus 0.854; P=0.023). Early reocclusion was an independent predictor of unfavorable outcome at 90 days (aOR for modified Rankin Scale ≤2, 0.13; 95% CI, 0.03-0.57). Conclusions- Early reocclusion within 48 hours after successful mechanical thrombectomy is rare but associated with poor outcome. Patients with high platelets on admission and residual embolic fragments or stenosis at the thrombectomy site are at high risk for reocclusion, which may be prevented or corrected after carefully re-evaluating the last angiographic run.

Cryptogenic Cerebrospinal Fluid Leaks in Spontaneous Intracranial Hypotension: Role of Dynamic CT Myelography.

Purpose To propose a modified dynamic CT myelographic technique to locate cerebrospinal fluid (CSF) leaks, also known as cryptogenic leaks, in patients with spontaneous intracranial hypotension (SIH) in whom previous imaging did not show the dural breach. Materials and Methods This retrospective analysis included 74 consecutive patients with SIH and a myelographically proven CSF leak who were evaluated between February 2013 and October 2017. In 14 patients, dynamic CT myelography in the prone or lateral position showed the exact leakage point after unsuccessful previous imaging. During image analysis, the first time point showing extrathecal contrast material was defined as the site of dural breach point. Results Mean population age was 44 years (range, 25-65 years [nine women; mean age, 44 years; age range, 25-65 years] [five men; mean age, 46 years; age range, 29-61 years]). All patients had previously undergone spine MRI, conventional dynamic myelography, and CT myelography. Subsequent dynamic CT myelography covered a mean range of seven vertebral levels. The leak was caused by a calcified microspur in 10 patients and by a dural tear at the axilla of a spinal nerve root in the remaining four. The mean volume CT dose index of dynamic CT myelography was 107 mGy (range, 12-246 mGy), and the mean dose-length product was 1347 mGy·cm (range, 550-3750 mGy·cm). Conclusion Dynamic CT myelography is a valuable adjunctive tool with which to identify the precise location of a dural tear when other examinations are unsuccessful. © RSNA, 2018 See also the editorial by Dillon in this issue.

Improving mTICI2b reperfusion to mTICI2c/3 reperfusions: A retrospective observational study assessing technical feasibility, safety and clinical efficacy.

BACKGROUND: Recent studies suggested that modified Thrombolysis in Cerebral Infarction grade (mTICI) 3 reperfusions are associated with superior outcome to mTICI2b reperfusions, questioning if neurointerventionalists should generally strive to achieve mTICI3. METHODS: Retrospective analysis of successfully reperfused MCA occlusions (n=246) with available angiography runs between every manoeuvre was performed. Final reperfusion success and those between all single manoeuvres were evaluated applying the modified version of the TICI score (including TICI2c). Final TICI2c/3 reperfusions were dichotomized as 'direct' (reperfusion before final manoeuvre ≤mTICI2a) or 'secondary improved' (mTICI2b was achieved). RESULTS: Patients with mTICI2c reperfusion had similar outcome to patients with mTICI3 rather than mTICI2b reperfusions. Compared with mTICI2c/3-patients, mTICI2b-patients had lower rates of neurological improvement (33.3% vs. 61.2%, p<0.001) and good functional outcome (28.7% vs. 46.5%, p=0.008). In 28 patients, mTICI2b reperfusion was improved to mTICI2c/3 without complications. Outcome of patients with 'direct' or 'secondary improved' mTICI2c/3 did not differ (p>0.5). CONCLUSION: Improving mTICI2b reperfusions to mTICI2c/3 reperfusions is sometimes technically feasible and safe, and associated with clinical benefit comparable to 'direct' mTICI2c/3 reperfusions. If confirmed, a more aggressive treatment approach in cases of already achieved mTICI2b may be justified, although proper patient selection is needed. KEY POINTS: • Patients with mTICI2c or 3 reperfusions have a comparable clinical course. • mTICI2c/3 are associated with a larger therapeutic benefit than are mTICI2b reperfusions. • Improving reperfusion from mTICI2b to mTICI2c/3 is sometimes feasible and reasonably safe. • Outcome of patients with 'secondary improved' and 'direct' mTICI2c/3 is not different.

L5 corpectomy-the lumbosacral segmental geometry and clinical outcome-a consecutive series of 14 patients and review of the literature.

