Endovascular treatment versus no endovascular treatment after 6-24 h in patients with ischaemic stroke and collateral flow on CT angiography (MR CLEAN-LATE) in the Netherlands: a multicentre, open-label, blinded-endpoint, randomised, controlled, phase 3 trial.

BACKGROUND: Endovascular treatment for anterior circulation ischaemic stroke is effective and safe within a 6 h window. MR CLEAN-LATE aimed to assess efficacy and safety of endovascular treatment for patients treated in the late window (6-24 h from symptom onset or last seen well) selected on the basis of the presence of collateral flow on CT angiography (CTA). METHODS: MR CLEAN-LATE was a multicentre, open-label, blinded-endpoint, randomised, controlled, phase 3 trial done in 18 stroke intervention centres in the Netherlands. Patients aged 18 years or older with ischaemic stroke, presenting in the late window with an anterior circulation large-vessel occlusion and collateral flow on CTA, and a neurological deficit score of at least 2 on the National Institutes of Health Stroke Scale were included. Patients who were eligible for late-window endovascular treatment were treated according to national guidelines (based on clinical and perfusion imaging criteria derived from the DAWN and DEFUSE-3 trials) and excluded from MR CLEAN-LATE enrolment. Patients were randomly assigned (1:1) to receive endovascular treatment or no endovascular treatment (control), in addition to best medical treatment. Randomisation was web based, with block sizes ranging from eight to 20, and stratified by centre. The primary outcome was the modified Rankin Scale (mRS) score at 90 days after randomisation. Safety outcomes included all-cause mortality at 90 days after randomisation and symptomatic intracranial haemorrhage. All randomly assigned patients who provided deferred consent or died before consent could be obtained comprised the modified intention-to-treat population, in which the primary and safety outcomes were assessed. Analyses were adjusted for predefined confounders. Treatment effect was estimated with ordinal logistic regression and reported as an adjusted common odds ratio (OR) with a 95% CI. This trial was registered with the ISRCTN, ISRCTN19922220. FINDINGS: Between Feb 2, 2018, and Jan 27, 2022, 535 patients were randomly assigned, and 502 (94%) patients provided deferred consent or died before consent was obtained (255 in the endovascular treatment group and 247 in the control group; 261 [52%] females). The median mRS score at 90 days was lower in the endovascular treatment group than in the control group (3 [IQR 2-5] vs 4 [2-6]), and we observed a shift towards better outcomes on the mRS for the endovascular treatment group (adjusted common OR 1·67 [95% CI 1·20-2·32]). All-cause mortality did not differ significantly between groups (62 [24%] of 255 patients vs 74 [30%] of 247 patients; adjusted OR 0·72 [95% CI 0·44-1·18]). Symptomatic intracranial haemorrhage occurred more often in the endovascular treatment group than in the control group (17 [7%] vs four [2%]; adjusted OR 4·59 [95% CI 1·49-14·10]). INTERPRETATION: In this study, endovascular treatment was efficacious and safe for patients with ischaemic stroke caused by an anterior circulation large-vessel occlusion who presented 6-24 h from onset or last seen well, and who were selected on the basis of the presence of collateral flow on CTA. Selection of patients for endovascular treatment in the late window could be primarily based on the presence of collateral flow. FUNDING: Collaboration for New Treatments of Acute Stroke consortium, Dutch Heart Foundation, Stryker, Medtronic, Cerenovus, Top Sector Life Sciences & Health, and the Netherlands Brain Foundation.

Endovascular Therapy for Stroke Due to Basilar-Artery Occlusion.

