RESUMEN
PURPOSE: Stereotactic radiotherapy (SRT) is the predominant method for the irradiation of resection cavities after resection of brain metastases (BM). Intraoperative radiotherapy (IORT) with 50 kV x-rays is an alternative way to irradiate the resection cavity focally. We have already reported the outcome of our first 40 IORT patients treated until 2020. Since then, IORT has become the predominant cavity treatment in our center due to patients´ choice. METHODS: We retrospectively analyzed the outcomes of all patients who underwent resection of BM and IORT between 2013 and August 2023 at Augsburg University Medical Center (UKA). RESULTS: We identified 105 patients with 117 resected BM treated with 50 kV x-ray IORT. Median diameter of the resected metastases was 3.1 cm (range 1.3 - 7.0 cm). Median applied dose was 20 Gy. All patients received standardized follow-up (FU) including three-monthly MRI of the brain. Mean FU was 14 months, with a median MRI FU for patients alive of nine months. Median overall survival (OS) of all treated patients was 18.2 months (estimated 1-year OS 57.7%). The observed local control (LC) rate of the resection cavity was 90.5% (estimated 1-year LC 84.2%). Distant brain control (DC) was 61.9% (estimated 1-year DC 47.9%). Only 16.2% of all patients needed WBI in the further course of disease. The observed radio necrosis rate was 2.6%. CONCLUSION: After 117 procedures IORT still appears to be a safe and appealing way to perform cavity RT after neurosurgical resection of BM with low toxicity and excellent LC.
Asunto(s)
Neoplasias Encefálicas , Procedimientos Neuroquirúrgicos , Humanos , Neoplasias Encefálicas/secundario , Neoplasias Encefálicas/radioterapia , Neoplasias Encefálicas/cirugía , Masculino , Femenino , Persona de Mediana Edad , Estudios Retrospectivos , Anciano , Adulto , Anciano de 80 o más Años , Cuidados Intraoperatorios , Estudios de Seguimiento , Resultado del Tratamiento , Tasa de SupervivenciaAsunto(s)
Isquemia Encefálica , Procedimientos Endovasculares , Accidente Cerebrovascular , Humanos , Presión Sanguínea , Hemorragias Intracraneales/diagnóstico por imagen , Hemorragias Intracraneales/terapia , Accidente Cerebrovascular/diagnóstico por imagen , Accidente Cerebrovascular/terapia , Resultado del Tratamiento , Isquemia Encefálica/terapia , TrombectomíaRESUMEN
In this anthropomorphic head phantom study, samples containing blood and contrast agent with concentrations ranging from 0 to 6 mg iodine per milliliter and another set of samples without blood for reference were scanned with a photon-counting detector CT using a standard cranial protocol. It was demonstrated that photon-counting detector CT can reliably distinguish hemorrhage and contrast media, including density determination of the latter. The technology promises to add value in several neuroimaging applications.
Asunto(s)
Medios de Contraste , Yodo , Humanos , Fotones , Tomografía Computarizada por Rayos X/métodos , Hemorragia , Fantasmas de ImagenRESUMEN
INTRODUCTION: Emergent stenting of the extracranial internal carotid artery (ICA) in stroke patients requires antiplatelet therapy to prevent in-stent thrombosis with a higher risk of intracranial haemorrhage. AIM OF THE STUDY: Assess the efficacy and safety of emergent carotid stenting with intravenous tirofiban in acute ischemic stroke patients. METHODS: Primary endpoint: symptomatic hemorrhage. Secondary endpoints: 90-day functional outcome and mortality. RESULTS: Of the 62 patients, 21 (34%) received tirofiban as a single antiplatelet, and 41 (66%) received combined therapy. Premedication with anticoagulants and antiplatelets was significantly more frequent in the tirofiban-only group. The rate of symptomatic haemorrhage was significantly lower in the tirofiban-only group than in the combined group (4.8% vs. 27%, pâ¯= 0.046). The patients with tirofiban alone had a significantly better functional outcome at day 90 than the combined group (52% vs. 24%, pâ¯= 0.028). Mortality was equal (24%) in both groups. Pre-interventional NIHSS score (pâ¯= 0.003), significant blood pressure fluctuations (pâ¯= 0.012), tandem occlusion (pâ¯= 0.023), and thrombolysis (pâ¯= 0.044) showed relevant influence on the rate of symptomatic hemorrhage in the entire patient cohort. CONCLUSIONS: A single antiplatelet therapy with tirofiban regardless of the premedication may improve the functional outcome in patients with stroke due to acute extracranial carotid lesion and emergent carotid stenting with lower rates of serious intracranial haemorrhage. For patients with high pre-interventional NIHSS score, tandem occlusion and after pre-interventional thrombolysis, caution is advised. Additionally, strict blood pressure monitoring should be conducted during the first 72â¯h after intervention.