PURPOSE: We analyzed the lumbosacral segmental geometry and clinical outcome in patients undergoing L5 corpectomy. METHODS: Fourteen consecutive patients who underwent L5 (n = 12) or L4 + 5 (n = 2) corpectomy at our department between January 2010 and April 2015 were included. All patients underwent a baseline physical and neurologic examination on admission. The diagnostic routine included MRI and CT scans and, if possible, an upright X-ray of the lumbar spine before and after surgery. The local lordosis angle [L4(L3)-S1] was measured. RESULTS: The most common pathology was infection (N = 7), followed by neoplastic disease (n = 3), pseudarthrosis (n = 2) after previous spinal fusion procedures and burst fractures (n = 2) of the L5 vertebral body. We observed seven complications (2 intraoperative; 5 postoperative) in five (36%) patients. Three patients needed revision surgery because of cage subsidence and/or dislodgement (21%). Additional anterior plating was used in two of the revision surgeries to secure the cage. Two spondylodiscitis patients (14%) with complications died of sepsis. Of the 12 remaining patients, 8 were available for follow-up. CONCLUSION: L5 corpectomy is a technically challenging but feasible procedure even though the overall complication rate can be as high as 36%. The radiologic and clinical outcome seems to be better in patients with a small lordosis angle between L4(L3) and S1, since an angle of >50 degrees seems to facilitate cage dislodgement. Anterior plating should be considered in these cases to prevent implant failure.

Imaging of the lumbar plexus: Optimized refocusing flip angle train design for 3D TSE.

PURPOSE: To study the effects of refocusing angle modulation with 3D turbo spin echo (TSE) on signal and sharpness of small oblique nerves embedded in muscle and suppressed fat in the lumbar plexus. MATERIALS AND METHODS: Flip angle trains were generated with extended phase graphs (EPG) for a sequence parameter subspace. Signal loss and width broadening were simulated for a single-pixel nerve embedded in muscle and suppressed fat to prescribe a flip angle modulation that gives the best compromise between signal and sharpness of small nerves. Two flip angle trains were defined based on the simulations of small embedded nerves: design denoted A, predicting maximum global signal, and design denoted B, predicting maximum signal for minimum width broadening. In vivo data of the lumbar plexus in 10 healthy volunteers was acquired at 3.0T with 3D TSE employing flip angle trains A and B. Quantitative and qualitative analyses of the acquired data were made to assess changes in width and signal intensity. RESULTS: Changing flip angle modulation from A to B resulted in: 1) average signal losses of 23% in (larger) L5 nerves and 9% in (smaller) L3 nerves; 2) average width reductions of 4% in L5 nerves and of 16% in L3 nerves; and 3) statistically significant sharpness improvement (P = 0.005) in L3 nerves. CONCLUSION: An optimized flip angle train in 3D TSE imaging of the lumbar plexus considering geometry-specific blurring effects from both the nerve and the surrounding tissue can improve the delineation of small nerves.

Heterogeneity of the Relative Benefits of TICI 2c/3 over TICI 2b50/2b67 : Are there Patients who are less Likely to Benefit?

PURPOSE: Incomplete reperfusion after mechanical thrombectomy (MT) is associated with a poor outcome. Rescue therapy would potentially benefit some patients with an expanded treatment in cerebral ischemia score (eTICI) 2b50/2b67 reperfusion but also harbors increased risks. The relative benefits of eTICI 2c/3 over eTICI 2b50/67 in clinically important subpopulations were analyzed. METHODS: Retrospective analysis of our institutional database for all patients with occlusion of the intracranial internal carotid artery (ICA) or the M1/M2 segment undergoing MT and final reperfusion of ≥eTICI 2b50 (903 patients). The heterogeneity in subgroups of different time metrics, age, National Institutes of Health Stroke Scale (NIHSS), number of retrieval attempts, Alberta Stroke Programme Early CT Score (ASPECTS) and site of occlusion using interaction terms (pi) was analyzed. RESULTS: The presence of eTICI 2c/3 was associated with better outcomes in most subgroups. Time metrics showed no interaction of eTICI 2c/3 over eTICI 2b50/2b67 and clinical outcomes (onset to reperfusion pi = 0.77, puncture to reperfusion pi = 0.65, onset to puncture pi = 0.63). An eTICI 2c/3 had less consistent association with mRS ≤2 in older patients (>82 years, pi = 0.038) and patients with either lower NIHSS (≤9) or very high NIHSS (>19, pi = 0.01). Regarding occlusion sites, the beneficial effect of eTICI 2c/3 was absent for occlusions in the M2 segments (aOR 0.73, 95% confidence interval [CI] 0.33-1.59, pi = 0.018). CONCLUSION: Beneficial effect of eTICI 2c/3 over eTICI 2b50/2b67 only decreased in older patients, M2-occlusions and patients with either low or very high NIHSS. Improving eTICI 2b50/2b67 to eTICI 2c/3 in those subgroups may be more often futile.

