RESUMEN
BACKGROUND AND PURPOSE: The Pipeline Embolization Device is a safe and effective treatment option for intracranial aneurysms. The newer Pipeline generations have received structural refinements and a surface modification to improve deliverability, procedural safety, and angiographic outcomes. This multicenter study evaluated the clinical safety and efficacy of the 2 surface-modified Pipeline iterations, Pipeline Vantage and Pipeline Flex with Shield Technology (PFS). MATERIALS AND METHODS: Consecutive patients treated between 2017 and 2023 were retrospectively reviewed for aneurysm characteristics, procedural details, complications, and angiographic outcomes. The safety end point was the rate of procedural and postprocedural major neurologic events occurring during the hospital stay. The efficacy end point was the rate of complete occlusion at last follow-up. RESULTS: One hundred forty-one patients underwent 112 Pipeline Vantage procedures and 32 PFS procedures for 147 aneurysms with a mean size of 8.0 (SD, 5.9) mm (11% ruptured, 16% posterior circulation, 18% nonsaccular morphology). All procedures were technically successful with a mean of 1.2 devices implanted. Balloon angioplasty was required in 20/144 (13.9%) procedures. Major neurologic adverse events occurred in 6/144 (4.2%) procedures (all ischemic stroke), resulting in death in 2 (1.4%) patients. There were no hemorrhagic complications. At a mean of 11 months, complete occlusion was achieved in 85/112 (75.9%) aneurysms, 15/112 (13.4%) had an entry remnant, and 12/112 (10.7%) had an aneurysm remnant. CONCLUSIONS: The results demonstrate high feasibility, procedural safety, and efficacy of the surface-modified Pipeline flow diverters.
RESUMEN
BACKGROUND: A study was undertaken to assess the effectiveness of open-source large language models (LLMs) in extracting clinical data from unstructured mechanical thrombectomy reports in patients with ischemic stroke caused by a vessel occlusion. METHODS: We deployed local open-source LLMs to extract data points from free-text procedural reports in patients who underwent mechanical thrombectomy between September 2020 and June 2023 in our institution. The external dataset was obtained from a second university hospital and comprised consecutive cases treated between September 2023 and March 2024. Ground truth labeling was facilitated by a human-in-the-loop (HITL) approach, with time metrics recorded for both automated and manual data extractions. We tested three models-Mixtral, Qwen, and BioMistral-assessing their performance on precision, recall, and F1 score across 15 clinical categories such as National Institute of Health Stroke Scale (NIHSS) scores, occluded vessels, and medication details. RESULTS: The study included 1000 consecutive reports from our primary institution and 50 reports from a secondary institution. Mixtral showed the highest precision, achieving 0.99 for first series time extraction and 0.69 for occluded vessel identification within the internal dataset. In the external dataset, precision ranged from 1.00 for NIHSS scores to 0.70 for occluded vessels. Qwen showed moderate precision with a high of 0.85 for NIHSS scores and a low of 0.28 for occluded vessels. BioMistral had the broadest range of precision, from 0.81 for first series times to 0.14 for medication details. The HITL approach yielded an average time savings of 65.6% per case, with variations from 45.95% to 79.56%. CONCLUSION: This study highlights the potential of using LLMs for automated clinical data extraction from medical reports. Incorporating HITL annotations enhances precision and also ensures the reliability of the extracted data. This methodology presents a scalable privacy-preserving option that can significantly support clinical documentation and research endeavors.
RESUMEN
OBJECTIVE: The flow re-direction endoluminal device (FRED) is a safe and effective treatment option for intracranial aneurysms. The novel FRED X features an antithrombotic surface coating ("X Technology") on an otherwise unmodified stent design. This two-center study evaluates the clinical safety and efficacy of FRED X and compares it to the literature. METHODS: Consecutive patients treated between 2020 and 2023 were retrospectively reviewed for aneurysm characteristics, procedural details and complications, and angiographic outcomes. A mini-review of the literature for FRED X clinical trials was performed and results were pooled using a random effects model. RESULTS: Thirty-four patients (mean age 56 years) were treated for 34 aneurysms. The mean aneurysm size was 7.7 ± 5.0â mm, 7 (21%) were ruptured, 6 (18%) were recurrent after previous treatment, 11 (32.3%) were located in the posterior circulation, and 4 (12.5%) had non-saccular morphology. All procedures were technically successful and no balloon angioplasty was required. There was 1 (2.9%) symptomatic complication (a transient ischemic attack) and no procedural morbidity or mortality. Technical asymptomatic events included 1 procedural stent occlusion that was reopened with thrombectomy and 3 cases of vasospasm. Complete and adequate occlusion rates were 68% (19/28) and 89% (25/28) at a mean follow-up time of 6 months, respectively. The results of this study are comparable to previous FRED X studies. CONCLUSIONS: The results demonstrate a high feasibility and procedural safety of the FRED X with adequate mid-term occlusion rates. Long-term and comparative studies are needed to evaluate the full potential of the FRED X.