Asunto(s)
Estenosis Carotídea , Procedimientos Endovasculares , Accidente Cerebrovascular Isquémico , Accidente Cerebrovascular , Humanos , Tirofibán , Accidente Cerebrovascular Isquémico/complicaciones , Infusiones Intravenosas , Estenosis Carotídea/complicaciones , Estenosis Carotídea/diagnóstico por imagen , Estenosis Carotídea/terapia , Inhibidores de Agregación Plaquetaria/efectos adversos , Resultado del Tratamiento , Stents , Accidente Cerebrovascular/tratamiento farmacológico , Accidente Cerebrovascular/etiología , Arteria Carótida Interna , Hemorragias Intracraneales/etiología , Estudios Retrospectivos , Procedimientos Endovasculares/efectos adversos , Trombectomía/efectos adversosRESUMEN
PURPOSE: Diagnostic cerebral catheter angiography is used to assess a variety of neurovascular pathologies especially in patients before and after endovascular neurointerventional treatment. In many centers diagnostic cerebral angiographies are performed with the patient staying for one night in the hospital because there are not yet sufficient data on the safety of ambulatory cerebral angiography. At the same time hospitals face a growing demand to perform ambulatory medical procedures. METHODS: A total of 426 ambulatory diagnostic cerebral angiographies were retrospectively analyzed. Technical details of the angiographies were analyzed to identify procedural risk factors. RESULTS: Out of 426 patients 14 (3.3%) had some form of complication, 3 developed minor transient neurological symptoms, 1 patient developed Quincke's edema probably as an adverse reaction to contrast agent, 1 patient had an asymptomatic carotid dissection and 1 had a fall of unknown etiology. Of the 14 complications 8 were puncture site complications with 1 re-bleeding, 1 dissection, and 6 minor complications, 421 punctures were femoral, 3 radial and 2 brachial. Out of 333 patients with magnetic resonance imaging (MRI) after angiography 21 showed focal diffusion-weighted imaging (DWI) lesions but none of these lesions were symptomatic. The rate of DWI lesions was significantly higher in selectively angiography territories than in other territories. The use of a Simmons 2 catheter significantly increased the rate of DWI lesions (pâ¯= 0.047), whereas 3D rotational angiography did not (pâ¯= 0.55). The rate of DWI lesions per selectively accessed vessel was 4.6% with a higher rate in the anterior than in the posterior circulation. CONCLUSION: Diagnostic cerebral catheter angiography can be safely performed in an ambulatory setting.
Asunto(s)
Imagen de Difusión por Resonancia Magnética , Imagen por Resonancia Magnética , Humanos , Angiografía Cerebral/métodos , Estudios Retrospectivos , CatéteresRESUMEN
Perimesencephalic nonaneurysmal subarachnoid hemorrhage (NASAH) is a rare type of subarachnoid hemorrhage (SAH), usually associated with minor complications compared to aneurysmal SAH. Up to date, data is scarce and consensus on therapeutic management and follow-up diagnostics of NASAH is often missing. This survey aims to evaluate the clinical management among neurosurgical departments in Germany. 135 neurosurgical departments in Germany received a hardcopy questionnaire. Encompassing three case vignettes with minor, moderate and severe NASAH on CT-scans and questions including the in-hospital treatment with initial observation, blood pressure (BP) management, cerebral vasospasm (CV) prophylaxis and the need for digital subtraction angiography (DSA). 80 departments (59.2%) answered the questionnaire. Whereof, centers with a higher caseload state an elevated complication rate (Chi2 < 0.001). Initial observation on the intensive care unit is performed in 51.3%; 47.5%, 70.0% in minor, moderate and severe NASAH, respectively. Invasive BP monitoring is performed more often in severe NASAH (52.5%, 55.0%, 71.3% minor, moderate, severe). CV prophylaxis and transcranial doppler ultrasound (TCD) are performed in 41.3%, 45.0%, 63.8% in minor, moderate and severe NASAH, respectively. Indication for a second DSA is set in the majority of centers, whereas after two negative ones, a third DSA is less often indicated (2nd: 66.2%, 72.5%, 86.2%; 3rd: 3.8%, 3.8%, 13.8% minor, moderate, severe). This study confirms the influence of bleeding severity on treatment and follow-up of NASAH patients. Additionally, the existing inconsistency of treatment pathways throughout Germany is highlighted. Therefore, we suggest to conceive new treatment guidelines including this finding.
