The importance of multimodal CT examination in stroke mimics diagnosis: design of prospective observational multicentre study.

Introduction: Non-contrast computed tomography (CT) and CT angiography are the gold standard in neuroimaging diagnostics in the case of suspected stroke. CT perfusion (CTP) may play an important role in the diagnosis of stroke mimics (SM), but currently, it is not a standard part of the stroke diagnostic procedure. The project is a multicentre prospective observational clinical research focused on refining the diagnostics of stroke and stroke mimics (SM) in hospital care. Aim: This study aimed to evaluate the degree of specificity and sensitivity of multimodal CT (NCCT, CTA, and CTP) in the diagnosis of SM versus stroke. Methodology: In this study, we will include 3,000 patients consecutively admitted to the comprehensive stroke centres with a diagnosis of suspected stroke. On the basis of clinical parameters and the results of multimodal CT and magnetic resonance imaging (MRI), the diagnosis of stroke and SM will be established. To clarify the significance of the use of the multimodal CT scan, the analysis will include a comparison of the blinded results for each imaging scan performed by radiologists and AI technology and a comparison of the initial and final diagnosis of the enrolled patients. Based on our results, we will compare the economic indicators and costs that would be saved by not providing inadequate treatment to patients with SM. Conclusion: The expected outcome is to present an optimised diagnostic procedure that results in a faster and more accurate diagnosis, thereby eliminating the risk of inadequate treatment in patients with SM. Clinical trial registration: clinicaltrials.gov, NCT06045455.

Influence of graft anastomosis and graft morphology on long-term patency of the saphenous vein after aortocoronary bypass.

OBJECTIVE: Several factors are involved in the preservation of graft function after surgical myocardial revascularization. This follow-up study aimed to evaluate the effects of vein graft anastomosis and graft morphology on long-term graft patency a minimum of 10 years after aortocoronary bypass grafting. Setting and Cohorts. This was a sub-analysis of a study that enrolled patients after isolated bypass surgery at the University Hospital Ostrava in order to evaluate the long-term graft patency of the saphenous vein after endoscopic harvest, a minimum of 10 years after aortocoronary bypass grafting. METHODS: Fifty angiograms, with a total of 90 grafts, after isolated myocardial revascularization were visualized using coronary computed tomography angiography, with 50% luminal stenosis or greater considered significant. RESULTS: The overall graft patency rate was 72.3%. The differences in occlusion rates between sequential and individual grafts were not statistically significant (P=0.156). All y-grafts were totally occluded. Graft and target artery diameters had a statistically significant influence on patency (P=1.000 and 0.381, respectively). Longer graft length and higher calcium scores were associated with statistically significant graft occlusion (P=0.033 and 0.005, respectively). CONCLUSION: Sequential grafts can be constructed safely, especially when the goal is complete myocardial revascularization.

Peak systolic velocity ratio for evaluation of internal carotid artery stenosis correlated with plaque morphology: substudy results of the ANTIQUE study.

Background: Accurate assessment of carotid stenosis severity is important for proper patient management. The present study aimed to compare the evaluation of carotid stenosis severity using four duplex sonography (DUS) measurements, including peak systolic velocity (PSV), PSV ratio in stenosis and distal to stenosis (PSVICA/ICA ratio), end-diastolic velocity (EDV), and B-mode, with computed tomography angiography (CTA), and to evaluate the impact of plaque morphology on correlation between DUS and CTA. Methods: Consecutive patients with carotid stenosis of ≥40% examined using DUS and CTA were included. Plaque morphology was also determined using magnetic resonance imaging. Spearman's correlation and Kendall's rank correlation were used to evaluate the results. Results: A total of 143 cases of internal carotid artery stenosis of ≥40% based on DUS were analyzed. The PSVICA/ICA ratio showed the highest correlation [Spearman's correlation r = 0.576) with CTA, followed by PSV (r = 0.526), B-mode measurement (r = 0.482), and EDV (r = 0.441; p < 0.001 in all cases]. The worst correlation was found for PSV when the plaque was calcified (r = 0.238), whereas EDV showed a higher correlation (r = 0.523). Correlations of B-mode measurement were superior for plaques with smooth surface (r = 0.677), while the PSVICA/ICA ratio showed the highest correlation in stenoses with irregular (r = 0.373) or ulcerated (r = 0.382) surfaces, as well as lipid (r = 0.406), fibrous (r = 0.461), and mixed (r = 0.403; p < 0.01 in all cases) plaques. Nevertheless, differences between the mentioned correlations were not statistically significant (p > 0.05 in all cases). Conclusion: PSV, PSVICA/ICA ratio, EDV, and B-mode measurements showed comparable correlations with CTA in evaluation of carotid artery stenosis based on their correlation with CTA results. Heavy calcifications and plaque surface irregularity or ulceration negatively influenced the measurement accuracy.

