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PURPOSE: Cone-beam CT in the interventional suite could be an alternative to CT to shorten door-to-thrombectomy time. However, image quality in cone-beam CT is limited by artifacts and poor differentiation between gray and white matter. This study compared non-contrast brain dual-layer cone-beam CT in the interventional suite to reference standard CT in stroke patients. METHODS: A prospective single-center study enrolled consecutive participants with ischemic or hemorrhagic stroke. The hemorrhage detection accuracy, per-region ASPECTS accuracy and subjective image quality (Likert scales for gray-white matter differentiation, structure perception and artifacts) were assessed by three neuroradiologists blinded to clinical data on dual-layer cone-beam CT 75â¯keV monoenergetic images compared to CT. Objective image quality was assessed by region-of-interest metrics. Non-inferiority for hemorrhage detection and ASPECTS accuracy was determined by the exact binomial test with a one-sided lower performance boundary prospectively set to 80% (98.75% CI). RESULTS: 27 participants were included (74 years⯱ 9; 19 female) in the hyperacute or acute stroke phase. One reader missed a small bleeding, but all hemorrhages were detected in the majority analysis (100% accuracy, CI lower boundary 86%, pâ¯= 0.002). ASPECTS majority analysis showed 90% accuracy (CI lower boundary 85%, pâ¯< 0.001). Sensitivity was 66% (individual readers 67%, 69%, and 76%), specificity was 97% (97%, 96%, 89%). Subjective and objective image quality were inferior to CT. CONCLUSION: In a small single-center cohort, dual-layer cone-beam CT showed non-inferior hemorrhage detection and ASPECTS accuracy to CT. Despite inferior image quality, the technique may be useful for stroke evaluation in the interventional suite. TRIAL REGISTRATION NUMBER: NCT04571099 (clinicaltrials.gov). Prospectively registered 2020-09-04.
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BACKGROUND: The comparative efficacy and safety of first-generation flow diverters (FDs), Pipeline Embolization Device (PED) (Medtronic, Irvine, California), Silk (Balt Extrusion, Montmorency, France), Flow Re-direction Endoluminal Device (FRED) (Microvention, Tustin, California), and Surpass Streamline (Stryker Neurovascular, Fremont, California), is not directly established and largely inferred. PURPOSE: This study aimed to compare the efficacy of different FDs in treating sidewall ICA intracranial aneurysms. METHODS: We conducted a retrospective review of prospectively maintained databases from eighteen academic institutions from 2009-2016, comprising 444 patients treated with one of four devices for sidewall ICA aneurysms. Data on demographics, aneurysm characteristics, treatment outcomes, and complications were analyzed. Angiographic and clinical outcomes were assessed using various imaging modalities and modified Rankin Scale (mRS). Propensity score weighting was employed to balance confounding variables. The data analysis used Kaplan-Meier curves, logistic regression, and Cox proportional-hazards regression. RESULTS: While there were no significant differences in retreatment rates, functional outcomes (mRS 0-1), and thromboembolic complications between the four devices, the probability of achieving adequate occlusion at the last follow-up was highest in Surpass device (HR: 4.59; CI: 2.75-7.66, pâ¯< 0.001), followed by FRED (HR: 2.23; CI: 1.44-3.46, pâ¯< 0.001), PED (HR: 1.72; CI: 1.10-2.70, pâ¯= 0.018), and Silk (HR: 1.0 ref. standard). The only hemorrhagic complications were with Surpass (1%). CONCLUSION: All the first-generation devices achieved good clinical outcomes and retreatment rates in treating ICA sidewall aneurysms. Prospective studies are needed to explore the nuanced differences between these devices in the long term.