RESUMEN
BACKGROUND: This multicenter study evaluated the safety and efficacy of coated flow diverters (cFDs) for the treatment of ruptured intracranial aneurysms. METHODS: Consecutive patients treated with different cFDs for ruptured aneurysms under tirofiban at eight neurovascular centers between 2016 and 2023 were retrospectively analyzed. The majority of patients were loaded with dual antiplatelet therapy after the treatment. Aneurysm occlusion was determined using the O'Kelly-Marotta (OKM) grading scale. Primary outcome measures were major procedural complications and aneurysmal rebleeding during hospitalization. RESULTS: The study included 60 aneurysms (posterior circulation: 28 (47%)) with a mean size of 5.8±4.7 mm. Aneurysm morphology was saccular in 28 (47%), blister-like in 12 (20%), dissecting in 13 (22%), and fusiform in 7 (12%). Technical success was 100% with a mean of 1.1 cFDs implanted per aneurysm. Adjunctive coiling was performed in 11 (18%) aneurysms. Immediate contrast retention was observed in 45 (75%) aneurysms. There was 1 (2%) major procedural complication (a major stroke, eventually leading to death) and no aneurysmal rebleeding. A good outcome (modified Rankin Scale 0-2) was achieved in 40 (67%) patients. At a mean follow-up of 6 months, 27/34 (79%) aneurysms were completely occluded (OKM D), 3/34 (9%) had an entry remnant (OKM C), and 4/34 (12%) had residual filling (OKM A or B). There was 1 (3%) severe in-stent stenosis during follow-up that was treated with balloon angioplasty. CONCLUSIONS: Treatment of ruptured aneurysms with cFDs was reasonably safe and efficient and thus represents a valid treatment option, especially for complex cases.
RESUMEN
OBJECTIVE: The diagnosis of neurosarcoidosis (NS) remains challenging due to the difficulty to obtain central nervous system (CNS) biopsies. Various diagnostic parameters are considered for the definition of possible, probable and definite NS. Magnetic resonance imaging (MRI) is the imaging gold standard and considered in diagnostic criteria. Fluorodeoxyglucose positron emission (18F-FDG PET) is sometimes performed additionally to identify possible systemic biopsy targets. However, at present, its findings are not incorporated into the diagnostic criteria for neurosarcoidosis (NS). METHODS: We conducted a single center retrospective search for the period 2020-2022, for patients with neurological symptoms in a diagnostic context of suspected NS who underwent MRI and additional 18F-FDG PET scans to identify potential hypermetabolism in the CNS and biopsy targets. RESULTS: We identified three cases of NS, where Gadolinium-enhanced MRI scans did not show abnormalities while 18F-FDG PET revealed hypermetabolic lesions in areas of the CNS. Additional MRI scans were still inconclusive for structural changes. We diagnosed a "probable" NS in all cases with histopathological confirmation of systemic sarcoidosis which led to an intensified therapy regime. DISCUSSION: 18F-FDG PET is an early indicator for metabolic changes. It appears to be a useful add-on to improve accuracy of diagnostic criteria in suspected NS without MRI findings.
RESUMEN
INTRODUCTION: Restricted retinal diffusion (RDR) has recently been recognized as a frequent finding on standard diffusion-weighted imaging (DWI) in central retinal artery occlusion (CRAO). However, data on early DWI signal evolution are missing. PATIENTS AND METHODS: Consecutive CRAO patients with DWI performed within 24 h after onset of visual impairment were included in a bicentric, retrospective cross-sectional study. Two blinded neuroradiologists assessed randomized DWI scans for the presence of retinal ischemia. RDR detection rates, false positive ratings, and interrater agreement were evaluated for predefined time groups. RESULTS: Sixty eight CRAO patients (68.4 ± 16.8 years; 25 female) with 72 DWI scans (76.4% 3 T, 23.6% 1.5 T) were included. Mean time-delay between onset of CRAO and DWI acquisition was 13.4 ± 7.0 h. Overall RDR detection rates ranged from 52.8% to 62.5% with false positive ratings in 4.2%-8.3% of cases. RDR detection rates were higher in DWI performed 12-24 h after onset, when compared with DWI acquired within the first 12 h (79.5%vs 39.3%, p < 0.001). The share of false positive ratings was highest for DWI performed within the first 6 h of symptom onset (up to 14.3%). Interrater reliability was "moderate" for DWI performed within the first 18 h (κ = 0.57-0.58), but improved for DWI acquired between 18 and 24 h (κ = 0.94). CONCLUSION: DWI-based detection of retinal ischemia in early CRAO is likely to be time-dependent with superior diagnostic accuracy for DWI performed 12-24 h after onset of visual impairment.