Comparison of carotid endarterectomy and repeated carotid angioplasty and stenting for in-stent restenosis (CERCAS trial): a randomised study.

BACKGROUND AND AIM: In-stent restenosis (ISR) belongs to an infrequent but potentially serious complication after carotid angioplasty and stenting in patients with severe carotid stenosis. Some of these patients might be contraindicated to repeat percutaneous transluminal angioplasty with or without stenting (rePTA/S). The purpose of the study is to compare the safety and effectiveness of carotid endarterectomy with stent removal (CEASR) and rePTA/S in patients with carotid ISR. METHODS: Consecutive patients with carotid ISR (≥80%) were randomly allocated to the CEASR or rePTA/S group. The incidence of restenosis after intervention, stroke, transient ischaemic attack myocardial infarction and death 30 days and 1 year after intervention and restenosis 1 year after intervention between patients in CEASR and rePTA/S groups were statistically evaluated. RESULTS: A total of 31 patients were included in the study; 14 patients (9 males; mean age 66.3±6.6 years) were allocated to CEASR and 17 patients (10 males; mean age 68.8±5.6 years) to the rePTA/S group. The implanted stent in carotid restenosis was successfully removed in all patients in the CEASR group. No clinical vascular event was recorded periproceduraly, 30 days and 1 year after intervention in both groups. Only one patient in the CEASR group had asymptomatic occlusion of the intervened carotid artery within 30 days and one patient died in the rePTA/S group within 1 year after intervention. Restenosis after intervention was significantly greater in the rePTA/S group (mean 20.9%) than in the CEASR group (mean 0%, p=0.04), but all stenoses were <50%. Incidence of 1-year restenosis that was ≥70% did not differ between the rePTA/S and CEASR groups (4 vs 1 patient; p=0.233). CONCLUSION: CEASR seems to be effective and save procedures for patients with carotid ISR and might be considered as a treatment option. TRIAL REGISTRATION NUMBER: NCT05390983.

A novel labeling modality of intra-abdominal lesions with Magseed magnetic marker and extirpation by Sentimag probe navigation.

OBJECTIVE: This study aimed to evaluate our experience with the use of Magseed, the magnetic metallic marker, as a localization technique followed by Sentimag probe detection in patients with solitary intra-abdominal local metastases with subsequent resection of the lesions. METHODS: Five patients underwent resection after the lesion was marked with the Magseed magnetic marker. Prior to the surgery, a computed tomography scan of the chest and abdomen and/or positron emission tomography was performed to rule out the dissemination of the disease. The indication for surgery was evaluated in a meeting of a multidisciplinary team, and the placement of the magnetic marker under computed tomography control had been performed the day before the planned procedure. RESULTS: The present preliminary outcomes have revealed that Magseed might be a promising technique that is feasible and safe, particularly when the postsurgical anatomic conditions in the abdominal cavity are altered and the lesions are not visible or palpable. Surgical extirpation of lesions occurred without complications in each case. In all the cases, the resection was complete and curative, and one wound infection in all (20%), without any major complications, had occurred. The mean hospital stay was 6.6 days. CONCLUSION: Magseed utilization, as a localization technique, followed by Sentimag probe detection in intra-abdominal tumors has not been reported before. Improving the visualization and, consequently, the precise marking of the lesion with subsequent radical removal can prevent insufficient or excessive removal of healthy tissue, leading to a faster diagnosis and better overall clinical outcomes.

Changes in Cognitive Functions after Carotid Endarterectomy and Carotid Stenting: A Decade-Apart Comparison.