BACKGROUND: The effectiveness of endovascular therapy in patients with stroke caused by basilar-artery occlusion has not been well studied. METHODS: We randomly assigned patients within 6 hours after the estimated time of onset of a stroke due to basilar-artery occlusion, in a 1:1 ratio, to receive endovascular therapy or standard medical care. The primary outcome was a favorable functional outcome, defined as a score of 0 to 3 on the modified Rankin scale (range, 0 to 6, with 0 indicating no disability, 3 indicating moderate disability, and 6 indicating death) at 90 days. The primary safety outcomes were symptomatic intracranial hemorrhage within 3 days after the initiation of treatment and mortality at 90 days. RESULTS: A total of 300 patients were enrolled (154 in the endovascular therapy group and 146 in the medical care group). Intravenous thrombolysis was used in 78.6% of the patients in the endovascular group and in 79.5% of those in the medical group. Endovascular treatment was initiated at a median of 4.4 hours after stroke onset. A favorable functional outcome occurred in 68 of 154 patients (44.2%) in the endovascular group and 55 of 146 patients (37.7%) in the medical care group (risk ratio, 1.18; 95% confidence interval [CI], 0.92 to 1.50). Symptomatic intracranial hemorrhage occurred in 4.5% of the patients after endovascular therapy and in 0.7% of those after medical therapy (risk ratio, 6.9; 95% CI, 0.9 to 53.0); mortality at 90 days was 38.3% and 43.2%, respectively (risk ratio, 0.87; 95% CI, 0.68 to 1.12). CONCLUSIONS: Among patients with stroke from basilar-artery occlusion, endovascular therapy and medical therapy did not differ significantly with respect to a favorable functional outcome, but, as reflected by the wide confidence interval for the primary outcome, the results of this trial may not exclude a substantial benefit of endovascular therapy. Larger trials are needed to determine the efficacy and safety of endovascular therapy for basilar-artery occlusion. (Funded by the Dutch Heart Foundation and others; BASICS ClinicalTrials.gov number, NCT01717755; Netherlands Trial Register number, NL2500.).

A Randomized Trial of Intravenous Alteplase before Endovascular Treatment for Stroke.

BACKGROUND: The value of administering intravenous alteplase before endovascular treatment (EVT) for acute ischemic stroke has not been studied extensively, particularly in non-Asian populations. METHODS: We performed an open-label, multicenter, randomized trial in Europe involving patients with stroke who presented directly to a hospital that was capable of providing EVT and who were eligible for intravenous alteplase and EVT. Patients were randomly assigned in a 1:1 ratio to receive EVT alone or intravenous alteplase followed by EVT (the standard of care). The primary end point was functional outcome on the modified Rankin scale (range, 0 [no disability] to 6 [death]) at 90 days. We assessed the superiority of EVT alone over alteplase plus EVT, as well as noninferiority by a margin of 0.8 for the lower boundary of the 95% confidence interval for the odds ratio of the two trial groups. Death from any cause and symptomatic intracerebral hemorrhage were the main safety end points. RESULTS: The analysis included 539 patients. The median score on the modified Rankin scale at 90 days was 3 (interquartile range, 2 to 5) with EVT alone and 2 (interquartile range, 2 to 5) with alteplase plus EVT. The adjusted common odds ratio was 0.84 (95% confidence interval [CI], 0.62 to 1.15; P = 0.28), which showed neither superiority nor noninferiority of EVT alone. Mortality was 20.5% with EVT alone and 15.8% with alteplase plus EVT (adjusted odds ratio, 1.39; 95% CI, 0.84 to 2.30). Symptomatic intracerebral hemorrhage occurred in 5.9% and 5.3% of the patients in the respective groups (adjusted odds ratio, 1.30; 95% CI, 0.60 to 2.81). CONCLUSIONS: In a randomized trial involving European patients, EVT alone was neither superior nor noninferior to intravenous alteplase followed by EVT with regard to disability outcome at 90 days after stroke. The incidence of symptomatic intracerebral hemorrhage was similar in the two groups. (Funded by the Collaboration for New Treatments of Acute Stroke consortium and others; MR CLEAN-NO IV ISRCTN number, ISRCTN80619088.).

Improvements in Endovascular Treatment for Acute Ischemic Stroke: A Longitudinal Study in the MR CLEAN Registry.