Asunto(s)
Isquemia Encefálica , Oclusión de la Arteria Retiniana , Enfermedades de la Retina , Humanos , Femenino , Isquemia Encefálica/diagnóstico , Estudios Retrospectivos , Estudios Transversales , Reproducibilidad de los Resultados , Imagen de Difusión por Resonancia Magnética , Oclusión de la Arteria Retiniana/diagnóstico por imagen , Trastornos de la Visión , IsquemiaRESUMEN
INTRODUCTION: In recent years, the role of intravenous thrombolysis (IVT) before endovascular stroke treatment (EVT) has been discussed intensively. Whether the discussion was accompanied by changing rates of bridging IVT is unknown. METHODS: Data were extracted from the prospectively maintained German Stroke Registry, including patients treated with EVT at one of 28 stroke centers in Germany between 2016 and 2021. Primary outcome parameters were the rate of bridging IVT (a) in the entire registry cohort and (b) in patients without formal contraindications to IVT (i.e. recent oral anticoagulants, time window ⩾4.5 h, extensive early ischemic changes) adjusted for demographic and clinical confounders. RESULTS: 10,162 patients (52.8% women, median age 77 years, median National Institutes of Health Stroke Scale score 14) were analyzed. In the entire cohort, the rate of bridging IVT decreased from 63.8% in 2016 to 43.6% in 2021 (average absolute annual decrease 3.1%, 95% CI 2.4%-3.8%), while the proportion of patients with at least one formal contraindication increased by only 1.2% annually (95% CI 0.6%-1.9%). Among 5460 patients without record of formal contraindications, the rate of bridging IVT decreased from 75.5% in 2016 to 63.2% in 2021 and was significantly associated with admission date in a multivariable model (average absolute annual decrease 1.4%, 95% CI 0.6%-2.2%). Clinical factors associated with lower odds of bridging IVT included diabetes mellitus, carotid-T-occlusion, dual antiplatelet therapy, and direct admission to a thrombectomy center. CONCLUSION: We observed a substantial decline in bridging IVT rates independent of demographic confounders and not explained by an increase in contraindications. This observation deserves further exploration in independent populations.
Asunto(s)
Arteriopatías Oclusivas , Enfermedades de las Arterias Carótidas , Procedimientos Endovasculares , Accidente Cerebrovascular Isquémico , Accidente Cerebrovascular , Trombosis , Estados Unidos , Humanos , Femenino , Anciano , Masculino , Accidente Cerebrovascular Isquémico/tratamiento farmacológico , Terapia Trombolítica/efectos adversos , Accidente Cerebrovascular/tratamiento farmacológico , Enfermedades de las Arterias Carótidas/tratamiento farmacológico , Trombosis/tratamiento farmacológico , Arteriopatías Oclusivas/tratamiento farmacológico , Procedimientos Endovasculares/efectos adversos , Sistema de RegistrosRESUMEN
BACKGROUND: Endovascular embolization is a feasible treatment for cranial dural arteriovenous fistulas (DAVFs). New embolic agents aim to improve the success of DAVF embolization. OBJECTIVE: To assess the safety, efficacy, and short-term outcome of the treatment of DAVFs using the new liquid embolic agent Squid. METHODS: The LIQUID study is a prospective, observational multicenter study on the treatment of high-grade (Cognard type ≥3) DAVFs with the embolic agent Squid. The primary outcome measures were safety (ie, morbidity and mortality), as well as the occlusion rate 90 to 180 days after treatment. RESULTS: In eight centers, 53 patients (mean age 59.8 years, 22.6% female) were treated in 55 treatment sessions. Of the DAVFs, 56.6% were Cognard type III, 41.5% type IV, and 18.9% were ruptured. Squid 18 was used in 83.6% and Squid 12 in 32.7% of the treatments. The overall rate of intraprocedural or postprocedural adverse events (AEs) was 18.2%. Procedure-related AEs resulting in permanent morbidity were observed in 3.6%. One patient (1.8%) died unrelated to the procedure due to pulmonary embolism. The final complete occlusion rate at 90 to 180 days was 93.2%. After a mean follow-up of 5.5 months, the modified Rankin Scale (mRS) score was stable or improved in 93.0%. In one of the patients, worsening of the mRS score was related to the procedure (1.8%). CONCLUSION: Squid is a safe and effective liquid embolic agent for the treatment of high-grade DAVFs.