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OBJECTIVE: Dural arteriovenous fistulas are rare vascular malformations that affect the brain and spinal cord. Spinal dural arteriovenous fistulas (sdAVFs) are the most frequently encountered vascular malformation affecting the spinal cord. The object of this study was to evaluate the impact of treatment delays on the long-term neurological outcomes of either open surgical or interventional treatment of sdAVFs. METHODS: In this retrospective, population-based cohort study, the authors examined consecutive patients with diagnosed sdAVFs at a tertiary care center between 2005 and 2020. Patients were assessed using the Aminoff-Logue disability scale (ALS) at various time points including symptom onset, primary care visit, first specialist outpatient visit, as well as both short and long-term follow-ups. The postoperative long-term ALS gait and bladder grades constituted the primary outcomes of the study. RESULTS: Among the 34 patients included in the study, the median age was 65 years, and there was a male predominance (71%). Most lesions were in the lumbar region (47%). Significant worsening in ALS gait and bladder grades was observed preoperatively, followed by postoperative improvements (p < 0.05). There was no difference in outcomes between surgical and endovascular treatments. Older age (OR 1.10, 95% CI 1.03-1.17, p = 0.007), worse preoperative ALS gait grades (OR 5.12, 95% CI 2.18-12.4, p < 0.001), and longer time from first specialist outpatient visit to first treatment (OR 1.00, 95% CI 1.00-1.01, p = 0.040) were independently associated with worse long-term gait outcomes. Only the preoperative ALS bladder score was a predictor of worse long-term bladder function (OR 92.7, 95% CI 28.0-306.7, p < 0.001). CONCLUSIONS: Both surgical and endovascular treatments for sdAVFs led to significant neurological improvements. However, treatment delays were associated with less favorable long-term outcomes. Prompt diagnosis and early intervention prior to symptom progression may enhance recovery and help to preserve neurological function.
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Malformaciones Vasculares del Sistema Nervioso Central , Retraso del Tratamiento , Humanos , Masculino , Anciano , Femenino , Estudios de Cohortes , Estudios Longitudinales , Estudios Retrospectivos , Malformaciones Vasculares del Sistema Nervioso Central/complicaciones , Malformaciones Vasculares del Sistema Nervioso Central/cirugíaRESUMEN
BACKGROUND: The hemorrhage risk of unruptured and untreated cerebral arteriovenous malformations (AVMs) has been shown to be higher for female patients than male patients in their child bearing ages. Although it has been neurosurgical practice to advise female patients in their childbearing ages to postpone pregnancy until proven AVM obliteration, there is no literature consensus regarding this potential hemorrhage risk increase. OBJECTIVE: To accurately quantify the risk increase for AVM hemorrhage during pregnancy. METHODS: This study is based on data from previous publications, consisting of known age at the first AVM hemorrhage in 3425 patients. The risk increase during pregnancy could be calculated from the difference in age distribution for the first AVM hemorrhage between male patients and female patients, taking the average pregnancy time per female into account. A comparison was also made with data for all hospital discharges (13 751) in Germany 2008 to 2018 with the diagnosis brain AVM. RESULTS: The average pregnancy and puerperium time was 1.54 years per female in the patient population, which was used to determine the annual AVM hemorrhage risk during pregnancy to be around 9%. The increased risk during pregnancy was further evidenced by analysis of a subgroup of 105 female patients, for which pregnancy status at the time of hemorrhage was known. CONCLUSION: The quantified annual risk for AVM hemorrhage during pregnancy is about 3 times higher than that of male patients at corresponding age. This provides an important basis for advising female patients with patent AVMs about the increased risk for hemorrhage that a pregnancy would entail.
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Malformaciones Arteriovenosas Intracraneales , Radiocirugia , Humanos , Masculino , Femenino , Embarazo , Periodo Posparto , Malformaciones Arteriovenosas Intracraneales/complicaciones , Malformaciones Arteriovenosas Intracraneales/epidemiología , Malformaciones Arteriovenosas Intracraneales/diagnóstico , Rotura , Hemorragia Cerebral/etiología , Radiocirugia/efectos adversos , Encéfalo , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Knowledge about the natural course of brain arteriovenous malformations (AVMs) have increased during the past 20 years, as has the number of AVMs treated, especially larger ones. It is thus timely to again analyze the risk for hemorrhage after Gamma Knife Surgery (GKS). OBJECTIVE: To confirm or contradict conclusions drawn 20 years ago regarding factors that affect the risk for post-GKS hemorrhage. METHODS: The outcome after GKS was studied in 5037 AVM patients followed for up to 2 years. The relation between post-treatment hemorrhage rate and a number of patient, AVM, and treatment parameters was analyzed. The results were also compared with the results from our earlier study. RESULTS: The annual post-treatment hemorrhage rate was 2.4% the first 2 years after GKS. Large size, low treatment dose, and old age were independent risk factors for AVM hemorrhage. After having compensated for the factors above, peripheral AVM location and female sex, at least during their child bearing ages, were factors associated with a lower post-GKS hemorrhage rate. CONCLUSION: Large AVMs (>5 cm 3 ) treated with low doses (≤16 Gy) had higher and small AVMs treated with high doses a lower risk for hemorrhage as compared with untreated AVMs. This was detectable within the first 6 months after GKS. No difference in hemorrhage rate could be detected for the other AVMs. Based on our findings, it is advisable to prescribe >16 Gy to larger AVMs, assuming that the risk for radiation-induced complications can be kept at an acceptable level.