Association of reperfusion success and emboli in new territories with long term mortality after mechanical thrombectomy.

BACKGROUND: The degree of reperfusion is the most important modifiable predictor of 3 month functional outcome and mortality in ischemic stroke patients treated with mechanical thrombectomy. Whether the beneficial effect of reperfusion also leads to a reduction in long term mortality is unknown. METHODS: Patients undergoing mechanical thrombectomy between January 2010 and December 2018 were included. The post-thrombectomy degree of reperfusion and emboli in new territories were core laboratory adjudicated. Reperfusion was evaluated according to the expanded Thrombolysis in Cerebral Infarction (eTICI) scale. Vital status was obtained from the Swiss population register. Adjusted hazard ratios (aHRs) using time split Cox regression models were calculated. Subgroup analyses were performed in patients with borderline indications. RESULTS: Our study included 1264 patients (median follow-up per patient 2.5 years). Patients with successful reperfusion had longer survival times, attributable to a lower hazard of death within 0-90 days and for >90 days to 2 years (aHR 0.34, 95% CI 0.26 to 0.46; aHR 0.37, 95% CI 0.22 to 0.62). This association was homogeneous across all predefined subgroups (p for interaction >0.05). Among patients with successful reperfusion, a significant difference in the hazard of death was observed between eTICI2b50 and eTICI3 (aHR 0.51, 95% CI 0.33 to 0.79). Emboli in new territories were present in 5% of patients, and were associated with increased mortality (aHR 2.3, 95% CI 1.11 to 4.86). CONCLUSION: Successful, and ideally complete, reperfusion without emboli in new territories is associated with a reduction in long term mortality in patients treated with mechanical thrombectomy, and this was evident across several subgroups.

Stent Retriever Thrombectomy with Mindframe Capture LP in Isolated M2 Occlusions.

BACKGROUND AND PURPOSE: Mechanical thrombectomy is an effective recanalization technique in acute ischemic stroke patients with large vessel occlusions; however, it is unclear to what extent stent retriever thrombectomy may be applicable to occlusions of smaller peripheral cerebral vessels. The outcome of patients with isolated M2 occlusions treated with the Mindframe Capture low profile (LP) stent retriever was reviewed. MATERIAL AND METHODS: A retrospective review of prospectively collected data on all consecutive patients treated for isolated M2 occlusions between June 2013 and December 2017 using the Mindframe Capture LP was performed. Technical aspects of the recanalization procedure, recanalization rate, complication rate, and clinical outcome were analyzed. RESULTS: Mechanical thrombectomy with the Mindframe Capture LP was performed in 38 patients (median age 79 years) with an isolated M2 occlusion. The median National Institutes of Health Stroke Scale (NIHSS) score on admission was 7.5 (interquartile range, IQR 5-12) and successful reperfusion modified Thrombolysis in Cerebral Infarction (mTICI 2b or 3) was achieved in 28 patients (74%). A compensated/adjusted modified Rankin Scale (mRS) 0-2 at 3 months was observed in 65% when taking pre-stroke disability into account. Symptomatic intracranial hemorrhage (sICH) occurred in 1 patient (2.6%). Asymptomatic intracranial hemorrhage (aICH) was noted in 8 patients (21%) and a small subarachnoid hemorrhage (SAH) in the immediate vicinity of the target vessel was apparent in 8 patients (21%). CONCLUSION: The Mindframe Capture LP is a technically effective thrombectomy device for the treatment of isolated M2 occlusions. The lower profile of the device is advantageous when targeting peripheral intracranial occlusions.

Endovascular treatment of tandem occlusions in vertebrobasilar stroke: technical aspects and outcome compared with isolated basilar artery occlusion.