Asunto(s)
Malformaciones Vasculares del Sistema Nervioso Central , Embolización Terapéutica , Humanos , Femenino , Persona de Mediana Edad , Masculino , Estudios Prospectivos , Resultado del Tratamiento , Malformaciones Vasculares del Sistema Nervioso Central/diagnóstico por imagen , Malformaciones Vasculares del Sistema Nervioso Central/terapia , Malformaciones Vasculares del Sistema Nervioso Central/etiología , Embolización Terapéutica/efectos adversos , Embolización Terapéutica/métodos , Polivinilos , Estudios RetrospectivosRESUMEN
BACKGROUND: The CLinical Assessment of WEB device in Ruptured aneurYSms (CLARYS) study has shown that the endovascular treatment of ruptured bifurcation aneurysms with the Woven EndoBridge (WEB) is safe and effective and provides protection against rebleeding at 1 month and 1 year. The 12-month angiographic follow-up is an important endpoint of the study. METHODS: The CLARYS study is a prospective multicenter study conducted in 13 European centers. The study enrolled 60 patients with 60 ruptured aneurysms of the anterior and posterior circulation. The study was conducted with an independent assessment of safety outcomes and imaging. RESULTS: Sixty patients with 60 ruptured bifurcation aneurysms to be treated with the WEB were included. Fifty-three aneurysms (88.3%) had a broad base with a dome to neck ratio <2 (mean 1.6). Of these, 46 patients were evaluated by an independent core laboratory with follow-up imaging performed at 12 months or before eventual retreatment. At 1 year, 19/46 aneurysms (41.3%) were completely occluded (Raymond-Roy grade I), 21/46 (45.7%) had a residual neck and 6/46 (13.0%) had residual aneurysm filling. Adequate occlusion was reported in 40/46 (87%) aneurysms. Six patients underwent target aneurysm retreatment. CONCLUSIONS: The CLARYS study has previously shown that the use of the WEB in the endovascular treatment of ruptured bifurcation aneurysms provides effective protection against rebleeding with a good safety profile. The angiographic occlusion rates at 1 year reported here are comparable to those already seen in previous multicenter studies which primarily included unruptured aneurysms.
Asunto(s)
Aneurisma Roto , Procedimientos Endovasculares , Aneurisma Intracraneal , Humanos , Resultado del Tratamiento , Estudios Prospectivos , Aneurisma Intracraneal/diagnóstico por imagen , Aneurisma Intracraneal/cirugía , Procedimientos Endovasculares/métodos , Aneurisma Roto/diagnóstico por imagen , Aneurisma Roto/cirugíaRESUMEN
PURPOSE: Endovascular treatment (ET) in patients with large vessel occlusion stroke (LVOS) with unknown onset or an extended time window can be safe and effective if patients are selected by defined clinical and imaging criteria; however, it is unclear if these criteria should also be applied to patients with unknown onset and unknown time last known well. In this study, we aimed to assess whether absent information on the time patients were last known to be well impacts outcome in patients with unknown onset LVOS. METHODS: We analyzed patients who were enrolled in the German Stroke Registry-Endovascular Treatment between 2015 and 2019. Patients with unknown onset and unknown time last known well (LKWu) were compared to patients with known onset (KO) and to patients with unknown onset but known time last known well (LKWk) regarding clinical and imaging baseline characteristics and outcome. RESULTS: Out of 5909 patients, 561 presented with LKWu (9.5%), 1849 with LKWk (31.3%) and 3499 with KO (59.2%). At 90 days, functional independency was less frequent in LKWu (27.0%) compared to KO (42.6%) and LKWk patients (31.8%). These differences were not significant after adjusting for confounders. A main confounder was the initial Alberta stroke program early CT score. CONCLUSION: The LKWu patients had a similar outcome after ET as KO and LKWk patients after adjusting for confounders. Thus, ET should not be withheld if the time last known well is unknown. Instead, LKWu patients may be selected for ET using the same criteria as in LKWk patients.
Asunto(s)
Procedimientos Endovasculares , Accidente Cerebrovascular Isquémico , Accidente Cerebrovascular , Humanos , Trombectomía/métodos , Procedimientos Endovasculares/métodos , Accidente Cerebrovascular/diagnóstico por imagen , Accidente Cerebrovascular/terapia , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular Isquémico/etiología , Factores de TiempoRESUMEN
BACKGROUND: Flow diverters are an increasingly used treatment option for intracranial aneurysms. A recent addition to the European market is the DERIVO®2 Embolization Device (DED2), promising improved radiopacity. We aimed to assess the safety and efficacy of the DED2 regarding angiographic and clinical outcomes in ruptured and unruptured cerebral aneurysms. METHODS: We performed a multicenter trial at six interventional centers. Data were prospectively collected and all patients treated with the DED2 were included. The primary endpoint was angiographic aneurysm occlusion at 6 months as assessed by the O'Kelly Marotta (OKM) grading scale with a favorable outcome definition of OKM C + D. Clinical outcome was evaluated according to the modified Rankin scale (mRS). RESULTS: Between August 2020 and July 2021, 37 patients were treated with the DED2 and were included in our analysis. Five patients presented with ruptured aneurysms. Median age was 60 years, 27 patients were female, and 10 male. Median mRS was 0 (range 0-4). Mean aneurysm size was 8.9 ± 7.1â mm with a mean neck size of 6.5 ± 6.1. The DED2 fully opened at deployment in all cases. Clinical follow-up was available for 30 patients (81%). Twenty-five (83%) had an mRS of 0 or 1. Three patients with ruptured aneurysms died during the follow-up period. No treatment-related major morbidity was observed. Follow-up imaging was available in 27 (90%) patients, with 23 patients (85%) showing satisfactory aneurysm occlusion OKM grade C-D. CONCLUSION: In this small cohort, the DED2 provided safe and effective treatment of ruptured and unruptured intracranial aneurysms.