BACKGROUND: This study investigates changes in cognitive function in patients with severe carotid stenosis who underwent carotid endarterectomy (CEA) and carotid stenting (CAS) over two decades. METHODS: We compared cognitive function within 30 days after the procedure in 267 patients (first 100 each for CEA and CAS in two periods: 2008-2012 and 2018-2022) in a single institution. Assessments used Adenbrooke's Cognitive Examination-Revised (ACE-R), the Mini-Mental State Examination (MMSE), Speech Fluency Test (SFT), and Clock Drawing Test (CDT), conducted before and 30 ± 2 days after surgery. RESULTS: Patients (mean age 67.2 years, 70%+ carotid stenosis) exhibited different cognitive changes over periods. In 2008-2012, significant declines in MMSE (CEA, p = 0.049) and CDT (CAS, p = 0.015) were observed among asymptomatic patients. On the contrary, in 2018-2022, improvements were observed in ACE-R and MMSE for symptomatic and asymptomatic patients undergoing CEA and CAS. CONCLUSION: Over a decade, advances in interventional techniques and patient management have reduced risks of cognitive decline in patients with asymptomatic carotid stenosis and also have improved cognitive functions in both symptomatic and asymptomatic individuals.

Endovascular Repair of Thoracic Aorta Injury: 17 Years of Single-Center Experience.

BACKGROUND Traumatic thoracic aortic transection is one of the most severe complications of high-energy injuries, but patients rarely receive treatment, and it is fatal in the vast majority of cases. Due to the complexity of surgical revision for transection, endovascular repair with stent graft implantation is the preferred approach. MATERIAL AND METHODS We retrospectively analyzed the short-term and long-term treatment results for 31 patients (29 men, 2 women) treated at the Interventional Radiology Department, University Hospital Ostrava, for the isthmus part of a descending thoracic aorta injury between 2004 and 2020. RESULTS The median patient age was 48 years (interquartile range [IQR]: 28-63 years). The most common causes of injury were traffic accidents and falls or jumps, with the trauma location at the Ishimaru zones 2 to 4 of the aortic isthmus. Aortic stent grafts were successfully implanted in all patients; 13% of patients had complications and 10% died due to the trauma severity. The median procedure duration was 30 min (IQR: 25-43 min) and the median hospital stay was 29 days (IQR: 28-63 days). CONCLUSIONS Aortic stent graft implantation appears to be a safe and effective method for dealing with thoracic aorta injury, with a low complication rate and high patient survival. The endovascular approach is the method of choice for treating this severe disease, and a multidisciplinary approach for emergency medical treatment with a comprehensive trauma protocol is essential.

MRI Diffusion-Weighted Imaging to Measure Infarct Volume: Assessment of Manual Segmentation Variability.

BACKGROUND AND PURPOSE: Manual segmentation of infarct volume on follow-up MRI diffusion-weighted imaging (MRI-DWI) is considered the gold standard but is prone to rater variability. We assess the variability of manual segmentations of MRI-DWI infarct volume. METHODS: Consecutive patients (May 2018 to May 2019) with the anterior circulation stroke and endovascularly treated were enrolled. All patients underwent 24- to 32-hour follow-up MRI. Three users manually segmented DWI infarct volumes slice by slice twice. The reference standard of DWI infarct volume was generated by the STAPLE algorithm. Intra- and interrater reliability was evaluated using the intraclass correlation coefficient (ICC) by comparing manual segmentations with the reference standard. Spatial measurements were evaluated using metrics of the Dice similarity coefficient (DSC). Volumetric measurements were compared using the lesion volume. RESULTS: The dataset consisted of 44 patients, mean (SD) age was 70.1 years (±10.3), 43% were women, and median baseline NIHSS score was 16. Among three users, the mean DSC for MRI-DWI infarct volume segmentations ranged from 80.6% ± 11.7% to 88.6% ± 7.5%, and the mean absolute volume difference was 2.8 ± 6.8 to 13.0 ± 14.0 ml. Interrater ICC among the users for DSC and infarct volume was .86 (95% confidence interval [95% CI]: .78-.91) and .997 (95% CI: .995-.998). Intrarater ICC for the three users was .83 (95% CI: .69-.93), .84 (95% CI: .72-.91), and .80 (95% CI: .64-.89) for DSC, and .99 (95% CI: .987-.996), .991 (95% CI: .983-.995), and .996 (95% CI: .993-.998) for infarct volume. CONCLUSIONS: Manual segmentation of infarct volume on follow-up MRI-DWI shows excellent agreement and good spatial overlap with the reference standard, suggesting its usefulness for measuring infarct volume on 24- to 32-hour MRI-DWI.

