Cineangiography versus standard digital subtraction angiography in mechanical thrombectomy: lowering the radiation exposure without sacrificing the outcome.

BACKGROUND: Endovascular thrombectomy has become a standard procedure for the treatment of acute ischemic stroke caused by large vessel occlusion. Radiation exposure to the patient and operators during mechanical thrombectomy procedures is a concern. METHODS: The use of a high frames per second unmasked protocol-cineangiography (CINE)-derived from cardiac intervention could mitigate radiation exposure without sacrificing procedural and clinical outcomes. RESULTS: The analysis of a prospective-maintained monocentric database of 131 patients who underwent mechanical thrombectomy (65 with the CINE protocol and 66 with the conventional digital subtraction angiography (DSA) protocol) showed a significant reduction in radiation exposure for both air kerma (AK) and dose-area product (DAP) indicators (AK 463.7 mGy vs 772 mGy, P<0.01; DAP 41.35 Gy/cm2 CINE vs 83.77 Gy/cm2 DSA, P<0.01), with no differences regarding both safety and efficacy outcomes (modified Thrombolysis In Cerebral Infarction (mTICI) ≥2b 78.4% CINE and 81.5% DSA, P=0.79; overall complications rate both intracranial and extracranial 23% CINE and 19.6% DSA, P=0.65). There were no significant differences in post-thrombectomy radiographic hemorrhagic conversion rate (P=0.77) or functional independence on discharge defined as modified Rankin Scale score ≤2 (P=0.39). A post-hoc image assessment of vessel point occlusion and recanalization mTICI score performed by three experienced interventional neuroradiologists not involved in the procedure showed a non-significant difference between the two groups regarding occlusion point (0.928 vs 0.953, P=0.31) and recanalization grade (0.814 vs 0.847, P=0.62). CONCLUSIONS: Our initial experience demonstrated that reduction of the quality of CINE images caused no modifications in safety and efficacy and should fit within the context of diagnostic requests in an intracranial revascularization procedure.

Single-stage endovascular treatment in aneurysmal subarachnoid haemorrhage with multiple intracranial aneurysms: Systematic review of the literature and multicentric retrospective experience.

OBJECTIVES: The presence of multiple intracranial aneurysms in patients with acute subarachnoid haemorrhage is a condition with no evidence of optimal treatment strategy, especially in case of uncertain haemorrhage patterns on cumputed tomography. The aim of this study was to analyse the safety and efficacy profile of single-stage endovascular treatment of multiple intracranial aneurysms with aneurysmal subarachnoid haemorrhage in the literature and in a retrospective case series. MATERIALS AND METHODS: A systematic review of the present literature was conducted to identify studies related to single-stage endovascular treatment for ≥2 aneurysms; in addition, a retrospective multicentric review was performed. Data on clinical presentation, aneurysm size and location, occlusion rates, intracranial complications and clinical outcome were recorded. RESULTS: Thirteen articles were identified (all little case series) reporting 189 patients harbouring 389 aneurysms. And 85.6% presented with a Hunt-Hess scale 1-3, and 14.4% 4-5. Intracranial complications rate was 11.5%. Baseline and follow-up (20.5 months) occlusion rates were adequate (Raymond-Roy occlusion scale I-II) in 93% and 96.2%, respectively. 81% of patients had favourable clinical outcomes (modified Rankin Scale (mRS) ≤2; Glasgow outcome scale (GOS) 5-4) and 19% poor (mRS 3-6; GOS 3-1). The retrospective database identified 53 patients with 115 aneurysms. Clinical presentation was Hunt-Hess (HH) 1-3/WNFS 1-2 75% and HH 4-5/WNFS 3-5 25%. Intracranial complication rate was 24.5%. Occlusion rate RROC I-II was 78.7% at baseline and 15 months and 90.2% at follow up. Clinical outcome at 3 months was mRS ≤2 68.6% and mRS 3-6 31.4%. CONCLUSIONS: Single-staged endovascular treatment can be feasible, although a higher risk of intraprocedural complications, with clinical presentation being the major factor to influence the outcome.

Time-Resolved Magnetic Resonance Angiography for Follow-Up of Treated Dural and Epidural Spinal Arteriovenous Fistula.

BACKGROUND: Spinal arteriovenous fistulas (AVFs) are uncommon vascular malformations of spinal dural and epidural vessels. Actually digital subtraction angiography (DSA) is the gold standard for diagnosis and follow-up. The aim of this study is to demonstrate the validity of the multiphasic magnetic resonance angiography (MRA) to identify recurrent/residual AVFs or their correct surgical and/or endovascular closure. METHODS: A retrospective cases series with perimedullary venous plexus congestion due to spinal dural or epidural AVF was performed at our center from April 2014 to September 2019. After 1 month from treatment, the patients were subjected to time-resolved MRA and DSA to demonstrate recurrence or correct closure of AVFs. RESULTS: We collected a series of 26 matched time-resolved MRA and DSA in 20 patients who underwent an endovascular and/or surgical procedure. In our series, we reported five cases of recurrence. Time-resolved MRA detected six cases of recurrence, with 100% sensitivity and 95% specificity (p < 0.001). We used DSA as the standard reference. CONCLUSION: Time-resolved MRA is a valid tool in posttreatment follow-up to detect recurrent or residual AVFs. It has high sensitivity and specificity and may replace DSA.

Neuroform Atlas stent-assisted coiling of ruptured intracranial aneurysms: A multicenter study.