BACKGROUND AND PURPOSE: Acute basilar artery occlusion (BAO) is a devastating disease with a high rate of mortality and morbidity, and early recanalization is crucial to achieve a good prognosis. The best treatment strategy for BAO combined with a proximal stenosis (tandem occlusion) is not yet clear. Our study aimed to evaluate whether and how vertebrobasilar tandem occlusions can be treated effectively and safely compared with isolated BAO. MATERIALS AND METHODS: Fifty-two patients with acute vertebrobasilar occlusive stroke treated with mechanical thrombectomy were identified in a prospective database from March 2010 to September 2016. We retrospectively analysed the clinical, technical, and functional outcomes of the patients. RESULTS: Of the 52 patients, 15 presented with a tandem occlusion, 14 with a single intracranial occlusion due to an underlying stenosis, and 23 with a single embolic BAO. Successful recanalization was achieved in all of the patients with tandem occlusions (modified Thrombolysis in Cranial Infarction 2b/3) and in 35 of 37 patients with a single BAO (with and without stenosis). A favourable outcome was achieved (modified Rankin Scale ≤2) in 8 of the 15 patients with a tandem occlusion compared with 4 of the 14 patients with a single BAO with underlying stenosis and 5 of the 23 patients with isolated embolic BAO (p=0.18). CONCLUSIONS: We suggest that endovascular treatment of vertebrobasilar tandem occlusions is safe and feasible, with a high rate of good outcome.

Infarct in new territory after endovascular stroke treatment: A diffusion-weighted imaging study.

Data on infarcts in new territory (INT) in patients undergoing endovascular stroke treatment for acute large-vessel occlusions are sparse. Aim of this study was to assess the prevalence, risk factors, and clinical relevance of INT. For this purpose, all patients in a single-center prospective registry who underwent endovascular stroke treatment and received pre- and post-interventional diffusion-weighted imaging were included (N = 259). Using an established scoring system, INT were classified according to size (I-III, ≤2 mm, >2 mm ≤20 mm, >20 mm) and likelihood of being related to the intervention (A, high likelihood; B, low likelihood). Additionally, a new type of infarct, that occurred in a territory distal to the occlusion, but was initially not hypoperfused, was defined as an infarct in initially not hypoperfused territory (IINHT). A total of 180 INT and 38 IINHT were observed in 32.8% (N = 85/259) of patients. In most patients, INT were angiographically occult (90.2%), and 13 patients had INT/IINHT larger than 2 cm (type III). Absence of protection during stent-retrieval and a cardio-embolic stroke origin were associated with higher incidence of INT/IINHT, whereas pretreatment with IV tPA showed no association, even when different bolus timing was considered. INT/IINHT were associated with lower rates of functional independence with increasing size type after adjusting for confounders (adjusted Odds Ratio per size group increase 0.63, 95% confidence interval 0.46-0.86). In conclusion, INT and IINHT are not rare, are associated with poor outcome with increasing size, and they may serve as a surrogate endpoint for safety evaluation of new devices and endovascular techniques. Further research on associated factors is warranted.

Surface dose in the treatment of breast cancer with helical tomotherapy.

PURPOSE: Investigation of the effects of breathing motion- and misregistration-induced errors on the superficial dose in the treatment of breast cancer using helical tomotherapy (HT). MATERIAL AND METHODS: Surface dose measurements were performed with thermoluminescence dosimetry (TLD). Two treatment plans with different planning target volume (PTV) definitions of the left breast were used: PTVskin had its ventral border exactly on skin level, while PTVair included also a 10-mm extension ventral to the PTVskin. With a thoracic static phantom, misregistration errors in an HT were simulated. A dynamic phantom was used to simulate a breathing patient during HT. Surface doses of breast cancer patients were measured both for an HT (179 points) and a conventional three-dimensional conformal treatment (70 points). RESULTS: In the static phantom misregistration setup, dose deviations of -31.9% for PTVskin to +35.4% for PTVair could be observed. The dynamic phantom measurements resulted in surface dose deviations from those in a static position between 0.8% and 3.8% without a significant difference for the PTV definitions. The measured surface doses on patients averaged (mean +/- standard deviation) 1.65 +/- 0.13 Gy for the HT and 1.42 +/- 0.11 Gy for the three-dimensional conformal treatment. CONCLUSION: HT enables a homogeneous and reproducible surface dose with small dose deviations in the treatment of breast cancer. HT is a feasible method to treat breast cancer under free shallow breathing of the patient using a treatment plan with a ventral PTV border on the skin level.