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Malformaciones Arteriovenosas Intracraneales , Traumatismos por Radiación , Radiocirugia , Humanos , Femenino , Malformaciones Arteriovenosas Intracraneales/complicaciones , Resultado del Tratamiento , Radiocirugia/efectos adversos , Radiocirugia/métodos , Hemorragia Cerebral/etiología , Hemorragia Cerebral/complicaciones , Factores de Riesgo , Traumatismos por Radiación/etiología , Estudios Retrospectivos , Estudios de SeguimientoRESUMEN
Paediatric intracranial dural arteriovenous shunts have clinical presentations and evolutions, with angiographic characteristics that differ from those described in adults. We report our experience concerning their therapeutic management, emphasizing the relevance of early diagnosis and appropriate treatment for satisfactory neurocognitive development. Using a prospective database, we reviewed the clinical and radiological data of all children with dural arteriovenous shunts managed between 2002 and 2020. Dural shunts were categorized into three types: dural sinus malformations with arteriovenous shunts; infantile dural arteriovenous shunts; and adult-type dural arteriovenous shunts. Therapeutic strategies and outcomes were analysed depending on lesional subtypes. Modified Rankin Scale for the paediatric population was assessed pre-treatment and at last follow-up. Twenty-eight patients [16 girls (57.1%); 12 boys (42.9%)] were included: 17 dural sinus malformation [10 boys (58.8%); seven girls (41.2%)], three infantile shunts [three girls (100%)], eight adult-type shunts [four girls (50%)]; four boys (50%)], with a mean age of 19.2 ± 36.6 months at presentation. Twelve (42.9%) had a modified Rankin Scale score of 0-2, four (14.3%) had a score of 3, three (10.7%) had a score of 4 and eight (28.6%) had a score of 5. Embolization was performed in 22 children [78.6%; 12 girls (54.5%); 10 boys (45.5%)]. Fifteen patients could be cured (68.2%): 11 dural sinus malformations (73.3%), four adult-type lesions (100%) but no infantile shunt. Mean post-treatment follow-up was 39.5 months (max. 139 months): 14 patients (63.6%) presented a modified Rankin Scale score of 0-2 and eight (36.4%) had a score ≥3. In the dural sinus malformation group, the modified Rankin Scale score was improved in 11 patients (73.3%) and unchanged in three (20%). Only one patient with infantile subtype (33.3%) improved clinically. In the adult-subtype group, all children (100%) improved. Of six untreated patients [four girls (66.7%); two boys (33.3%)], four with adult-subtype shunts showed uneventful evolutions, one with dural sinus malformation died, and therapeutic abortion was conducted in an antenatally diagnosed dural sinus malformation. Paediatric dural fistulas comprise different subtypes with variable clinical courses. Proper diagnosis is mandatory for optimal therapeutic strategies within appropriate therapeutic windows.