BACKGROUND: We evaluated data from all patients in the Netherlands who underwent endovascular treatment for acute ischemic stroke in the past 3.5 years, to identify nationwide trends in time to treatment and procedural success, and assess their effect on clinical outcomes. METHODS: We included patients with proximal occlusions of the anterior circulation from the second and first cohorts of the MR CLEAN (Multicenter Randomized Clinical trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry (March 2014 to June 2016; June 2016 to November 2017, respectively). We compared workflow times and rates of successful reperfusion (defined as an extended Thrombolysis in Cerebral Infarction score of 2B-3) between cohorts and chronological quartiles (all included patients stratified in chronological quartiles of intervention dates to create equally sized groups over the study period). Multivariable ordinal logistic regression was used to assess differences in the primary outcome (ordinal modified Rankin Scale at 90 days). RESULTS: Baseline characteristics were similar between cohorts (second cohort n=1692, first cohort n=1488) except for higher age, poorer collaterals, and less signs of early ischemia on computed tomography in the second cohort. Time from stroke onset to groin puncture and reperfusion were shorter in the second cohort (median 185 versus 210 minutes; P<0.001 and 236 versus 270 minutes; P<0.001, respectively). Successful reperfusion was achieved more often in the second than in the first cohort (72% versus 66%; P<0.001). Functional outcome significantly improved (adjusted common odds ratio 1.23 [95% CI, 1.07-1.40]). This effect was attenuated by adjustment for time from onset to reperfusion (adjusted common odds ratio, 1.12 [95% CI, 0.98-1.28]) and successful reperfusion (adjusted common odds ratio, 1.13 [95% CI, 0.99-1.30]). Outcomes were consistent in the analysis per chronological quartile. CONCLUSIONS: Clinical outcomes after endovascular treatment for acute ischemic stroke in routine clinical practice have improved over the past years, likely resulting from improved workflow times and higher successful reperfusion rates.

Arterio-Ureteral Fistula: Systematic Review of 445 Patients.

PURPOSE: Arterio-ureteral fistula (AUF) is an uncommon diagnosis, but increasingly reported and potentially lethal. This systematic review comprehensively presents risk factors, pathophysiology, location and clinical presentation of AUF aiming to increase clinical awareness of this rare but life-threatening condition, and to put this entity into a contemporary perspective with modern diagnostic tools and treatment strategies. MATERIALS AND METHODS: This review was performed according to the PRISMA (Preferred Reporting Items for a Systematic Review and Meta-Analysis of Individual Participant Data) guidelines. A literature search in PubMed® and EMBASE™ was conducted. In addition, retrieved articles were cross-referenced. Data parameters included oncologic, vascular and urological history, diagnostics, treatment, and followup, and were collected using a standard template by 2 independent reviewers. RESULTS: A total of 245 articles with 445 patients and 470 AUFs were included. Most patients had chronic indwelling ureteral stents (80%) and history of pelvic oncology (70%). Hematuria was observed in 99% of the patients, of whom 76% presented with massive hematuria with or without previous episodes of (micro)hematuria. For diagnosis, angiography had a sensitivity of 62%. The most predominant location of AUF was at the common iliac artery ureteral crossing. AUF-specific mortality before 2000 vs after 2000 is 19% vs 7%, coinciding with increasing use of endovascular stents. CONCLUSIONS: AUF should be considered in patients with a medical history of vascular surgery, pelvic oncologic surgery, irradiation and/or chronic indwelling ureteral stents presenting with intermittent (micro)hematuria. A multidisciplinary consultation is necessary for diagnosis and treatment. The most sensitive test is angiography and the preferred initial treatment is endovascular.

Arterio-ureteral fistula: a nationwide cross-sectional questionnaire analysis.

PURPOSE: Arterio-ureteral fistula (AUF) is an uncommon diagnosis, but potentially lethal. Although the number of reports has increased over the past two decades, the true incidence and contemporary urologists' experience and approach in clinical practice remains unknown. This research is conducted to provide insight in the incidence of AUF in The Netherlands, and the applied diagnostic tests and therapeutic approaches in modern practice. METHODS: A nationwide cross-sectional questionnaire analysis was performed by sending a survey to all registered Dutch urologists. Data collection included information on experience with patients with AUF; and their medical history, diagnostics, treatment, and follow-up, and were captured in a standardized template by two independent reviewers. Descriptive statistics were used. RESULTS: Response rate was 62% and 56 AUFs in 53 patients were reported between 2003 and 2018. The estimated incidence of AUF in The Netherlands in this time period is 3.5 AUFs per year. Hematuria was observed in all patients; 9% intermittent microhematuria, and 91% presenting with, or building up to massive hematuria. For the final diagnosis, angiography was the most efficient modality, confirming diagnosis in 58%. Treatment comprised predominantly endovascular intervention. CONCLUSION: The diagnosis AUF should be considered in patients with persistent intermittent or massive hematuria.