RESUMEN
Purpose: To evaluate a commercially available mobile device for the highly specialized task of detection of intracranial arterial aneurysm in telemedicine. Methods: Six radiologists with three different levels of experience retrospectively interpreted 60 computed tomography (CT) angiographies for the presence of intracranial arterial aneurysm, among them 30 cases with confirmed positive findings. Each radiologist reviewed the angiography datasets twice: once on a dedicated medical-grade workstation and on a commercially available mobile consumer-grade tablet with an interval of 3 months. Diagnostic performance, reading efficiency and subjective scorings including diagnostic confidence were analyzed and compared. Results: Diagnostic performance was comparable on both devices regardless of readers' experience, and no significant differences in sensitivity (66-87.5%) and specificity (79.4-87%) were found. Results obtained with tablets and medical workstations were also comparable in terms of subjective assessment across all reader groups. Conclusions: There was no significant difference between tablet and workstation readings of angiography datasets for the presence of intracranial arterial aneurysm. Sensitivity, specificity, efficiency and subjective scorings were similar with the two devices for all three reader groups. While medical workstations are 10 times more expensive, tablets allow higher mobility especially for radiologists on call.
RESUMEN
Radiolucent carbon-fiber reinforced PEEK (CFRP) implants have helped improve oncological follow-up and radiation therapy. Here, we investigated the performance of 3D intraoperative imaging and navigation systems for instrumentation and precision assessment of CFRP pedicle screws across the thoraco-lumbar spine. Thirty-three patients with spinal tumors underwent navigated CFRP instrumentation with intraoperative CT (iCT), robotic cone-beam CT (rCBCT) or cone-beam CT (CBCT) imaging. Two different navigation systems were used for iCT-/rCBCT- and CBCT-based navigation. Demographic, clinical and outcome data was assessed. Four blinded observers rated image quality, assessability and accuracy of CFRP pedicle screws. Inter-observer reliability was determined with Fleiss` Kappa analysis. Between 2018 and 2021, 243 CFRP screws were implanted (iCT:93, rCBCT: 99, CBCT: 51), of which 13 were non-assessable (iCT: 1, rCBCT: 9, CBCT: 3; *p = 0.0475; iCT vs. rCBCT). Navigation accuracy was highest using iCT (74%), followed by rCBCT (69%) and CBCT (49%) (*p = 0.0064; iCT vs. CBCT and rCBCT vs. CBCT). All observers rated iCT image quality higher than rCBCT/CBCT image quality (*p < 0.01) but relevant pedicle breaches were reliably identified with substantial agreement between all observers regardless of the imaging modality. Navigation accuracy for CFRP pedicle screws was considerably lower than expected from reports on titanium implants and CT may be best for reliable assessment of CFRP materials.
Asunto(s)
Fusión Vertebral , Cirugía Asistida por Computador , Benzofenonas , Fibra de Carbono , Humanos , Cetonas , Plásticos , Polietilenglicoles , Polímeros , Reproducibilidad de los Resultados , Estudios Retrospectivos , Fusión Vertebral/métodos , Cirugía Asistida por Computador/métodos , Titanio , Tomografía Computarizada por Rayos X/métodosRESUMEN
PURPOSE: The present study aimed to assess the feasibility, safety and accuracy of navigated spinopelvic fixation with focus on S2-alar-iliac screws (S2AIS) and tricortical S1 pedicle screw implantation with the use of high-resolution three-dimensional intraoperative imaging and real-time spinal navigation. METHODS: Patients undergoing navigated intraoperative CT-based spinopelvic stabilization between January 2016 and September 2019 were included. Pelvic fixation was achieved by implantation of S2AIS or iliac screws (IS). S1 screws were implanted with the goal of achieving tricortical purchase. In all cases, instrumentation was performed with real-time spinal navigation and intraoperative screw positioning was assessed using intraoperative computed tomography (iCT), cone-beam CT (CBCT) and robotic cone-beam CT (rCBCT). Screw accuracy was evaluated based on radiographic criteria. To identify predictors of complications, univariate analysis was performed. RESULTS: Overall, 52 patients (85%) received S2AIS and nine patients (15%) received IS instrumentation. Intraoperative imaging and spinal navigation were performed with iCT in 34 patients, CBCT in 21 patients and rCBCT in six patients. A total number of 10/128 (7.8%) iliac screws underwent successful intraoperative correction due to misalignment. Tricortical purchase was successfully accomplished in 58/110 (53%) of the S1 screws with a clear learning curve in the course of time. S2AIS implantation was associated with significantly fewer surgical side infection-associated surgeries. CONCLUSIONS: Real-time navigation facilitated spinopelvic instrumentation with increasing accuracy of S2AIS and tricortical S1 screws. Intraoperative imaging by iCT, CBCT or rCBCT permitted screw assessment with the chance of direct navigated revision of misplaced iliac screws to avoid secondary screw revision surgery.