The use of a battery of examination methods for detection of cervical metastases in squamous cell carcinoma of the oral cavity.

INTRODUCTION: In patients with squamous cell carcinoma of the orofacial area, the presence of cervical metastases represents a single most significant prognostic factor. This fact underlines the importance of thorough examination of the cervical lymph nodes for potential tumor involvement. To verify this, the most common investigative methods are physical examination (PE), sonography (US) and computed tomography (CT), which have also been used to assess the stage of the disease in the patients in our research. OBJECTIVE: To evaluate the performance of individual methods (physical examination, sonography, computed tomography) and combinations. METHOD: Patients with squamous cell carcinoma of the oral cavity, who had undergone physical, US and CT examinations at our department followed by radical neck dissection were included in this retrospective study. A total of 57 patients were included. RESULTS: The sensitivity of PE, US and CT were 38%, 69% and 61%, respectively, however CT+US combination yielded 83% sensitivity and combination of all these methods 86% sensitivity. The number of false positives was however relatively high with specificity of the 3-way combination at 65%. CONCLUSION: A combination of our three widely available inexpensive methods detected 86% of metastases in cervical nodes. The large number of false positives however indicates that the method should rather be used for screening in selecting patients who need additional and more expensive imaging than for diagnosing cervical metastases. Also, as 14% of cervical metastases pass undetected using our method, we would recommend an additional examination at least by US+PE several weeks to a few months after the initial examination.

Computed Tomography (CT)-Navigated Translumbar Hemodialysis Catheters: A 10-Year Single-Center Experience.

BACKGROUND In dialysis patients with exhausted usual central venous access sites, the translumbar hemodialysis catheter (TLC) provides a viable option for dialysis access. The technical success of catheter insertion, associated complications, and long-term patency of TLC were evaluated in this study. MATERIAL AND METHODS This retrospective study included 37 patients with occluded central thoracic veins in whom 39 TLC implantation procedures were performed and 196 patients with internal jugular vein hemodialysis catheters (JVC). TLC implantation was performed as a hybrid procedure with computed tomography (CT)-navigated translumbar inferior vena cava cannulation and subsequent fluoroscopy-guided hemodialysis catheter placement. RESULTS The rates of technical success of the implantations and minor periprocedural complications were 97.4% and 10.3% in the TLC group and 98.6% and 4.2% in the JVC group, respectively. The median follow-up in the TLC and JVC groups was 673 days and 310 days, respectively. The primary-assisted patency at the 1-year and 3-year follow-up was 88.7% and 72.0% in the TLC group and 81.6% and 67.0% in the JVC group, respectively, with no statistically significant difference between the 2 groups. The incidence rate of infection-related and patency-related complications calculated for 1000 catheter-days was 0.15 and 0.11 in the TLC group and 0.33 and 0.25 in the JVC group, respectively. CONCLUSIONS The CT-guided implantation of the TLC is a useful option to create dialysis access with a low complication rate and satisfactory long-term patency in patients without usual venous access.

Machine learning volumetry of ischemic brain lesions on CT after thrombectomy-prospective diagnostic accuracy study in ischemic stroke patients.

PURPOSE: Ischemic lesion volume (ILV) is an important radiological predictor of functional outcome in patients with anterior circulation stroke. Our aim was to assess the agreement between automated ILV measurements on NCCT using the Brainomix software and manual ILV measurements on diffusion-weighted imaging (DWI). METHODS: This was a prospective single-center observational study of patients with CT angiography (CTA) proven anterior circulation occlusion treated with endovascular thrombectomy (May 2018 to May 2019). NCCT ILV was measured automatically by the Brainomix software. DWI ILV was measured manually. The McNemar's test was used to test sensitivity and specificity. The Somer's delta was used to test the differences between concordant and discordant ASPECTS regions. The Bland-Altman plot was calculated to compare the differences between Brainomix and DWI ILVs. RESULTS: Forty-five patients were included. Median Brainomix ILV was 23 ml (interquartile range [IQR], 15-39 ml), and median DWI ILV was 11.5 ml (IQR, 7-32 ml) in the TICI 2b-3 group. In the TICI 0-2a, the NCCT ILV was 39 ml (IQR, 18-62 ml) and DWI ILV was 30 (IQR, 11-105 ml). The DWI ILVs in patients with good clinical outcome (mRS 0-2) was significantly lower compared with patients with mRS ≥ 3 (10 mL vs 59 mL, p = 0.002). Similar trend was observed for Brainomix ILV measurements (21 mL vs 39 mL, p = 0.012). There was a high correlation and accuracy in the detection of follow-up ischemic changes in particular ASPECTS regions. CONCLUSION: NCCT ILV measured automatically by the Brainomix software might be considered a valuable radiological outcome measure.