Functional and educational outcomes after treatment for intracranial arteriovenous malformations in children.

BACKGROUND: Arteriovenous malformations (AVMs) in the pediatric population are rare, yet they form the most frequent cause of hemorrhagic stroke in children. Compared to adults, children have been suggested to have beneficial neurological outcomes. However, few studies have focused on other variables than neurological outcomes. This study aims to assess the long-term functional and educational outcomes of children after multimodality approach of treatment for intracranial AVMs. METHODS: All children treated in our center between 1998 and 2016 for intracranial AVMs were reviewed. Patient characteristics, as well as AVM specifics, were collected. Functional outcomes were compared using the modified Rankin scale (mRs). Educational levels, using the International Standard Classification of Education (ISCED), were compared to the age-matched general population of the Netherlands. RESULTS: In total, 25 children were included at mean age of 10 years (range 2-16 years). Nineteen patients (76%) presented with intracranial bleeding. Mean follow-up was 11.5 ± 5.3 years (range 4.1-24.4). Four (16%) of patients were treated with embolization, three (12%) with microsurgery, and 18 patients (72%) received a combination of different treatment modalities. Altogether, 21 (84%) were embolized, 14 (56%) were treated with microsurgery, and eight (32%) received stereotactic radiosurgery. One child had a worse mRs at discharge compared to admission; all others improved (n = 11) or were stable (n = 13). At follow-up, all patients scored a stable or improved mRs compared to discharge, with 23 children (92%) scoring mRs 0 or 1. These 23 children followed regular education during follow-up without specialized or adapted schooling. No significant differences in educational level with the age-matched general population were found. CONCLUSION: This retrospective review shows positive long-term results of both functional and educational outcomes after multidisciplinary treatment of pediatric brain AVMs.

Bare metal stents for treatment of extracranial internal carotid artery aneurysms: long-term results.

PURPOSE: To examine the long-term outcomes of bare metal stent placement for exclusion of extracranial internal carotid artery (ICA) aneurysms. METHODS: From 2006 to 2011, 7 consecutive symptomatic patients (4 men; mean age 52 years) with surgically inaccessible extracranial ICA aneurysms were treated with a bare stent at a single center. Patients received clopidogrel for 3 months after the procedure and aspirin for life. Clinical follow-up with duplex ultrasound and/or computed tomographic angiography was performed at 3, 6, and 12 months and yearly thereafter. RESULTS: All procedures were technically successful; no neurological complications occurred. After 6 months, there was complete thrombosis of the aneurysm in all except one case. In this asymptomatic patient, the residual active flow was successfully obliterated by additional coil embolization. Over a mean follow-up of 57 ± 22 months, all patients were alive and free of local or central neurological symptoms. All stents were patent, and thrombosis of the aneurysms was complete. CONCLUSION: In this small series, treatment of extracranial ICA aneurysms with a bare stent seems technically feasible and safe. All treated extracranial ICA aneurysms were excluded by primary intervention or secondary coil embolization.

The Wallstent: long-term follow-up of metal stent placement for the treatment of benign ureteroileal anastomotic strictures after Bricker urinary diversion.