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PURPOSE: Conventional cone-beam computed tomography CT (CBCT) provides limited discrimination between low-contrast tissues. Furthermore, it is limited to full-spectrum energy integration. A dual-energy CBCT system could be used to separate photon energy spectra with the potential to increase the visibility of clinically relevant features and acquire additional information relevant in a multitude of clinical imaging applications. In this work, the performance of a novel dual-layer dual-energy CBCT (DL-DE-CBCT) C-arm system is characterized for the first time. METHODS: A prototype dual-layer detector was fitted into a commercial interventional C-arm CBCT system to enable DL-DE-CBCT acquisitions. DL-DE reconstructions were derived from material-decomposed Compton scatter and photoelectric base functions. The modulation transfer function (MTF) of the prototype DL-DE-CBCT was compared to that of a commercial CBCT. Noise and uniformity characteristics were evaluated using a cylindrical water phantom. Effective atomic numbers and electron densities were estimated in clinically relevant tissue substitutes. Iodine quantification was performed (for 0.5-15 mg/ml concentrations) and virtual noncontrast (VNC) images were evaluated. Finally, contrast-to-noise ratios (CNR) and CT number accuracies were estimated. RESULTS: The prototype and commercial CBCT showed similar spatial resolution, with a mean 10% MTF of 5.98 cycles/cm and 6.28 cycles/cm, respectively, using a commercial standard reconstruction. The lowest noise was seen in the 80 keV virtual monoenergetic images (VMI) (7.40 HU) and the most uniform images were seen at VMI 60 keV (4.74 HU) or VMI 80 keV (1.98 HU), depending on the uniformity measure used. For all the tissue substitutes measured, the mean accuracy in effective atomic number was 98.2% (SD 1.2%) and the mean accuracy in electron density was 100.3% (SD 0.9%). Iodine quantification images showed a mean difference of -0.1 (SD 0.5) mg/ml compared to the true iodine concentration for all blood and iodine-containing objects. For VNC images, all blood substitutes containing iodine averaged a CT number of 43.2 HU, whereas a blood-only substitute measured 44.8 HU. All water-containing iodine substitutes measured a mean CT number of 2.6 in the VNC images. A noise-suppressed dataset showed a CNR peak at VMI 40 keV and low at VMI 120 keV. In the same dataset without noise suppression applied, a peak in CNR was obtained at VMI 70 keV and a low at VMI 120 keV. The estimated CT numbers of various clinically relevant objects were generally very close to the calculated CT number. CONCLUSIONS: The performance of a prototype dual-layer dual-energy C-arm CBCT system was characterized. Spatial resolution and noise were comparable with a commercially available C-arm CBCT system, while offering dual-energy capability. Iodine quantifications, effective atomic numbers, and electron densities were in good agreement with expected values, indicating that the system can be used to reliably evaluate the material composition of clinically relevant tissues. The VNC and monoenergetic images indicate a consistent ability to separate clinically relevant tissues. The results presented indicate that the system could find utility in diagnostic, interventional, and radiotherapy planning settings.
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Yodo , Imagen Radiográfica por Emisión de Doble Fotón , Tomografía Computarizada de Haz Cónico , Fantasmas de Imagen , Estudios Retrospectivos , Relación Señal-RuidoRESUMEN
BACKGROUND: Wide necked bifurcation aneurysms (WNBA) are among the most difficult aneurysms to treat. Very low dome-to-neck (DTN) and aspect ratios provide an even greater challenge in the management of WNBAs. We present the safety and efficacy profile for endovascular clip system (eCLIPs) device in the treatment of this subset of WNBAs with very unfavorable morphologies. METHODS: In our case series, 24 patients treated at 12 international centers were taken from a larger prospective voluntary post-marketing registry of 65 patients treated with the eCLIPs device and coiling. Those who had WNBAs at either the carotid or basilar terminus with a DTN ratio <1.6 and aspect ratio <1.2 were included. Radiologic and clinical outcomes were assessed immediately after the procedure and at the latest follow-up. RESULTS: The eCLIPs device was successfully deployed in 23 cases (96%). One patient (4.2%) died due to guidewire perforation distal to the implant site. No other complications were documented. After a mean follow-up of 15.8 months (range 3-40 months), good radiologic outcomes (modified Raymond-Roy classification (MRRC) scores of 1 or 2) were documented in 20 of 21 patients (95%) with follow-up data. The lone patient with an MRRC score of 3 showed coiled compaction after incomplete neck coverage with the device. CONCLUSION: Our series of patients with aneurysms having adverse DTN and aspect ratios demonstrated that the eCLIPs device has a safety and efficacy profile comparable with currently available devices in the treatment of WNBAs.