PURPOSE: To assess efficacy, safety and to discuss optimal medical therapy of stent-assisted coiling of ruptured intracranial aneurysms. METHODS: Ruptured intracranial aneurysms treated with stent-assisted coiling in eight different institutions were retrospectively reviewed. Medical treatment regimens varied among the centers, mainly regarding heparin administration and post-procedural single or double antiplatelet therapy. Clinical and angiographic results, including complications and outcomes were analyzed and related to the different therapies. RESULTS: Sixty-one consecutive patients (male/female 23/38), aged 59.1 years (36-86) underwent stent-assisted coiling for ruptured intracranial aneurysm without antiplatelet pre-medication. Intravenous acetylsalicylic acid (ASA) 500mg was administered to all patients immediately after stent deployment. At the same time heparin was given as bolus in 15 patients (24.6%) as part of local protocol. Intravenous glycoprotein 2b/3a inhibitors (antiGP2b3a) were used as bail-out therapy for stent thrombosis. Stent thrombosis occurred in 22 patients (36.1%), of which 4 (6.5%) lead to incomplete and 18 (29.6) to complete occlusion of the stent. Heparin administration had no effect on thrombosis rate. Thrombosis resolution occurred in all cases with intravenous antiGP2b3a (7 tirofiban, 15 abciximab), without increasing overall complication rate. Single antiplatelet therapy with ASA (28 patients, 45.9%) or double antiplatelet therapy including ASA and clopidogrel (33 patients, 54.1%) were administered after procedure, depending on local protocols and on neurointerventionists' experience. Overall complication rate, including ischemia and hemorrhage was higher in patients in which only ASA was administered (21.4% vs. 12.1%). No late stent thrombosis was seen, regardless of whether a single or double antiplatelet regimen was used. Nevertheless, the small sample size suggests caution in interpreting these results. Moreover, a possible bias may arise from the decision whether to modify the maintenance therapy or not depending on the severity of the intracranial hemorrhage in a case-by-case assessment. At three months, 34 out of 38 patients with HH grade 1-2 (89.4%), and 11 out of 23 with Hunt-Hess grade of 3-4 (47.8%) were independent (Modified Ranking Scale 0-2). CONCLUSION: Stent assisted coiling of ruptured intracranial aneurysms is a feasible option when simple coiling is not possible. Optimal medical treatment is still controversial because balance between hemorrhagic and ischemic risks is difficult to evaluate. In our series, heparin bolus had no effect on subsequent stent thrombosis. In all cases peri-operative stent thrombosis was successfully managed using bail-out intravenous antiGP2b3a, which did not increase post-procedural hemorrhage rates. A non-significant trend towards increased complications rate was noticed in patients treated with single antiplatelet therapy versus double antiplatelet therapy.

Acute Occlusion of the Distal Internal Carotid Artery : Single Center Experience in 46 Consecutive Cases, review of the literature and proposal of a classification.

PURPOSE: The acute distal intracranial occlusion of the internal carotid artery (ICA) is a very complex heterogeneous pathology, characterized by various patterns. Aim of this work is to identify the different types and propose a classification. METHODS: Among the patients admitted for stroke in the anterior circulation from august 2014 to October 2017, 46 (25%) presented with intracranial distal carotid artery occlusion. The mean age of the patients was 71 (SD 13.7), 65,2% female. The protocol included general and specific neurological examinations, CT, CT-Angiography with multiphase CTA, followed by Angiography. The occlusion was treated by aspiration device alone or associated with stent-retriever. NIHSS at the admission, at discharge and modified ranking Scale (mRS) at four months were examined. RESULTS: The occlusions presented with various patterns. Depending on its site (located at the distal ICA bifurcation or more proximal at the level of the ophthalmic segment of ICA, with or without extent to ICA bifurcation) taking also into account the various involvement of the cerebral vessels and anatomic variations of Circle of Willis, three groups of occlusion types could be identified (T1, T2 and T3). The collateral circulation, and the possibilities of the endovascular revascularization important for the final outcome, were clearly connected with the type of occlusion. NIHSS at admission was 19.1 (Range from 8 to 30, SD 4.4). Good outcome defined as mRS 0-2 at for months was obtained in 17 patients (37%). CONCLUSIONS: The proposed classification reproduces more precisely the complexity and heterogeneity of this pathology, being useful in the diagnosis and treatment of these patients.

The role of imaging in the choice of correct treatment of unstable thoraco-lumbar fractures.

The concept of unstable burst fracture has been discussed since over 50 years and this injury has received much attention in the literature as regards its radiological diagnosis and clinical treatment. The purpose of this article is to review the way we use imaging to diagnose the injury and to guide treatment.

Follow-up of patients affected by manganese-induced Parkinsonism after treatment with CaNa2EDTA.

In the period of 1998-2004, seven workers affected by manganese-induced Parkinsonism were diagnosed, studied and treated with CaNa2EDTA at our Occupational Health Ward. Biological markers, as well as magnetic resonance imaging and clinical examinations, were used to assess the disease trend. Those workers still employed were immediately removed from exposure. Our results seem to confirm that very good clinical, biological and neuroradiological results can be obtained by timely removal from exposure and chelating treatment, and that amelioration can persist in time. Manganism is, however, a severe condition that can also progress independent of further exposure. Therefore, chelating treatment can be a great aid in overt manganism, but particular attention must be paid to primary prevention, as this disease should now be totally preventable and definitely merits eradication.