OBJECTIVE: To evaluate the long-term follow-up (primary and secondary patency) of metal stent placement in benign ureteroileal anastomotic strictures after Bricker urinary diversion and to compare the failed treatment group with the group of successfully treated patients to search for predisposing factors of stent failure. PATIENTS AND METHODS: For patients treated since 1989 for benign ureteroileal strictures after Bricker urinary diversion with end-to-side anastomosis, we retrospectively collected data on clinical history, stent placement, auxiliary measures and patency rates from a prospectively kept database. RESULTS: In all, 49 patients (mean age 64 years) underwent 56 metal stent procedures. Placement of the stent was possible in all patients. Stent patency without auxiliary treatment remained adequate in 23 cases (primary patency of 41.1%, mean follow-up 37.7 months). A secondary treatment was successfully performed in 11 patients who had stent obstruction, mostly caused by hyperplastic reaction, encrustation, or migration of the stent. The secondary patency rate was 60.7% (mean follow-up 55.8 months), comparable with patency rates of 36-100% described in literature with mostly small patient groups and much shorter follow-up periods. CONCLUSION: To the best of our knowledge we report the largest series of metal stenting in benign ureteroileal anastomotic strictures with the longest follow-up. We show that placement of a metal stent can lead to a permanent de-obstruction in approximately six out of 10 patients with preservation of renal function.

The course of unilateral intracranial arteriopathy in young adults with arterial ischemic stroke.

BACKGROUND AND PURPOSE: Unilateral intracranial focal nonprogressive arteriopathy is often found in children with arterial ischemic stroke. We aimed to investigate the course of unilateral intracranial arteriopathy in young adults. METHODS: We searched the Utrecht Stroke Database for patients between 16 and 50 years of age diagnosed with anterior circulation arterial ischemic stroke and a nonatherosclerotic, unilateral intracranial large-artery arteriopathy between 1991 and 2005. We assessed clinical features, potential causes, risk factors, extent of infarction and arteriopathy at presentation, long-term angiographic course, and clinical outcome. RESULTS: Of 356 patients with anterior circulation arterial ischemic stroke, 17 (5%) had a documented unilateral intracranial arteriopathy, of whom 14 could be included for follow-up investigations (median age, 34 years; range, 27-49 years). Median duration of follow-up was 8.8 years (range, 1.7-12.8 years). In 11 patients, onset of symptoms was not abrupt. The arteriopathy normalized completely in 5 and improved in 3 patients; in none of the patients did the arteriopathy worsen. Two of 14 patients had recurrent symptoms. Ten patients (71%) had a good outcome (modified Rankin Scale score≤2). CONCLUSIONS: In young adults, arterial ischemic stroke is rarely caused by a unilateral intracranial arteriopathy. Similar to children, onset of symptoms in young adults is often not abrupt and the arteriopathy may improve over time. Late recurrences were rare. Possibly, a monophasic inflammatory process, as has been suggested for childhood intracranial focal nonprogressive arteriopathies, also occurs in young adults.

Coil-treated aneurysms: decision making regarding additional treatment based on findings of MR angiography and intraarterial DSA.

PURPOSE: To assess whether magnetic resonance (MR) angiography can be used as a noninvasive alternative to intraarterial digital subtraction angiography (DSA) to indicate additional treatment in the follow-up of patients with coil-treated intracranial aneurysms. MATERIALS AND METHODS: This was an ethics committee-approved multicenter study. Consecutive patients who were scheduled for follow-up intraarterial DSA after coil placement were invited for additional MR angiography after providing written informed consent. Interventional neuroradiologists gave treatment advice (additional treatment, extended follow-up imaging, or discharge from follow-up) for each imaging modality. Agreement between treatment advices based on intraarterial DSA and MR angiographic findings and interobserver agreement were assessed with weighted κ statistics. RESULTS: Agreement between intraarterial DSA- and MR angiography-based treatment recommendations was substantial (κ = 0.73; 95% confidence interval [CI]: 0.66, 0.80). In 34 of the 310 patients (11%), the advice was additional treatment based on findings of both modalities. In six patients (2%), the advice based on intraarterial DSA findings was additional treatment, while that based on MR angiographic findings was extended follow-up imaging; therefore, none of these patients were discharged from follow-up on the basis of MR angiographic findings. In six other patients (2%), the advice based on MR angiographic findings was additional treatment, while that based on intraarterial DSA findings was extended follow-up imaging (four patients), discharge from follow-up (one patient), and noninterpretable DSA (one patient). Extended follow-up imaging was suggested for 37 patients (12%) after intraarterial DSA and for 49 patients (16%) after MR angiography (difference: 4%; 95% CI: -0.6%, 8.4%). Interobserver agreement was substantial for intraarterial DSA (κ = 0.73; 95% CI: 0.64, 0.82) and moderate for MR angiography (κ = 0.53; 95% CI: 0.36, 0.70). CONCLUSION: The overall proportion of patients advised to undergo additional treatment is similar based on intraarterial DSA and MR angiographic findings, with only few individual discrepancies. MR angiography can therefore be used for therapeutic decision making in the follow-up of patients with coil-treated aneurysms. SUPPLEMENTAL MATERIAL: http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.12112608/-/DC1.