Novel strategy in the treatment of liver metastases - Hepatic resection combined with stereotactic body radiotherapy.

BACKGROUND: To evaluate the safety, feasibility and outcomes of patients treated for colorectal liver metastases (CLM) with an innovative combined approach - hepatic resection and Stereotactic body radiotherapy (SBRT) using CyberKnife® system. METHODS: This was a retrospective cohort study conducted in a single institution. Patients with CLM and no evidence of extrahepatic disease were included during a 6-year study period. RESULTS: In total, 19 patients with 63 liver lesions underwent liver resection combined with SBRT of unresectable lesions. Major hepatectomy was performed in 42.1% patients; postoperative complications were noted in 31.6% patients. 27 unresectable lesions were treated by SBRT with a total dose of 50-60 Gy in five fractions. The median follow-up of study patients was 29.7 ± 20.58 months. Local control of CLM at 1 and 2 years was achieved in 89.5% of patients. Out-of-field hepatic recurrence was diagnosed in 63.1% patients. The 1-year disease-free survival (DFS) was 52.6%; 2-year DFS was 31.6%. The overall actuarial survival rates at 1 and 2 years were 88.2% and 50.4%. CONCLUSION: Liver resection combined with SBRT presents a promising therapeutic option for patients with CLM which traditionally are unresectable. The additional use of SBRT allows for the effective clearance of the disease for thoroughly selected patients.

Parastomal and incisional hernia following laparoscopic/open abdominoperineal resection: is there a real difference?

BACKGROUND: The aim of the present study was to explore incidence and severity of parastomal hernia (PSH) formation during the first 2 years after open/laparoscopic abdominoperineal resection (APR). METHODS: This was a retrospective cohort study conducted in a single institution. All patients who underwent laparoscopic/open APR for low rectal cancer within a 10-year study period were assessed for study eligibility. RESULTS: In total, 148 patients were included in the study (97 patients after laparoscopic APR; 51 patients after open APR). There were no statistically significant differences between study subgroups regarding demographic and clinical features. The incidence of PSH detected by physical examination was significantly higher in patients after laparoscopic APR 1 year after the surgery (50.5% vs. 19.6%, p < 0.001) and 2 years after the surgery (57.7% vs. 29.4%, p = 0.001). The incidence of radiologically detected PSH was significantly higher in laparoscopically operated patients after 1 year (58.7% vs. 35.3%, p = 0.007) and after 2 years (61.8% vs. 37.2%, p = 0.004). The mean diameter of PSH was similar in both study subgroups. The incidence of incisional hernia was significantly higher in patients who underwent open APR after 1 year (25.5% vs. 7.2%, p = 0.002) and after 2 years (31.3% vs. 7.2%, p < 0.001). CONCLUSIONS: The risk of PSH development after laparoscopic APR appears to be significantly higher in comparison with patients undergoing open APR. Higher incidence of PSH should be considered a potential disadvantage of minimally invasive approach to patients with low rectal cancer.

Comparison of Mechanical Thrombectomy with Contact Aspiration, Stent Retriever, and Combined Procedures in Patients with Large-Vessel Occlusion in Acute Ischemic Stroke.