Asunto(s)
Hemorragia Subaracnoidea , Vasoespasmo Intracraneal , Humanos , Hemorragia Subaracnoidea/diagnóstico por imagen , Hemorragia Subaracnoidea/terapia , Hemorragia Subaracnoidea/complicaciones , Espacio Subaracnoideo , Tomografía Computarizada por Rayos X/efectos adversos , Vasoespasmo Intracraneal/diagnóstico por imagen , Vasoespasmo Intracraneal/terapia , Vasoespasmo Intracraneal/complicaciones , Angiografía de Substracción Digital , Angiografía CerebralRESUMEN
The use of stents is well established in the treatment of broad-based intracranial aneurysms. The aim of this study is to report on safety, feasibility and midterm follow-up of the new LVIS EVO braided stent for the treatment of cerebral aneurysms. All consecutive patients with intracranial aneurysms who were treated with the LVIS EVO stent in two high volume neurovascular centers were retrospectively enrolled in this observational study. Clinical and technical complications, angiographic outcome and clinical short-term and midterm results were evaluated. The study included 112 patients with 118 aneurysms. 94 patients presented with incidental aneurysms, 13 patients with acute SAH and 2 patients with acute cranial nerve palsy. For 100 aneurysms a jailing technique was used, re-crossing of the stent was performed in 3 cases. For the residual 15 cases the stent was placed as a bail-out or as a second step. Immediate complete occlusion was observed in 85 aneurysms (72%). Midterm follow-up was available for 84 patients with 86 aneurysms (72.9%). One stent showed asymptomatic complete occlusion on follow-up imaging, in all other cases no in-stent stenosis was observed. The rate of complete occlusion was 79.1% at 6 months and 82.2% at 12-18 months. Midterm follow-up data of this retrospective observational cohort of two neurovascular centers corroborates the safety profile of the LVIS EVO device for treatment of ruptured and unruptured intracranial aneurysms.
Asunto(s)
Embolización Terapéutica , Procedimientos Endovasculares , Aneurisma Intracraneal , Humanos , Aneurisma Intracraneal/cirugía , Estudios Retrospectivos , Estudios de Seguimiento , Resultado del Tratamiento , Angiografía Cerebral/métodos , Stents/efectos adversos , Procedimientos Endovasculares/métodosRESUMEN
BACKGROUND: Coronavirus disease 2019 (COVID-19) is an infection which can affect the central nervous system. In this study, we sought to investigate associations between neuroimaging findings with clinical, demographic, blood and cerebrospinal fluid (CSF) parameters, pre-existing conditions and the severity of acute COVID-19. MATERIALS AND METHODS: Retrospective multicenter data retrieval from 10 university medical centers in Germany, Switzerland and Austria between February 2020 and September 2021. We included patients with COVID-19, acute neurological symptoms and cranial imaging. We collected demographics, neurological symptoms, COVID-19 severity, results of cranial imaging, blood and CSF parameters during the hospital stay. RESULTS: 442 patients could be included. COVID-19 severity was mild in 124 (28.1%) patients (moderate n = 134/30.3%, severe n = 43/9.7%, critical n = 141/31.9%). 220 patients (49.8%) presented with respiratory symptoms, 167 (37.8%) presented with neurological symptoms first. Acute ischemic stroke (AIS) was detected in 70 (15.8%), intracranial hemorrhage (IH) in 48 (10.9%) patients. Typical risk factors were associated with AIS; extracorporeal membrane oxygenation therapy and invasive ventilation with IH. No association was found between the severity of COVID-19 or blood/CSF parameters and the occurrence of AIS or IH. DISCUSSION: AIS was the most common finding on cranial imaging. IH was more prevalent than expected but a less common finding than AIS. Patients with IH had a distinct clinical profile compared to patients with AIS. There was no association between AIS or IH and the severity of COVID-19. A considerable proportion of patients presented with neurological symptoms first. Laboratory parameters have limited value as a screening tool.