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Procedimientos Endovasculares/métodos , Aneurisma Intracraneal/diagnóstico por imagen , Aneurisma Intracraneal/cirugía , Instrumentos Quirúrgicos , Adulto , Anciano , Estudios de Cohortes , Procedimientos Endovasculares/instrumentación , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Sistema de Registros , Resultado del TratamientoRESUMEN
BACKGROUND: Torcular dural sinus malformations (tDSMs) with arteriovenous shunts are rare congenital intracranial vascular malformations that carry a high rate of neurologic impairment and death in the neonatal, infant and young pediatric population. Their impact on brain venous drainage, especially the deep venous system, is one of the key factors in the clinical prognosis and natural history of the disease. We describe our therapeutic strategy for tDSMs, disconnecting the reflux into the deep venous system by performing an endovascular straight sinus occlusion. METHODS: Among all children with dural sinus malformations seen between 2002 and 2020, we retrospectively reviewed those with tDSM in whom straight sinus occlusion had been performed. RESULTS: Our databank included nine patients with tDSM that were embolized. Mean age at the clinical onset was 8.9±9.6 months (min-max=0-31). Five patients presented a significant reflux in the straight sinus on digital subtraction angiography. Those patients were initially clinically worse (mean modified Rankin Scale (mRS) 3.8) than those who did not present with reflux (mean mRS 2.25), this reflux being responsible for intraventricular hemorrhage in three patients. The reflux was suppressed by transarterial embolization in one patient and by transvenous straight sinus occlusion in four patients. Staged endovascular treatment resulted in a complete cure in six patients without complications, and clinical improvement in all patients. CONCLUSION: Straight sinus occlusion is a feasible technique that needs to be considered in the treatment strategy for tDSM with deep venous reflux in order to avoid or minimize brain damage.
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Fístula Arteriovenosa/diagnóstico por imagen , Fístula Arteriovenosa/cirugía , Manejo de la Enfermedad , Procedimientos Endovasculares/métodos , Malformaciones Arteriovenosas Intracraneales/diagnóstico por imagen , Malformaciones Arteriovenosas Intracraneales/cirugía , Angiografía de Substracción Digital/métodos , Angiografía Cerebral/métodos , Preescolar , Senos Craneales/diagnóstico por imagen , Senos Craneales/cirugía , Femenino , Humanos , Lactante , Masculino , Estudios Prospectivos , Estudios RetrospectivosRESUMEN
OBJECTIVES: To test the hypothesis that intraoperative cone beam computed tomography (CBCT) using the Allura augmented reality surgical navigation (ARSN) system in a dedicated hybrid operating room (OR) matches computed tomography (CT) for identification of pedicle screw breach during spine surgery. METHODS: Twenty patients treated with spinal fixation surgery (260 screws) underwent intraoperative CBCT as well as conventional postoperative CT scans (median 12 months after surgery) to identify and grade the degree of pedicle screw breach on both scan types, according to the Gertzbein grading scale. Blinded assessments were performed by three independent spine surgeons and the CT served as the standard of reference. Screws graded as Gertzbein 0 or 1 were considered clinically accurate while grades 2 or 3 were considered inaccurate. Sensitivity, specificity, and negative predictive value were the primary metrics of diagnostic performance. RESULTS: For this patient group, the negative predictive value of an intraoperative CBCT to rule out pedicle screw breach was 99.6% (CI 97.75-99.99%). Among 10 screws graded as inaccurate on CT, 9 were graded as such on the CBCT, giving a sensitivity of 90.0% (CI 55.5-99.75%). Among the 250 screws graded as accurate on CT, 244 were graded as such on the CBCT, giving a specificity of 97.6% (CI 94.85-99.11%). CONCLUSIONS: CBCT, performed intraoperatively with the Allura ARSN system, is comparable and non-inferior to a conventional postoperative CT scan for ruling out misplaced pedicle screws in spinal deformity cases, eliminating the need for a postoperative CT. KEY POINTS: ⢠Intraoperative cone beam computed tomography (CT) using the Allura ARSN is comparable with conventional CT for ruling out pedicle screw breaches after spinal fixation surgery. ⢠Intraoperative cone beam computed tomography can be used to assess need for revisions of pedicle screws making routine postoperative CT scans unnecessary. ⢠Using cone beam computed tomography, the specificity was 97.6% and the sensitivity was 90% for detecting pedicle screw breaches and the negative predictive value for ruling out a pedicle screw breach was 99.6%.