Stent-Retriever Thrombectomy and Rescue Treatment of M1 Occlusions Due to Underlying Intracranial Atherosclerotic Stenosis: Cohort Analysis and Review of the Literature.

BACKGROUND AND PURPOSE: Data on the management of large vessel occlusion in patients with anterior circulation acute ischemic stroke (AIS) due to underlying intracranial stenosis are scarce. The aim of this retrospective study was to compare endovascular treatment and outcome in AIS patients with and without underlying stenosis of the M1 segment. MATERIALS AND METHODS: A total of 533 acute stroke patients with an isolated M1 occlusion who underwent mechanical thrombectomy between 02/2010 and 08/2017 were included. Underlying intracranial atherosclerotic stenosis (ICAS) was present in 10 patients (1.9%), whereas 523 patients (98.1%) had an embolic occlusion without stenosis. RESULTS: There was no difference in age, admission National Institutes of Health Stroke Scale, risk factors, Alberta stroke program early CT score or collaterals between the groups. Procedure time (155 vs 40 min, P = 0.001) was significantly longer in the ICAS group where rescue stent-angioplasty was performed in all patients. There was no statistical difference in final modified thrombolysis in cerebral infarction score between both groups (70 vs 88%, P = 0.115). Favorable outcome (modified Rankin Scale ≤ 2) at 90 days was less frequent in patients with ICAS than in the embolic group (0 vs 49.4%, P = 0.004). The mortality rate tended to be higher in the ICAS group (44.4 vs 19.4%, P = 0.082). CONCLUSION: In patients with AIS, rescue therapy with stent placement to treat underlying ICAS of the M1 segment is technically feasible; however, in our study, a significantly lower rate of favorable outcome was observed in these patients compared to those with thromboembolic M1 occlusions. LEVEL OF EVIDENCE: Level 3, non-randomized controlled study.

Prevalence and Evolution of Susceptibility-Weighted Imaging Lesions in Patients With Artificial Heart Valves.

Background In patients with mechanical heart valves, cerebral susceptibility-weighted imaging (SWI) lesions on magnetic resonance imaging, postulated to be caused by degenerative metallic abrasion, are frequently referred to as valve abrasion. It remains unclear whether valve implantation not requiring cardiopulmonary bypass or biological heart valves also shows those lesions. Methods and Results Two blinded readers rated SWI lesions and cerebral amyloid angiopathy probability according to established criteria on brain magnetic resonance imaging pre- and postinterventionally. We assessed the association between valve type/cardiopulmonary bypass use and SWI lesion count on the first postinterventional scan using multivariable logistic regression. On postinterventional magnetic resonance imaging, 57/58 (98%) patients with mechanical heart valves had at least 1 and 46/58 (79%) 3 or more SWI lesions, while 92/97 (95%) patients with biological heart valves had at least 1 and 72/97 (74%) 3 or more SWI lesions. On multivariate analysis, duration of cardiopulmonary bypass during implantation significantly increased the odds of having SWI lesions on the first postinterventional magnetic resonance imaging (ß per 10 minutes 0.498; 95% CI, 0.116-0.880; P=0.011), whereas valve type showed no significant association (P=0.338). Thirty-seven of 155 (23.9%) patients fulfilled the criteria of possible/probable cerebral amyloid angiopathy. Conclusions SWI lesions in patients with artificial heart valves evolve around the time point of valve implantation and the majority of patients had multiple lesions. The missing association with the valve type weakens the hypothesis of degenerative metallic abrasion and highlights cardiopulmonary bypass as the main risk factor for SWI occurrence. SWI lesions associated with cardiac procedures can mimic cerebral amyloid angiopathy. Further research needs to clarify whether those lesions are associated with intracranial hemorrhage after intravenous thrombolysis or anticoagulation.

Assessing Spinal Cerebrospinal Fluid Leaks in Spontaneous Intracranial Hypotension With a Scoring System Based on Brain Magnetic Resonance Imaging Findings.