Asunto(s)
COVID-19 , Accidente Cerebrovascular Isquémico , Accidente Cerebrovascular , Humanos , COVID-19/complicaciones , Accidente Cerebrovascular Isquémico/complicaciones , Hemorragias Intracraneales/diagnóstico por imagen , Hemorragias Intracraneales/epidemiología , Hemorragias Intracraneales/etiología , Neuroimagen , Factores de Riesgo , Estudios Retrospectivos , Accidente Cerebrovascular/complicaciones , Accidente Cerebrovascular/diagnóstico por imagen , Accidente Cerebrovascular/epidemiologíaRESUMEN
PURPOSE: Intracranial rescue stent angioplasty is a bailout strategy for acute stroke patients in cases of unsuccessful endovascular thrombectomy due to underlying atherosclerotic stenosis. However, there is no consensus on a preprocedural and intraprocedural antiplatelet regimen. The aim of this single-centre study was to compare the safety and efficacy of emergency stenting in patients exhibiting intracranial atherosclerotic stenosis-related acute large-vessel occlusion with or without peri-interventional intravenous infusion of tirofiban. MATERIALS AND METHODS: We performed a retrospective analysis of 78 patients who were treated with rescuestent angioplasty between 2010 and 2019 due to acute ischaemic stroke. The patients were divided into 2 groups: those who received peri-interventional intravenous tirofiban and those who did not receive tirofiban. We compared clinical safety and functional outcomes in both treatment groups with symptomatic haemorrhage as the primary endpoint. Bivariate and multivariable logistic regression was performed to investigate the association between tirofiban and outcome measures. RESULTS: Thirty-seven patients were treated with intravenous tirofiban (47.4%), and 41 patients did not receive intravenous tirofiban (52.6%). Statistical analysis revealed no significant difference between the two groups in the rate of symptomatic haemorrhage (16.2% in the tirofiban group versus 14.6% in the control group, p = 0.847). The 3-month mortality (21.6% in the tirofiban group versus 17.1% in the control group, p = 0.611) and good functional outcomes according to the modified Rankin scale (45.9% versus 34.1%, p = 0.289) were comparable. CONCLUSION: The results of our study suggest that the application of tirofiban for rescue stenting after failed mechanical thrombectomy is safe.
Asunto(s)
Isquemia Encefálica , Procedimientos Endovasculares , Arteriosclerosis Intracraneal , Accidente Cerebrovascular , Humanos , Tirofibán/efectos adversos , Accidente Cerebrovascular/terapia , Isquemia Encefálica/complicaciones , Infusiones Intravenosas , Estudios Retrospectivos , Constricción Patológica , Trombectomía/métodos , Arteriosclerosis Intracraneal/complicaciones , Stents , Resultado del TratamientoRESUMEN
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
Non-aneurysmal subarachnoid hemorrhage (NASAH) is rare and mostly benign. However, complications such as cerebral vasospasm (CV), delayed cerebral ischemia (DCI), or post-hemorrhagic hydrocephalus (HC) may worsen the prognosis. The aim of this study was to evaluate the rate of these complications comparing perimesencephalic (PM) and non-perimesencephalic (NPM) SAH. Monocentric, retrospective analysis of patients diagnosed with NASAH from 01/2010 to 01/2021. Diagnosis was set only if vascular pathologies were excluded in at least one digital subtraction angiography, and NASAH was confirmed by cranial computed tomography (cCT) or lumbar puncture (LP). One hundred patients (62 female) with a mean age of 54.9 years (27-84) were identified. Seventy-three percent had a World Federation of Neurological Surgeons (WFNS) grading scale score I, while 9% were WFNS score IV or V at the time of admission. SAH was diagnosed by cCT in 86%, in 14% by lumbar puncture. Twenty-five percent necessitated short-term CSF diversion by extraventricular drainage or lumbar drainage, whereof 7 suffered from long-term HC treated with ventriculoperitoneal shunting (VPS). One patient without a short-term CSF drainage developed long-term HC. Ten percent developed CV, four of whom received intraarterial spasmolysis. Radiological DCI was diagnosed in 2%; none of these correlated with CV. Despite a mortality of 3% occurring solely in NPM SAH, the analyzed complication rate was comparable in both groups. We observed post-hemorrhagic complications in 35% of cases during the first 3 weeks after bleeding, predominantly in patients with NPM SAH. For this reason, close observation and cranial imaging within this time may be indicated not to overlook these complications.