BACKGROUND We investigated the properties and effects of 5 mechanical thrombectomy procedures in patients with acute ischemic stroke. The relationships between the type of procedure, the time required, the success of recanalization, and the clinical outcome were analyzed. MATERIAL AND METHODS This prospective comparative analysis included 500 patients with acute ischemic stroke and large-vessel occlusion. We compared contact aspiration thrombectomy (ADAPT, n=100), stent retriever first line (SRFL, n=196), the Solumbra technique (n=64), mechanical thrombectomy plus stent implantation (n=81), and a combined procedure (n=59). RESULTS ADAPT provided shorter procedure (P<0.001) and recanalization times (P<0.001) than the other techniques. Better clinical outcome was achieved for ischemia in the anterior circulation than ischemia in the posterior fossa (P<0.001). Compared to the other techniques, patients treated with ADAPT procedure had increased odds of achieving better mTICI scores (P=0.002) and clinical outcome (NIHSS) after 7 days (P=0.003); patients treated with SRFL had increased odds of achieving better long-term clinical status (3M-mRS=0-2; P=0.040). Patients with SRFL and intravenous thrombolysis (IVT) had increased odds of better clinical status (3M-mRS=0-2; P=0.031) and decreased odds of death (P=0.005) compared to patients with SRFL without IVT. The other treatment approaches had no additional effect of IVT. Patients with SRFL with a mothership transfer had increased odds of achieving favorable clinical outcome (3M-mRS) compared to SRFL with the drip-and-ship transfer paradigm (P=0.015). CONCLUSIONS Our results showed that ADAPT and SRFL provided significantly better outcomes compared to the other examined techniques. A mothership transfer and IVT administration contributed to the success of the SRFL approach.

The Role of von Willebrand Factor, ADAMTS13, and Cerebral Artery Thrombus Composition in Patient Outcome Following Mechanical Thrombectomy for Acute Ischemic Stroke.

BACKGROUND The aim of the study was to investigate the role of von Willebrand factor (vWF), the vWF-cleaving protease, ADAMTS13, the composition of thrombus, and patient outcome following mechanical cerebral artery thrombectomy in patients with acute ischemic stroke. MATERIAL AND METHODS A prospective cohort study included 131 patients with ischemic stroke (<6 hours) with or without intravenous thrombolysis. Interventional procedure parameters, hemocoagulation markers, vWF, ADAMTS13, and histological examination of the extracted thrombi were performed. The National Institutes of Health Stroke Scale (NIHSS) score was used on hospital admission, after 24 hours, at day 7; the three-month modified Rankin Scale score was used. RESULTS Mechanical thrombectomy resulted in a Treatment in Cerebral Ischemia (TICI) score of 2-3, with recanalization in 89% of patients. Intravenous thrombolysis was used in 101 (78%). Patients with and without intravenous thrombolysis therapy had a good clinical outcome (score 0-2) in 47% of cases (P=0.459) using the three-month modified Rankin Scale. Patients with a National Institutes of Health Stroke Scale (NIHSS) score ≥15 had significantly increased vWF levels (P=0.003), and a significantly increased vWF: ADAMTS13 ratio (P=0.038) on hospital admission. Significant correlation coefficients were found for plasma vWF and thrombo-embolus vWF (r=0.32), platelet (r=0.24), and fibrin (r=0.26) levels. In the removed thrombus, vWF levels were significantly correlated with platelet count (r=0.53), CD31-positive cells (r=0.38), and fibrin (r=0.48). CONCLUSIONS In patients with acute ischemic stroke, mechanical cerebral artery thrombectomy resulted in a good clinical outcome in 47% of cases, with and without intravenous thrombolysis therapy.

Interrater variability for CT angiography evaluation between neurologists and neuroradiologist in acute stroke patients.

OBJECTIVE: The diagnosis of arterial occlusion has a considerable impact on the indication of mechanical thrombectomy, and CT angiography (CTA) is recommended in the management of acute stroke. The goal of the present study is to assess the interrater agreement in the diagnosis of occlusion of intracranial arteries on CTA between a neuroradiologist and neurologists. METHODS: CTA images of 75 acute stroke patients were evaluated for occlusion of intracranial arteries by an experienced interventional neuroradiologist, and stroke and general neurologists. RESULTS: 75 patients who were treated by intravenous thrombolysis were enrolled in the study. CTA images were available for all 75 patients (34 females; mean age ± SD, 72 ± 14 years; National Institutes of Health Stroke Scale 10; median 8-14; and Alberta Stroke Program Early CT mean 9.7). The agreement between the neuroradiologist and neurologists in evaluation of intracranial artery occlusion was as follows: occlusion of the middle cerebral artery segment M1: observer agreement 77%, kappa (κ) = 0.61 and middle cerebral artery M2: observer agreement 77%, κ 0.48; internal carotid artery: observer agreement 92%, κ 0.84; T occlusion: observer agreement 90.0%, κ 0.33; posterior cerebral artery segments P1 and P2: observer agreement 98%, κ 0.97; basilar artery: observer agreement 96%, κ 0.92; and vertebral artery segment V4: observer agreement 88%, κ 0.48. CONCLUSION: Interrater agreement of CTA evaluation of occlusion between the neurologists and the neuroradiologist was very strong. The ability of the trained neurologists to read an intracranial large vessel occlusion correctly may improve the door-to-needle times in acute stroke. Advances in knowledge: In this study, the neurologists were able to recognize occlusion of intracranial arteries. This could accelerate the management of acute stroke care.