Asunto(s)
Tornillos Pediculares , Fusión Vertebral , Humanos , Imagenología Tridimensional/métodos , Estudios Retrospectivos , Fusión Vertebral/métodos , Columna Vertebral/cirugíaRESUMEN
Focal brain damage after aneurysmal subarachnoid haemorrhage predominantly results from intracerebral haemorrhage, and early and delayed cerebral ischaemia. The prospective, observational, multicentre, cohort, diagnostic phase III trial, DISCHARGE-1, primarily investigated whether the peak total spreading depolarization-induced depression duration of a recording day during delayed neuromonitoring (delayed depression duration) indicates delayed ipsilateral infarction. Consecutive patients (n = 205) who required neurosurgery were enrolled in six university hospitals from September 2009 to April 2018. Subdural electrodes for electrocorticography were implanted. Participants were excluded on the basis of exclusion criteria, technical problems in data quality, missing neuroimages or patient withdrawal (n = 25). Evaluators were blinded to other measures. Longitudinal MRI, and CT studies if clinically indicated, revealed that 162/180 patients developed focal brain damage during the first 2 weeks. During 4.5 years of cumulative recording, 6777 spreading depolarizations occurred in 161/180 patients and 238 electrographic seizures in 14/180. Ten patients died early; 90/170 developed delayed infarction ipsilateral to the electrodes. Primary objective was to investigate whether a 60-min delayed depression duration cut-off in a 24-h window predicts delayed infarction with >0.60 sensitivity and >0.80 specificity, and to estimate a new cut-off. The 60-min cut-off was too short. Sensitivity was sufficient [= 0.76 (95% confidence interval: 0.65-0.84), P = 0.0014] but specificity was 0.59 (0.47-0.70), i.e. <0.80 (P < 0.0001). Nevertheless, the area under the receiver operating characteristic (AUROC) curve of delayed depression duration was 0.76 (0.69-0.83, P < 0.0001) for delayed infarction and 0.88 (0.81-0.94, P < 0.0001) for delayed ischaemia (reversible delayed neurological deficit or infarction). In secondary analysis, a new 180-min cut-off indicated delayed infarction with a targeted 0.62 sensitivity and 0.83 specificity. In awake patients, the AUROC curve of delayed depression duration was 0.84 (0.70-0.97, P = 0.001) and the prespecified 60-min cut-off showed 0.71 sensitivity and 0.82 specificity for reversible neurological deficits. In multivariate analysis, delayed depression duration (ß = 0.474, P < 0.001), delayed median Glasgow Coma Score (ß = -0.201, P = 0.005) and peak transcranial Doppler (ß = 0.169, P = 0.016) explained 35% of variance in delayed infarction. Another key finding was that spreading depolarization-variables were included in every multiple regression model of early, delayed and total brain damage, patient outcome and death, strongly suggesting that they are an independent biomarker of progressive brain injury. While the 60-min cut-off of cumulative depression in a 24-h window indicated reversible delayed neurological deficit, only a 180-min cut-off indicated new infarction with >0.60 sensitivity and >0.80 specificity. Although spontaneous resolution of the neurological deficit is still possible, we recommend initiating rescue treatment at the 60-min rather than the 180-min cut-off if progression of injury to infarction is to be prevented.