Asunto(s)
Isquemia Encefálica , Hidrocefalia , Hemorragia Subaracnoidea , Vasoespasmo Intracraneal , Humanos , Femenino , Persona de Mediana Edad , Hemorragia Subaracnoidea/complicaciones , Hemorragia Subaracnoidea/cirugía , Hemorragia Subaracnoidea/diagnóstico , Estudios Retrospectivos , Vasoespasmo Intracraneal/etiología , Vasoespasmo Intracraneal/complicaciones , Isquemia Encefálica/complicaciones , Infarto Cerebral/complicaciones , Hidrocefalia/cirugía , Hidrocefalia/complicacionesRESUMEN
PURPOSE: Does focal cavity radiotherapy after resection of brain metastasis "spare" whole-brain radiotherapy, which is associated with toxicity for patients, through the complete course of their disease without compromising long-term local control of the brain? METHODS: We retrospectively analyzed outcomes of patients who underwent adjuvant focal cavity radiotherapy between 2014 and 2021â¯at our center. RESULTS: A total of 83 patients with 86 resected brain metastases were analyzed. 64% had singular, 36% two to four brain metastases. In cases with multiple metastases, omitted lesions were treated with radiosurgery. Median follow-up was 7.3 months (range 0-71.2 months), 1year overall survival rate was 57.8% (95% CI 44.9-68.8%). Radiotherapy was administered with a median biologically effective dose (α/ß 10) surrounding the planning target volume of 48â¯Gy (range 23.4-60â¯Gy). Estimated 1year local control rate was 82.7% (95% CI 67.7-91.2%), estimated 1year distant brain control rate was 55.7% (95% CI 40.5-68.4%), estimated 1year leptomeningeal disease rate was 16.0% (95% CI 7.3-32.9%). Eleven distant brain recurrences could be salvaged with radiosurgery. In the further course of disease, 14 patients (17%) developed disseminated metastatic disease in the brain. Estimated 1year free of whole-brain radiotherapy rate was 72.3% (95% CI 57.1-82.9%). All applied treatments led to an estimated 1year neuro-control rate of 79.1% (95% CI 65.0-88.0%), estimated 1year radionecrosis rate was 23% (95% CI 12.4-40.5%). CONCLUSION: In our single-center study, focal cavity radiotherapy was associated with high local control. In three out of four patients, whole-brain radiotherapy could be avoided in the complete course of disease, using radiosurgery as salvage approach without compromising neuro-control.
Asunto(s)
Neoplasias Encefálicas , Radiocirugia , Humanos , Estudios Retrospectivos , Neoplasias Encefálicas/radioterapia , Neoplasias Encefálicas/cirugía , Neoplasias Encefálicas/secundario , Terapia Recuperativa , Radioterapia Adyuvante , Irradiación CraneanaRESUMEN
Background: The importance of an A1 aplasia remains unclear in stroke patients. In this work, we analyze the impact of an A1 aplasia contralateral to an acute occlusion of the distal internal carotid artery (ICA) on clinical outcomes. Methods: We conducted a retrospective study of consecutive stroke patients treated with mechanical thrombectomy at 12 tertiary care centers between January 2015 and February 2021 due to an occlusion of the distal ICA. Functional A1 aplasia was defined as the absence of A1 or hypoplastic A1 (>50% reduction to the contralateral site). Functional independence was measured by the modified Rankin Scale (mRS ≤ 2). Results: In total, 81 out of 1068 (8%) patients had functional A1 aplasia contralateral to distal ICA occlusion. Patients with functional contralateral A1 aplasia were more severely affected on admission (median NIHSS 18, IQR 15−23 vs. 17, IQR 13−21; aOR: 0.672, 95% CI: 0.448−1.007, p = 0.054) and post-interventional ischemic damage was larger (median ASPECTS 5, IQR 1−7, vs. 6, IQR 3−8; aOR: 1.817, 95% CI: 1.184−2.789, p = 0.006). Infarction occurred more often within the ipsilateral ACA territory (20/76, 26% vs. 110/961, 11%; aOR: 2.482, 95% CI: 1.389−4.437, p = 0.002) and both ACA territories (8/76, 11% vs. 5/961, 1%; aOR: 17.968, 95% CI: 4.979−64.847, p ≤ 0.001). Functional contralateral A1 aplasia was associated with a lower rate of functional independence at discharge (6/81, 8% vs. 194/965, 20%; aOR: 2.579, 95% CI: 1.086−6.122, p = 0.032) and after 90 days (5/55, 9% vs. 170/723, 24%; aOR: 2.664, 95% CI: 1.031−6.883, p = 0.043). Conclusions: A functional A1 aplasia contralateral to a distal ICA occlusion is associated with a poorer clinical outcome.