Intracranial aneurysms treated with coil placement: test characteristics of follow-up MR angiography--multicenter study.

PURPOSE: To determine the test characteristics of magnetic resonance (MR) angiography in the assessment of occlusion of aneurysms treated with coil placement. MATERIALS AND METHODS: This was an ethics committee-approved multicenter study. written informed consent was obtained in 311 patients with 343 aneurysms, who had been treated with coil placement and were scheduled for routine follow-up with intraarterial digital subtraction angiography (DSA). Thirty-five patients participated two or three times. Either 3.0- or 1.5-T time-of-flight (TOF) and contrast material-enhanced MR angiography were performed in addition to intraarterial DSA. Aneurysm occlusion was evaluated by independent readers at DSA and MR angiography. The test characteristics of MR angiography were assessed by using DSA as the standard. The area under the receiver operating characteristic curve (AUC) was calculated for 3.0- versus 1.5-T MR angiography and for TOF versus contrast-enhanced MR angiography, and factors associated with discrepancies between MR angiography and DSA were assessed with logistic regression. RESULTS: Aneurysm assessments (n = 381) at DSA and MR angiography were compared. Incomplete occlusion was seen at DSA in 88 aneurysms (23%). Negative predictive value of MR angiography was 94% (95% confidence interval [CI]: 91%, 97%), positive predictive value was 69% (95% CI: 60%, 78%), sensitivity was 82% (95% CI: 72%, 89%), and specificity was 89% (95% CI: 85%, 93%). AUCs were similar for 3.0- (0.90 [95% CI: 0.86, 0.94]) and 1.5-T MR (0.87 [95% CI: 0.78, 0.95]) and for TOF MR (0.86 [95% CI: 0.81, 0.91]) versus contrast-enhanced MR (0.85 [95% CI: 0.80, 0.91]). A small residual lumen (odds ratio, 2.1 [95% CI: 1.1, 4.3]) and suboptimal projection at DSA (odds ratio, 5.5 [95% CI: 1.5, 21.0]) were independently associated with discordance between intraarterial DSA and MR angiography. CONCLUSION: Documentation of good diagnostic performance of TOF MR angiography at both 1.5 and 3.0 T in the current study represents an important step toward replacing intraarterial DSA with MR angiography in the follow-up of patients with aneurysms treated with coils.

Symptomatic vertebral artery stent fracture: a case report.

Percutaneous transluminal angioplasty (PTA) with stent placement is the preferred treatment modality at present for atherosclerotic stenotic lesions of vertebral artery origin. A complication of stent placement in the vertebral artery origin that has received little attention is the risk of stent fracture. A case with four-vessel pathology treated with PTA and stent placement in the left vertebral artery origin is presented. Symptoms recurred 4 months after stent placement, and arteriogram revealed a fractured stent, which was treated surgically with stent removal and vertebral artery-common carotid artery reimplantation.

Frequency and consequences of early in-stent lesions after carotid artery stent placement.