Importance: Various signs may be observed on brain magnetic resonance imaging (MRI) in patients with spontaneous intracranial hypotension (SIH). However, the lack of a classification system integrating these findings limits decision making in clinical practice. Objective: To develop a probability score based on the most relevant brain MRI findings to assess the likelihood of an underlying spinal cerebrospinal fluid (CSF) leak in patients with SIH. Design, Setting, and Participants: This case-control study in consecutive patients investigated for SIH was conducted at a single hospital department from February 2013 to October 2017. Patients with missing brain MRI data were excluded. Three blinded readers retrospectively reviewed the brain MRI scans of patients with SIH and a spinal CSF leak, patients with orthostatic headache without a CSF leak, and healthy control participants, evaluating 9 quantitative and 7 qualitative signs. A predictive diagnostic score based on multivariable backward logistic regression analysis was then derived. Its performance was validated internally in a prospective cohort of patients who had clinical suspicion for SIH. Main Outcomes and Measures: Likelihood of a spinal CSF leak based on the proposed diagnostic score. Results: A total of 152 participants (101 female [66.4%]; mean [SD] age, 46.1 [14.3] years) were studied. These included 56 with SIH and a spinal CSF leak, 16 with orthostatic headache without a CSF leak, 60 control participants, and 20 patients in the validation cohort. Six imaging findings were included in the final scoring system. Three were weighted as major (2 points each): pachymeningeal enhancement, engorgement of venous sinus, and effacement of the suprasellar cistern of 4.0 mm or less. Three were considered minor (1 point each): subdural fluid collection, effacement of the prepontine cistern of 5.0 mm or less, and mamillopontine distance of 6.5 mm or less. Patients were classified into groups at low, intermediate, or high probability of having a spinal CSF leak, with total scores of 2 points or fewer, 3 to 4 points, and 5 points or more, respectively, on a scale of 9 points. The discriminatory ability of the proposed score could be demonstrated in the validation cohort. Conclusions and Relevance: This 3-tier predictive scoring system is based on the 6 most relevant brain MRI findings and allows assessment of the likelihood (low, intermediate, or high) of a positive spinal imaging result in patients with SIH. It may be useful in identifying patients with SIH who are leak positive and in whom further invasive myelographic examinations are warranted before considering targeted therapy.

Safety of the Solitaire 4 × 40 mm Stent Retriever in the Treatment of Ischemic Stroke.

PURPOSE: Stent retrievers apply mechanical force to the intracranial vasculature. Our aim was to evaluate the safety and efficacy of the long Solitaire 4 × 40 mm stent retriever for large vessel occlusion in stroke patients. METHODS: We conducted a retrospective analysis of all patients treated for acute ischemic large vessel occlusion stroke with the Solitaire 2 FR 4 × 40 device between May and October 2016 at our institution. Patient-specific data at baseline and at discharge were documented. Reperfusion was graded with the thrombolysis in cerebral infarction (TICI) classification. Postinterventional angiograms and follow-up cross-sectional imaging were used to evaluate complications. RESULTS: TICI 2b/3 recanalization was achieved in 20 of 23 patients (87.0%), in 17 patients with the first retriever pass. NIHSS improved from a mean score at presentation of 16 (range 4-36) to 11 (range 0-41) at discharge. Mean mRS score at discharge was 3 (range 0-6) and 3 (range 0-6) at 90 days post-treatment. No infarcts in other territories were observed. One patient showed a (reversible) vasospasm in the postinterventional angiogram and another a small contrast extravasation in follow-up imaging. CONCLUSION: The Solitaire 2 FR 4 × 40 stent retriever is a safe and efficient device for large vessel occlusion acute ischemic stroke with a high recanalization rate and a low peri- and postinterventional complication rate together with a good clinical outcome. Despite potentially higher friction and shearing forces, no increased incidence of visible damage to the vessel wall was observed.

Thrombectomy of calcified emboli in stroke. Does histology of thrombi influence the effectiveness of thrombectomy?