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Tornillos Pediculares , Fusión Vertebral , Cirugía Asistida por Computador , Tomografía Computarizada de Haz Cónico , Humanos , Vértebras Lumbares/diagnóstico por imagen , Vértebras Lumbares/cirugía , Columna VertebralRESUMEN
BACKGROUND: A significant difference exists between the published results reporting the clinical outcome following brain arteriovenous malformation (AVM) ruptures. Information about the outcome following hemorrhage in an AVM population treated with radiosurgery could provide additional information to assess the risk of mortality and morbidity following an AVM hemorrhage. METHODS: Clinical outcome was studied in 383 patients, the largest patient population yet studied, who suffered from a symptomatic hemorrhage after Gamma Knife® surgery (GKS) but before confirmed AVM obliteration. The impact of different patient, AVM, and treatment parameters on the clinical outcome was analyzed. The aim was to generate outcome predictions by comparing our data to and combining them with earlier published results. RESULTS: No relation was found between clinical outcome and treatment parameters, indicating that the results are applicable also on untreated AVMs. Twenty-one percent of the patients died, 45% developed or experienced worsening of neurological sequelae, and 35% recovered completely after the hemorrhage. Old age was a predictor of poor outcome. Sex, AVM location, AVM volume, and history of prior hemorrhage did not influence the outcome. The mortality rate was comparable to earlier published prospective data, but higher than that found in retrospective studies. CONCLUSIONS: The mortality rates in earlier published retrospective series as well as in studies focusing on clinical outcome following AVM hemorrhage significantly underestimate the risk for a mortal outcome following an AVM hemorrhage. Based on our findings, an AVM rupture has around 20% likelihood to result in mortality, 45% likelihood to result in a minor or major deficit, and 35% likelihood of complete recovery. The findings are probably applicable also for AVM ruptures in general. The cumulative mortality and morbidity rates 25 years after diagnosis were estimated to be around 40% in a patient with a patent AVM.
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Hemorragia/etiología , Malformaciones Arteriovenosas Intracraneales/cirugía , Complicaciones Posoperatorias/etiología , Radiocirugia/efectos adversos , Adolescente , Adulto , Niño , Femenino , Hemorragia/epidemiología , Hemorragia/mortalidad , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/mortalidad , Radiocirugia/métodosRESUMEN
PURPOSE: With the rapid expansion of the field of interventional neuroradiology (INR) and the diverse background of aspiring neuro-interventionists, there is an ever increasing need to establish consensus criteria for training and accreditation in INR. MATERIALS AND METHODS: We performed a survey to explore the current state of criteria for training and accreditation in INR. The questionnaire consisting of 11 questions was emailed to the members of World Federation of Interventional and Therapeutic Neuroradiology (WFITN) worldwide. It was focused on the training charter, training program, qualifying examination, and education after training program as perceived by practitioners in each country. RESULTS: A total of 52 WFITN members in 19 countries responded to the questionnaire. There was a huge variation internationally and nationally due to the unique situation and challenges in each country and institution. Criteria for training and accreditation in INR were well established in some countries of Europe, North America, and Asia but not specified in other countries. CONCLUSION: It is critical to establish consensus criteria for training and accreditation in INR in order to ensure safe practice and continued expansion and development of INR as a specialty.
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BACKGROUND: Studies have shown that the modified thrombolysis in cerebral ischemia (mTICI) 2B score is associated with better functional outcome; however, 50-99% reperfusion is a large range and there may be factors which can differentiate this further. The effects of very late leptomeningeal collaterals (VLLC) on mTICI-2B patients were studied. METHOD: A prospectively collected registry of anterior circulation AIS patients treated with the EmboTrap revascularization device from 2013 to 2016 was evaluated. Imaging parameters and timings, including the mTICI score were verified by an external core laboratory blinded to the clinical data. The final angiogram was examined for the appearance of VLLC in predicting 3month outcomes including excellent functional outcomes, defined as modified Rankin scale (mRS) 0-1, bleeding risk and mortality. RESULTS: A total of 177 consecutive anterior circulation stroke patients were included in the analysis. Of these 94 (53.1%) achieved only mTICI-2B reperfusion, 16/94 (17.0%) patients achieved excellent functional outcomes at 3 months and 26 (27.7%) had hyperdensity on follow-up computed tomography (CT). On univariate analysis, the presence of VLLC was inversely associated with excellent functional outcomes at 3 months and positively associated with mortality in patients with mTICI-2B reperfusion. On multivariate analysis VLLC was inversely associated with excellent outcomes (odds ratio 0.075, 95% confidence interval 0.007-0.765, Pâ¯= 0.029) but not associated with mortality. CONCLUSION: The mTICI-2B grade may be further refined by secondary radiological markers. The VLLC sign is associated with the loss of excellent functional outcomes at 3 months. It is a simple sign to discriminate mTICI-2B into different grades but should be verified in larger populations from other centers.