PURPOSE: To examine the prevalence of in-stent lesions 1 month after carotid artery stent placement with multidetector computed tomography (CT) angiography and to evaluate their possible causes and their consequences during 1-year follow-up. MATERIALS AND METHODS: Sixty-nine patients with symptomatic carotid artery stenosis underwent multidetector CT angiography of the carotid arteries 1 month after carotid artery stent placement. Patients were followed-up until 1 year after stent placement, when duplex ultrasonography (US) was performed. In-stent lesions were defined as hypo- or hyperattenuating lesions at the stent wall found with multidetector CT. Significant restenosis (70%) at 1 year was defined as a peak systolic velocity of more than 300 cm/sec at duplex US. The Fisher exact test was used to assess the relationship between early in-stent lesions and ischemic events and restenosis. RESULTS: At 1 month, 14 of the 69 patients (20%) were found to have in-stent lesions. In one patient, the stent was occluded. The other 13 in-stent lesions did not result in significant lumen reduction. In the year following stent placement, no difference in ischemic events was found between patients with (14%) and those without (13%) early in-stent lesions (P = .99). There was no difference in the occurrence of restenosis at 1 year (7% vs 4%, P = .59). CONCLUSIONS: At 1 month after carotid artery stent placement, in-stent lesions are found in about one-fifth of patients. These lesions do not appear to be related to recurrent ischemic events or to restenosis at 1 year.

Treatment of an extracranial internal carotid artery aneurysm with a flow-diverting stent.

No evidenced-based guidelines exist for the treatment of extracranial carotid artery aneurysms (ECAAs). The "gold standard" for symptomatic ECAAs is surgical intervention. In distally located ECAAs just below the base of the skull, endovascular monotherapy may be beneficial. We present the case of a 21-year-old man with a symptomatic saccular aneurysm in the distal internal carotid artery receiving a flow-diverting stent. The stent was successfully positioned without adverse procedural events. At 6 months, computed tomography angiography revealed secondary occlusion of the aneurysm without further complications. The flow-diverting stent may serve as an additional treatment option for the endovascular specialist considering invasive treatment in patients with an ECAA.

Excimer laser-assisted bypass in aneurysm treatment: short-term outcomes.

OBJECT: If clip application or coil placement for treatment of intracranial aneurysms is not feasible, the parent vessel can be occluded to induce thrombosis of the aneurysm. The Excimer laser-assisted anastomosis technique allows the construction of a high-flow bypass in patients who cannot tolerate such an occlusion. The authors assessed the complications of this procedure and clinical outcomes after the construction of high-flow bypasses in patients with intracranial aneurysms. METHODS: Data were retrospectively collected on patient and aneurysm characteristics, procedural complications, and functional outcomes in 77 patients in whom a high-flow bypass was constructed. Logistic regression analysis was used to quantify the relationships between patient and aneurysm characteristics on the one hand and outcome measures on the other. Fifty-one patients harbored a giant aneurysm, 24 patients suffered from a ruptured aneurysm, and 35 patients from an unruptured symptomatic aneurysm. In 22 patients (29%; 95% confidence interval [CI] 19-40%) a permanent deficit developed from an operative complication. At a median follow-up period of 2.5 months, 25 patients (32%; 95% CI 22-44%) were dependent or had died; in 10 of these patients (13% of all patients; 95% CI 6-23%) operative complications were the single cause of this poor outcome. Univariate analysis demonstrated that a poor clinical condition before treatment (odds ratio [OR] 4.7; 95% CI 1.7-13.3) and a history of cardiovascular disease (OR 4.1; 95% CI 1-16.2) increased the risk of poor outcome. Multivariate analysis demonstrated that only the clinical condition before treatment was significantly related to outcome (OR 4; 95% CI 1.3-11.9). CONCLUSIONS: In patients with an intracranial aneurysm that cannot be treated by clip application or coil placement, and in whom occlusion of the parent artery cannot be tolerated, the construction of a high-flow bypass should be considered. This procedure carries a considerable risk of complications, but this should be weighed against the disabling or life-threatening effects of compression, the high risk of rupture, and the substantial chance of poor outcome after the rupture of such aneurysms.

Changes in cerebral perfusion after revascularization of symptomatic carotid artery stenosis: CT measurement.