BACKGROUND AND PURPOSE: Thrombus composition has been postulated to affect the success of endovascular therapy. Calcified clots are composed of large amounts of calcium phosphate which influences their mechanical properties and may serve as a model for testing this hypothesis. The aim of this study was to evaluate the recanalization and complication rates of calcified thromboemboli in patients with acute ischemic stroke who underwent thrombectomy. MATERIAL AND METHODS: A retrospective analysis was performed of all calcified intracranial thromboemboli in patients suffering an acute ischemic stroke, referred for endovascular therapy at two centers between January 2013 and July 2016. RESULTS: Eight patients with a calcified intracranial clot underwent stent retriever thrombectomy (five women; mean age 80 years). Mean clot attenuation was 305 HU (range 150-640 HU). Successful reperfusion defined, as Thrombolysis in Cerebral Infarction grade 2b-3 was achieved in only one patient (12.5%). Two periprocedural adverse events occurred: one peripheral vessel perforation which was coiled and one inadvertent stent retriever detachment due to fracture of the stent retriever wire. CONCLUSION: Stent retriever thrombectomy of calcified thromboemboli seems less effective than with other types of clots. Different mechanical properties of calcified clots may render them stiffer and less accessible for stent retrievers. When faced with a calcified intracranial thromboembolus in clinical practice, a more contained approach may be warranted in view of low recanalization rates, and the potential for periprocedural adverse events.

Balloon-assisted coil embolization and large stent delivery for cerebral aneurysms with a new generation of dual lumen balloons (Copernic 2L).

INTRODUCTION: Dual coaxial lumen balloon microcatheters through which small stents can be delivered have recently been described. We report a series of a new type of dual lumen balloon catheter with a parallel lumen design enabling enhanced inflation and deflation properties through which larger stents may be deployed, including flow diverters (FD). METHODS: All aneurysms that were treated with a Copernic 2L (COP2L) dual lumen balloon catheter at our institution between February 2014 and December 2016 were assessed. Patient demographics, aneurysm characteristics, clinical and angiographic follow-up, as well as adverse events were analyzed. RESULTS: A total of 18 aneurysms in 16 patients (14 women) were treated with the COP2L. Mean maximal aneurysm diameter was 6.4 mm, mean neck size was 3.3 mm (min 1; max 6.3), and mean aneurysm height/width was 1.1 (min 0.5; max 2.1). The COP2L was used for balloon-remodeled coiling exclusively in 2 aneurysms; coiling and FD stenting in 8; coiling and braided stent delivery in 3; coiling, braided and FD stenting in 1; and FD stenting without coiling in 4 (stenting alone). The rate of Roy-Raymond 1 (complete occlusion) changed from 22% in the immediate postoperative period to 100% at 3 months (mean imaging follow-up 8.2 months). There were three technical complications (3/16, 18.7%), including a perforation and two thromboembolic asymptomatic events that were rapidly controlled with the COP2L. There was no immediate or delayed morbidity or mortality (modified Rankin Scale score 0-1 in 100% of patients). CONCLUSION: The COP2L is a new type of dual lumen balloon catheter that may be useful for balloon and/or stent-assisted coiling of cerebral aneurysms. The same device can be used to deliver stents up to 4.5 mm and to optimize stent/wall apposition or serve as a life-saving tool in case of thromboembolic or hemorrhagic events. Long-term efficacy and safety need to be further assessed with larger case-controlled cohorts.

Aneurysms in the target vessels of stroke patients subjected to mechanical thrombectomy: prevalence and impact on treatment.

BACKGROUND AND PURPOSE: Coincidental aneurysms in the target vessels of stroke patients with large vessel occlusions (LVO) may pose risks during endovascular mechanical thrombectomy (MTE), but there are almost no data on this subject. Motivated by an incident of rupture of a hidden aneurysm induced by withdrawal of a stent retriever during a MTE procedure, this study examines the prevalence of aneurysms, associated complications, and implications for treatment strategies in patients with LVO stroke. METHODS: A single-center retrospective analysis of angiographic and CT/MRI images and case records of 300 consecutive patients with LVO stroke treated with MTE was performed. RESULTS: Aneurysms related to target vessels were detected in 11/300 patients, in 10/11 in the anterior circulation. In 9/11 patients the aneurysms were unknown prior to the stroke. The observed prevalence was >2-fold higher than expected for a healthy reference population. There was one complication (aneurysm rupture), as described above. In two subsequent patients with known aneurysms, MTE was conducted mainly with aspiration techniques which failed, contributing to a low recanalization rate in patients with aneurysm (45%). CONCLUSIONS: The prevalence of aneurysms is relatively high in patients with LVO stroke, particularly in older, female, hypertensive patients, presumably reflecting overlapping risk factors. MTE should not be withheld from patients with LVO stroke with aneurysms, but particularly cautious approaches may be warranted. Further research in larger samples is required to obtain precise data on the prevalence and associated complication rates in MTE procedures. This is necessary to estimate the true risk and to tailor endovascular strategies in these patients.