Asunto(s)
Lesiones Encefálicas , Depresión de Propagación Cortical , Hemorragia Subaracnoidea , Lesiones Encefálicas/complicaciones , Infarto Cerebral/complicaciones , Electrocorticografía , Humanos , Estudios Prospectivos , Hemorragia Subaracnoidea/complicaciones , Hemorragia Subaracnoidea/diagnóstico por imagenRESUMEN
To describe our experience with mechanical thrombectomy (MT) in distal anterior cerebral artery (ACA) occlusions regarding recanalization rates, MT techniques and procedural safety. From a prospectively maintained thrombectomy database all patients with distal ACA occlusions treated with MT between April 2013 and February 2021 were retrospectively identified. Imaging data and angiographic features as well as clinical data were collected. 41 patients were included in the study, including 23 patients (56.1%) with distal main stem occlusions (occlusions distal to the anterior communicating artery but proximal to the origin of the pericallosal and callosomarginal arteries) and 18 patients (46.3%) with distal individual branch occlusions (occlusions of the pericallosal or callosomarginal arteries and their ramifications). A stent retriever mediated technique was applied in 34 patients (82.9%), the ADAPT technique in 7 patients (17.1%). Successful (mTICI 2b/3) and complete recanalization (mTICI 3) rates did not differ for the distal ACA main stem occlusion group (82.6%/56.5%), and the individual branch occlusion group (83.3%/55.6%) (p â« 0.05). No severe complications specific to distal MT maneuvers were noted. MT for acute distal individual ACA branch occlusions beyond the common A2/3 trunk appears safe and technically effective in different clinical settings and occlusion patterns with high recanalization rates. However, further studies are required to determine the clinical effectiveness.
Asunto(s)
Arteriopatías Oclusivas , Trombectomía , Arteria Cerebral Anterior/cirugía , Arteriopatías Oclusivas/cirugía , Humanos , Estudios Retrospectivos , Stents , Trombectomía/efectos adversos , Trombectomía/métodos , Resultado del TratamientoRESUMEN
BACKGROUND: Follow-up imaging in intracerebral hemorrhage is not standardized and radiologists rely on different imaging modalities to determine hematoma growth. This study assesses the volumetric accuracy of different imaging modalities (MRI, CT angiography, postcontrast CT) to measure hematoma size. METHODS: 28 patients with acute spontaneous intracerebral hemorrhage referred to a tertiary stroke center were retrospectively included between 2018 and 2019. Inclusion criteria were (1) spontaneous intracerebral hemorrhage (supra- or infratentorial), (2) noncontrast CT imaging performed on admission, (3) follow-up imaging (CT angiography, postcontrast CT, MRI), and (4) absence of hematoma expansion confirmed by a third cranial image within 6 days. Two independent raters manually measured hematoma volume by drawing a region of interest on axial slices of admission noncontrast CT scans as well as on follow-up imaging (CT angiography, postcontrast CT, MRI) using a semi-automated segmentation tool (Visage image viewer; version 7.1.10). Results were compared using Bland-Altman plots. RESULTS: Mean admission hematoma volume was 18.79 ± 19.86 cc. All interrater and intrarater intraclass correlation coefficients were excellent (1; IQR 0.98-1.00). In comparison to hematoma volume on admission noncontrast CT volumetric measurements were most accurate in patients who received postcontrast CT (bias of - 2.47%, SD 4.67: n = 10), while CT angiography often underestimated hemorrhage volumes (bias of 31.91%, SD 45.54; n = 20). In MRI sequences intracerebral hemorrhage volumes were overestimated in T2* (bias of - 64.37%, SD 21.65; n = 10). FLAIR (bias of 6.05%, SD 35.45; n = 13) and DWI (bias of-14.6%, SD 31.93; n = 12) over- and underestimated hemorrhagic volumes. CONCLUSIONS: Volumetric measurements were most accurate in postcontrast CT while CT angiography and MRI sequences often substantially over- or underestimated hemorrhage volumes.
Asunto(s)
Hemorragia Cerebral/diagnóstico por imagen , Hematoma/diagnóstico por imagen , Neuroimagen/métodos , Anciano , Anciano de 80 o más Años , Angiografía por Tomografía Computarizada , Medios de Contraste , Interpretación Estadística de Datos , Femenino , Humanos , Procesamiento de Imagen Asistido por Computador , Imagen por Resonancia Magnética , Masculino , Estudios Retrospectivos , Tomografía Computarizada por Rayos X/métodosRESUMEN
OBJECTIVE: A direct comparison of intraoperative CT (iCT), cone-beam CT (CBCT), and robotic cone-beam CT (rCBCT) has been necessary to identify the ideal imaging solution for each individual user's need. Herein, the authors sought to analyze workflow, handling, and performance of iCT, CBCT, and rCBCT imaging for navigated pedicle screw instrumentation across the entire spine performed within the same surgical environment by the same group of surgeons. METHODS: Between 2014 and 2018, 503 consecutive patients received 2673 navigated pedicle screws using iCT (n = 1219), CBCT (n = 646), or rCBCT (n = 808) imaging during the first 24 months after the acquisition of each modality. Clinical and demographic data, workflow, handling, and screw assessment and accuracy were analyzed. RESULTS: Intraoperative CT showed image quality and workflow advantages for cervicothoracic cases, obese patients, and long-segment instrumentation, whereas CBCT and rCBCT offered independent handling, around-the-clock availability, and the option of performing 2D fluoroscopy. All modalities permitted reliable intraoperative screw assessment. Navigated screw revision was possible with each modality and yielded final accuracy rates > 92% in all groups (iCT 96.2% vs CBCT 92.3%, p < 0.001) without a difference in the accuracy of cervical pedicle screw placement or the rate of secondary screw revision surgeries. CONCLUSIONS: Continuous training and an individual setup of iCT, CBCT, and rCBCT has been shown to permit safe and precise navigated posterior instrumentation across the entire spine with reliable screw assessment and the option of immediate revision. The perceived higher image quality and larger scan area of iCT should be weighed against the around-the-clock availability of CBCT and rCBCT technology with the option of single-handed robotic image acquisition.