Functional compared to anatomical imaging in the initial evaluation of patients with suspected coronary artery disease: An international, multi-center, randomized controlled trial (IAEA-SPECT/CTA study).

OBJECTIVE: To test the hypothesis that, in the initial evaluation of patients with suspected coronary artery disease (CAD), stress myocardial perfusion imaging (MPI) would result in less downstream testing than coronary computed tomographic angiography (CCTA). METHODS: In this international, randomized trial, mildly symptomatic patients with an intermediate likelihood of having CAD, and asymptomatic patients at intermediate risk of cardiac events, underwent either initial stress-rest MPI or CCTA. The primary outcome was downstream noninvasive or invasive testing at 6 months. Secondary outcomes included cumulative effective radiation dose (ERD) and costs at 12 months. RESULTS: We recruited 303 patients (151 MPI and 152 CTA) from 6 centers in 6 countries. The initial MPI was abnormal in 29% (41/143) and CCTA in 56% (79/141) of patients. Fewer patients undergoing initial stress-rest MPI had further downstream testing at 6 months (adjusted OR 0.51, 95% CI 0.28-0.91, P = 0.023). There was a small increase in the median cumulative ERD with MPI (9.6 vs. 8.8 mSv, P = 0.04), but no difference in costs between the two strategies at 12 months. CONCLUSION: In the management of patients with suspected CAD, a strategy of initial stress MPI is substantially less likely to require further downstream testing than initial testing with CCTA. TRIAL REGISTRATION: clinicaltrials.gov identification number NCT01368770.

A single reference measurement can predict liver tumor motion during respiration.

AIM: To evaluate liver tumor motion and how well reference measurement predicts motion during treatment. MATERIAL AND METHODS: This retrospective study included 20 patients with colorectal cancer that had metastasized to the liver who were treated with stereotactic ablative radiotherapy. An online respiratory tumor tracking system was used. Tumor motion amplitudes in the superior-inferior (SI), latero-lateral (LL), and anterior-posterior (AP) directions were collected to generate patient-specific margins. Reference margins were generated as the mean motion and 95th percentile of motion from measurements recorded for different lengths of time (1, 3, and 5 min). We analyzed the predictability of tumor motion in each axis, based on the reference measurement and intra-/interfraction motions. RESULTS: About 96,000 amplitudes were analyzed. The mean tumor motions were 9.9 ± 4.2 mm, 2.6 ± 0.8 mm, and 4.5 ± 1.8 mm in the SI, LL, and AP directions, respectively. The intrafraction variations were 3.5 ± 1.8 mm, 0.63 ± 0.35 mm, and 1.4 ± 0.65 mm for the SI, LL, and AP directions, respectively. The interfraction motion variations were 1.32 ± 0.79 mm, 0.31 ± 0.23 mm, and 0.68 ± 0.62 mm for the SI, LL, and AP directions, respectively. The Pearson's correlation coefficients for margins based on the reference measurement (mean motion or 95th percentile) and margins covering 95% of the motion during the whole treatment were 0.8-0.91, 0.57-0.7, and 0.77-0.82 in the SI, LL, and AP directions, respectively. CONCLUSION: Liver tumor motion in the SI direction can be adequately represented by the mean tumor motion amplitude generated from a single 1 min reference measurement. Longer reference measurements did not improve results for patients who were well-educated about the importance of regular breathing. Although the study was based on tumor tracking data, the results are useful for ITV delineation when tumor tracking is not available.