PURPOSE: To prospectively evaluate changes in brain perfusion computed tomographic (CT) parameters after revascularization of unilateral symptomatic carotid artery stenosis and to determine whether pretreatment perfusion CT parameters can be used to predict changes in cerebral hemodynamics after treatment. MATERIALS AND METHODS: This study was medical ethics committee approved, and written informed consent was obtained from all patients. Thirty-six patients (23 men, 13 women; mean age, 67 years) with unilateral symptomatic carotid artery stenosis underwent multi-detector row perfusion CT before and after revascularization. Mean transit time (MTT), cerebral blood volume (CBV), and cerebral blood flow (CBF) were calculated, and relative values based on the comparison between symptomatic and asymptomatic hemispheres-specifically, relative CBV, relative CBF, and difference in MTT-were derived. The absolute and relative perfusion values before treatment were assessed and compared with posttreatment values. These analyses were performed for the group as a whole by using the t test and after subdividing patients into three tertiles according to the difference in MTT by using the Wilcoxon signed rank test. RESULTS: Among the absolute perfusion values, only the MTT in the symptomatic hemisphere improved significantly after treatment (P < .01). All relative values (difference in MTT, relative CBV, and relative CBF) changed significantly after treatment (P < .05). When the patients were subdivided into three tertiles according to difference in MTT, no significant change in any relative perfusion value could be demonstrated in the lowest tertile, only the difference in MTT improved significantly (P = .004) in the middle tertile, and all relative perfusion values changed significantly (P = .002) in the highest tertile. CONCLUSION: Compared with relative CT perfusion values based on interhemispheric comparison, absolute perfusion CT values are less suited for demonstrating changes in cerebral perfusion after revascularization in patients with unilateral symptomatic carotid artery stenosis.

Optimal scan delay in spiral CT for the diagnosis of acute pulmonary embolism.

PURPOSE: The purpose of this work was to assess whether easily obtained clinical parameters can predict optimal scan delay for contrast-enhanced spiral CT of pulmonary arteries and to compare image quality between individualized contrast timing versus a fixed scan delay. METHOD: We used an individualized delay in 85 patients by measuring the contrast transit time through the pulmonary circulation (Group A) and assessed the correlation between transit time and clinical parameters. In 56 patients (Group B), we used a 20 s fixed scan delay. The CT examinations of both groups were compared with regard to image quality. RESULTS: Contrast transit times (mean 10.5 s, range 4-26 s) did not correlate significantly with heart rate, blood pressure, body length, weight, body surface area, or cardiac function. Although contrast transit times were significantly related to gender and age, only 14.8% of the variation could be explained by these clinical parameters. Data of 57 patients in Group A and 50 patients in Group B were available for analysis. Image quality was not significantly different between Groups A and B, which was good, moderate, and poor in 61, 32, and 7% in Group A and 60, 34, and 6% in Group B, respectively (p = 1.0). CONCLUSION: One cannot predict individual scan delay from easily obtainable clinical parameters. Fortunately, a 20 s fixed scan delay provides equal image quality as individualized contrast timing.

Quality of life after treatment of unruptured intracranial aneurysms by neurosurgical clipping or by embolisation with coils. A prospective, observational study.

BACKGROUND: Relatively high rates of complications occur after operation for unruptured intracranial aneurysms. Published data on endovascular treatment suggest lower rates of complications. We measured the impact of treatment of unruptured aneurysms by clipping or coiling on functional health, quality of life, and the level of anxiety and depression. METHODS: In three centres, we prospectively collected data on patients with an unruptured aneurysm who were treated by clipping or coiling. Treatment assignment was left to the discretion of the treating physicians. Before, 3 and 12 months after treatment, we used standardised questionnaires to assess functional health (Rankin Scale score), quality of life (SF-36, EuroQol), and the level of anxiety and depression (Hospital Anxiety and Depression Scale). RESULTS: Nineteen patients were treated by coiling and 32 by clipping. In the surgical group, 4 patients (12%) had a permanent complication; 36 of all 37 aneurysms (97%) were successfully clipped. Three months after operation, quality of life was worse than before operation; 12 months after operation, it had improved but had not completely returned to baseline levels. Scores for depression were higher than in the general population. In the endovascular group, no complications with permanent deficits occurred; 16 of 19 aneurysms (84%) were occluded by more than 90%. One patient died from rupture of the previously coiled aneurysm. In the others, quality of life after 3 months and after 1 year was similar to that before treatment. CONCLUSIONS: In the short term, operation of patients with an unruptured aneurysm has a considerable impact on functional health and quality of life. After 1 year, recovery occurs but it is incomplete. Coil embolisation does not affect functional health and quality of life.