RESUMEN
BACKGROUND: Chronic subdural hematoma (CSDH) is a common neurosurgical condition with high recurrence rates. Repeated microbleedings from fragile neo-vessels supplied by peripheral branches of the middle meningeal artery (MMA) are believed to be responsible for the growth and recurrence of CSDH. Thus, MMA embolization might be a promising method to prevent re-bleedings and recurrences. This study aims to assess the efficacy, complication rates, and mid-term outcome of MMA embolization with or without burr hole irrigation compared with burr hole irrigation alone. METHODS: Patients diagnosed with CSDH who underwent MMA embolization and/or surgical treatment were retrospectively recruited to this single-center study. The outcome variables were defined as treatment-related complications, clinical outcome at discharge, rate of revision surgery, and CT findings during the follow-up period. RESULTS: A total of 132 patients with CSDH were included in the study. The use of antiplatelet/anticoagulant medication was significantly higher in the combined treatment and embolization group (p<0.001). A trend towards fewer revision surgeries was found in the group of patients who received MMA embolization combined with burr hole irrigation (p=0.083). Follow-up was available for 73 patients (55.3%) with a mean follow-up period of 3.4±2.2 months. Eight patients (15.1%) of the surgery group showed hematoma re-accumulation and needed surgical rescue, whereas only one patient (5.0%) of the combined treatment group needed revision surgery. In all patients treated with only MMA embolization, complete hematoma resolution was found. CONCLUSION: MMA embolization is a safe and efficacious minimal invasive adjuvant and/or alternative procedure for the treatment of CSDH with a reduced recurrence rate.
Asunto(s)
Embolización Terapéutica , Hematoma Subdural Crónico , Terapia Combinada , Embolización Terapéutica/efectos adversos , Embolización Terapéutica/métodos , Hematoma Subdural Crónico/diagnóstico por imagen , Hematoma Subdural Crónico/cirugía , Humanos , Arterias Meníngeas/diagnóstico por imagen , Arterias Meníngeas/cirugía , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND AND OBJECTIVES: To establish serum concentration of protein S100B as an objective biomarker surrogate for astroglial tissue damage after mechanical thrombectomy in patients with acute ischemic stroke. METHODS: This prospective 2-center study recruited patients with acute middle cerebral artery infarctions caused by large vessel occlusion treated with mechanical thrombectomy. Blood samples were collected at day 2 after intervention and analyzed for S100B serum concentrations using ELISA techniques. Infarct size was determined on follow-up brain imaging and functional outcome according to modified Rankin Scale (mRS) was assessed at 90 days. RESULTS: A total of 171 patients were included (mean age ± SD: 70 ± 14 years, 42% female). S100B levels correlated with infarct size. Median S100B concentrations at day 2 after intervention were lower in patients with favorable outcome (mRS score 0-1) at 90 days compared to patients with unfavorable outcome (mRS score 2-6) (median 0.10 µg/L [interquartile range 0.07-0.14] vs 0.20 µg/L [0.11-0.48], p < 0.001). Younger age (odds ratio [OR] 1.120 [confidence interval (CI) 1.068-1.174]; p < 0.001), lower National Institutes of Health Stroke Scale score 24 hours after symptom onset (OR 1.232 [CI 1.106-1.372]; p < 0.001), and lower S100B serum concentrations (OR 1.364 [CI 1.105-1.683]; p = 0.004) were independently associated with a favorable outcome. S100B was able to eliminate the lateralization bias associated with the use of mRS for functional outcome assessment at 90 days after stroke. DISCUSSION: S100B serum concentrations after mechanical thrombectomy indicate the extent of ischemic tissue damage. This can be assessed rapidly, independent of brain imaging and clinical outcome scales. Following prospective validation in further studies, this may provide an objective surrogate outcome measure both in clinical routine and interventional trials. CLASSIFICATION OF EVIDENCE: This study provides Class I evidence that S100B 2 days following mechanical thrombectomy for acute ischemic stroke accurately distinguishes favorable from unfavorable functional outcome.