Asunto(s)
Tornillos Pediculares , Procedimientos Quirúrgicos Robotizados , Fusión Vertebral , Cirugía Asistida por Computador , Tomografía Computarizada de Haz Cónico/métodos , Humanos , Estudios Retrospectivos , Fusión Vertebral/métodos , Cirugía Asistida por Computador/métodos , Flujo de TrabajoRESUMEN
Computer-assisted spine surgery based on preoperative CT imaging may be hampered by sagittal alignment shifts due to an intraoperative switch from supine to prone. In the present study, we systematically analyzed the occurrence and pattern of sagittal spinal alignment shift between corresponding preoperative (supine) and intraoperative (prone) CT imaging in patients that underwent navigated posterior instrumentation between 2014 and 2017. Sagittal alignment across the levels of instrumentation was determined according to the C2 fracture gap (C2-F) and C2 translation (C2-T) in odontoid type 2 fractures, next to the modified Cobb angle (CA), plumbline (PL), and translation (T) in subaxial pathologies. One-hundred and twenty-one patients (C1/C2: n = 17; C3-S1: n = 104) with degenerative (39/121; 32%), oncologic (35/121; 29%), traumatic (34/121; 28%), or infectious (13/121; 11%) pathologies were identified. In the subaxial spine, significant shift occurred in 104/104 (100%) cases (CA: *p = .044; T: *p = .021) compared to only 10/17 (59%) cases that exhibited shift at the C1/C2 level (C2-F: **p = .002; C2-T: *p < .016). The degree of shift was not affected by the anatomic region or pathology but significantly greater in cases with an instrumentation length > 5 segments ("∆PL > 5 segments": 4.5 ± 1.8 mm; "∆PL ≤ 5 segments": 2 ± 0.6 mm; *p = .013) or in revision surgery with pre-existing instrumentation ("∆PL presence": 5 ± 2.6 mm; "∆PL absence": 2.4 ± 0.7 mm; **p = .007). Interestingly, typical morphological instability risk factors did not influence the degree of shift. In conclusion, intraoperative spinal alignment shift due to a change in patient position should be considered as a cause for inaccuracy during computer-assisted spine surgery and when correcting spinal alignment according to parameters that were planned in other patient positions.
Asunto(s)
Vértebras Cervicales , Fusión Vertebral , Humanos , Estudios Retrospectivos , Factores de Riesgo , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND: The primary goal of the CLARYS study is to assess the protection against rebleeding when treating ruptured bifurcation aneurysms with the Woven EndoBridge (WEB) device. METHODS: The CLARYS study is a prospective, multicenter study conducted in 13 European centers. Patients with ruptured bifurcation aneurysms were consecutively included between February 2016 and September 2017. The primary endpoint was defined as the rebleeding rate of the target aneurysm treated with the WEB within 30 days postprocedure. Secondary endpoints included periprocedural and postprocedural adverse events, total procedure and fluoroscopy times, and modified Rankin Scale score at 1 month and 1 year. RESULTS: Sixty patients with 60 ruptured bifurcation aneurysms to be treated with the WEB were included. A WEB device was successfully implanted in 93.3%. The rebleeding rate at 1 month and 1 year was 0%. The mean fluoroscopy time was 27.0 min. Twenty-three periprocedural complications were observed in 18 patients and resolved without sequelae in 16 patients. Two of these complications were attributed to the procedure and/or the use of the WEB, leading to a procedure/device-related intraoperative complication rate of 3.3%. Overall mortality at 1 month and 1 year was 1.7% and 3.8%, respectively and overall morbidity at 1 month and 1 year was 15% and 9.6%, respectively. WEB-related 1-month and 1-year morbidity and mortality was 0%. CONCLUSIONS: The interim results of CLARYS show that the endovascular treatment of ruptured bifurcation aneurysms with the WEB is safe and effective and, in particular, provides effective protection against rebleeding. It may induce profound change in the endovascular management of ruptured bifurcation aneurysms.