Asunto(s)
Isquemia Encefálica , Accidente Cerebrovascular Isquémico , Accidente Cerebrovascular , Isquemia Encefálica/diagnóstico por imagen , Isquemia Encefálica/cirugía , Femenino , Humanos , Infarto de la Arteria Cerebral Media/etiología , Masculino , Estudios Retrospectivos , Subunidad beta de la Proteína de Unión al Calcio S100 , Accidente Cerebrovascular/diagnóstico por imagen , Accidente Cerebrovascular/cirugía , Trombectomía/efectos adversos , Resultado del TratamientoRESUMEN
PURPOSE: External-beam radiotherapy (EBRT) is the predominant method for localized brain radiotherapy (LBRT) after resection of brain metastases (BM). Intraoperative radiotherapy (IORT) with 50-kV xrays is an alternative way to focally irradiate the resection cavity after BM surgery, with the option of shortening the overall treatment time and limiting normal tissue irradiation. METHODS: We retrospectively analyzed the outcomes of all patients who underwent neurosurgical resection of BM and 50-kV xray IORT between 2013 and 2020â¯at Augsburg University Medical Center. RESULTS: We identified 40 patients with 44 resected BM treated with 50-kV xray IORT. Median diameter of the resected metastases was 2.8â¯cm (range 1.5-5.9â¯cm). Median applied dose was 20â¯Gy. All patients received standardized follow-up (FU) including 3monthly MRI of the brain. Mean FU was 14.4 months, with a median MRI FU for alive patients of 12.2 months. Median overall survival (OS) of all treated patients was 26.4 months (estimated 1year OS 61.6%). The observed local control (LC) rate of the resection cavity was 88.6% (estimated 1year LC 84.3%). Distant brain control (DC) was 47.5% (estimated 1year DC 33.5%). Only 25% of all patients needed WBI in the further course of disease. The observed radionecrosis rate was 2.5%. CONCLUSION: IORT with 50-kV xrays is a safe and appealing way to apply LBRT after neurosurgical resection of BM, with low toxicity and excellent LC. Close MRI FU is paramount to detect distant brain failure (DBF) early.
Asunto(s)
Neoplasias Encefálicas , Centros Médicos Académicos , Neoplasias Encefálicas/diagnóstico por imagen , Neoplasias Encefálicas/radioterapia , Neoplasias Encefálicas/cirugía , Humanos , Recurrencia Local de Neoplasia/radioterapia , Radiografía , Estudios Retrospectivos , Rayos XRESUMEN
Selective therapeutic hypothermia (TH) showed promising preclinical results as a neuroprotective strategy in acute ischemic stroke. We aimed to assess safety and feasibility of an intracarotid cooling catheter conceived for fast and selective brain cooling during endovascular thrombectomy in an ovine stroke model.Transient middle cerebral artery occlusion (MCAO, 3 h) was performed in 20 sheep. In the hypothermia group (n = 10), selective TH was initiated 20 minutes before recanalization, and was maintained for another 3 h. In the normothermia control group (n = 10), a standard 8 French catheter was used instead. Primary endpoints were intranasal cooling performance (feasibility) plus vessel patency assessed by digital subtraction angiography and carotid artery wall integrity (histopathology, both safety). Secondary endpoints were neurological outcome and infarct volumes.Computed tomography perfusion demonstrated MCA territory hypoperfusion during MCAO in both groups. Intranasal temperature decreased by 1.1 °C/3.1 °C after 10/60 minutes in the TH group and 0.3 °C/0.4 °C in the normothermia group (p < 0.001). Carotid artery and branching vessel patency as well as carotid wall integrity was indifferent between groups. Infarct volumes (p = 0.74) and neurological outcome (p = 0.82) were similar in both groups.Selective TH was feasible and safe. However, a larger number of subjects might be required to demonstrate efficacy.
Asunto(s)
Frío/efectos adversos , Hipotermia Inducida/efectos adversos , Infarto de la Arteria Cerebral Media/terapia , Accidente Cerebrovascular Isquémico/terapia , Angiografía de Substracción Digital/métodos , Animales , Arteria Carótida Común/diagnóstico por imagen , Arteria Carótida Común/patología , Arteria Carótida Común/cirugía , Cateterismo/métodos , Modelos Animales de Enfermedad , Procedimientos Endovasculares/métodos , Estudios de Factibilidad , Hipotermia Inducida/instrumentación , Infarto de la Arteria Cerebral Media/diagnóstico por imagen , Infarto de la Arteria Cerebral Media/patología , Accidente Cerebrovascular Isquémico/veterinaria , Fármacos Neuroprotectores/farmacología , Evaluación de Resultado en la Atención de Salud , Imagen de Perfusión/métodos , Seguridad , Ovinos , Trombectomía/métodosRESUMEN
PURPOSE: The aim of this study was the development and external validation of a logistic regression model to differentiate gliosarcoma (GSC) and glioblastoma multiforme (GBM) on standard MR imaging. METHODS: A univariate and multivariate analysis was carried out of a logistic regression model to discriminate patients histologically diagnosed with primary GSC and an age and sex-matched group of patients with primary GBM on presurgical MRI with external validation. RESULTS: In total, 56 patients with GSC and 56 patients with GBM were included. Evidence of haemorrhage suggested the diagnosis of GSC, whereas cystic components and pial as well as ependymal invasion were more commonly observed in GBM patients. The logistic regression model yielded a mean area under the curve (AUC) of 0.919 on the training dataset and of 0.746 on the validation dataset. The accuracy in the validation dataset was 0.67 with a sensitivity of 0.85 and a specificity of 0.5. CONCLUSIONS: Although some imaging criteria suggest the diagnosis of GSC or GBM, differentiation between these two tumour entities on standard MRI alone is not feasible.
Asunto(s)
Astrocitoma , Neoplasias Encefálicas , Glioblastoma , Gliosarcoma , Neoplasias Encefálicas/diagnóstico por imagen , Glioblastoma/diagnóstico por imagen , Gliosarcoma/diagnóstico por imagen , Humanos , Imagen por Resonancia MagnéticaRESUMEN
PURPOSE: Little is known about catheter-based endovascular treatment of vertebrobasilar artery branch occlusion (VEBABO) in acute ischemic stroke (AIS). Nonetheless, the experience of mechanical thrombectomy (MT) in distal small sized arteries of the anterior circulation seems promising in AIS. In this multicenter study, we report the feasibility, efficacy and safety of MT in VEBABO. METHODS: Retrospective analysis of consecutive AIS patients treated with MT due to VEBABO including posterior and anterior inferior cerebellar artery (PICA, AICA) and superior cerebellar artery (SCA) occlusions at seven tertiary care centers between January 2013 and May 2020. Baseline demographics and angiographic outcomes including recanalization success of the affected cerebellar arteries and procedural complications were recorded. Clinical outcomes were evaluated by the modified Rankin scale (mRS) at discharge and 90 days. RESULTS: Out of 668 endovascularly treated posterior circulation strokes we identified 16 (0.02%) cases with MT for VEBABO. Most frequently, MT of the SCA was done (13/16, 81%). Most VEBABOs occurred after MT of initial basilar/posterior cerebral artery occlusion (9/16, 56%). In 10/16 (63%) procedures, the affected VEBABO was successfully recanalized. Out of four patients three (75%) with isolated VEBABO had benefited from endovascular therapy. Subarachnoid hemorrhage was observed in 3/16 (19%) procedures. The rate of favorable outcome (mRS ≤2) was 40% at discharge and 47% at 90-day follow-up. Mortality was 13% (2/15). CONCLUSION: The use of MT for VEBABO is rare but appears to be feasible and effective; however, the comparatively high rate of procedure-related hemorrhage highlights that the indications for MT in these occlusion sites should be carefully weighed up.