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Isquemia Encefálica/cirugía , Circulación Cerebrovascular , Circulación Colateral , Trombolisis Mecánica/métodos , Meninges/cirugía , Accidente Cerebrovascular/cirugía , Anciano , Isquemia Encefálica/complicaciones , Isquemia Encefálica/diagnóstico por imagen , Angiografía por Tomografía Computarizada/métodos , Femenino , Humanos , Masculino , Meninges/diagnóstico por imagen , Estudios Prospectivos , Sistema de Registros , Accidente Cerebrovascular/diagnóstico por imagen , Accidente Cerebrovascular/etiología , Resultado del TratamientoRESUMEN
STUDY DESIGN: Prospective observational study. OBJECTIVE: To assess staff and patient radiation exposure during augmented reality surgical navigation in spine surgery. SUMMARY OF BACKGROUND DATA: Surgical navigation in combination with intraoperative three-dimensional imaging has been shown to significantly increase the clinical accuracy of pedicle screw placement. Although this technique may increase the total radiation exposure compared with fluoroscopy, the occupational exposure can be minimized, as navigation is radiation free and staff can be positioned behind protective shielding during three-dimensional imaging. The patient radiation exposure during treatment and verification of pedicle screw positions can also be reduced. METHODS: Twenty patients undergoing spine surgery with pedicle screw placement were included in the study. The staff radiation exposure was measured using real-time active personnel dosimeters and was further compared with measurements using a reference dosimeter attached to the C-arm (i.e., a worst-case staff exposure situation). The patient radiation exposures were recorded, and effective doses (ED) were determined. RESULTS: The average staff exposure per procedure was 0.21â±â0.06âµSv. The average staff-to-reference dose ratio per procedure was 0.05% and decreased to less than 0.01% after a few procedures had been performed. The average patient ED was 15.8â±â1.8 mSv which mainly correlated with the number of vertebrae treated and the number of cone-beam computed tomography acquisitions performed. A low-dose protocol used for the final 10 procedures yielded a 32% ED reduction per spinal level treated. CONCLUSION: This study demonstrated significantly lower occupational doses compared with values reported in the literature. Real-time active personnel dosimeters contributed to a fast optimization and adoption of protective measures throughout the study. Even though our data include both cone-beam computed tomography for navigation planning and intraoperative screw placement verification, we find low patient radiation exposure levels compared with published data. LEVEL OF EVIDENCE: 3.
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Realidad Aumentada , Exposición a la Radiación/estadística & datos numéricos , Columna Vertebral/cirugía , Cirugía Asistida por Computador/métodos , Adulto , Tomografía Computarizada de Haz Cónico/métodos , Femenino , Fluoroscopía/métodos , Humanos , Imagenología Tridimensional/métodos , Masculino , Exposición Profesional , Tornillos Pediculares , Estudios Prospectivos , Dosis de RadiaciónRESUMEN
Idiopathic intracranial hypertension (IIH) is a disorder affecting both the pediatric and adult population. Investigations and treatments may differ considerably. There are no evidence-based guidelines for treatment. During a national multidisciplinary meeting in Stockholm January 2018 IIH experts from several Swedish regions met to discuss how to manage this patient group. These guidelines are based on this meeting and a review of current medical knowledge. To summarize: All patients should be investigated and treated for underlying factors that could be the cause of high intracranial pressure (ICP) (such as obesity, secondary causes such as intracranial tumors or other factors reported to affect ICP). When treating IIH the preservation of vision is crucial. Follow-up depends on visual status. In case of acute risk of visual impairment prompt surgical intervention must be considered. Symptomatic treatment of headache is recommended.
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Guías de Práctica Clínica como Asunto , Seudotumor Cerebral , Acetazolamida/administración & dosificación , Acetazolamida/uso terapéutico , Cirugía Bariátrica , Inhibidores de Anhidrasa Carbónica/administración & dosificación , Inhibidores de Anhidrasa Carbónica/uso terapéutico , Consenso , Vías Clínicas , Diagnóstico Diferencial , Femenino , Cefalea/etiología , Humanos , Obesidad/complicaciones , Obesidad/cirugía , Embarazo , Seudotumor Cerebral/complicaciones , Seudotumor Cerebral/diagnóstico , Seudotumor Cerebral/tratamiento farmacológico , Seudotumor Cerebral/cirugía , Factores de Riesgo , Stents , Suecia , Derivación VentriculoperitonealRESUMEN
Endosaccular flow disruption is an innovative method of treating wide-necked complex aneurysms. Currently four types of devices have obtained the CE mark for use within Europe. These are the Woven EndoBridge device (WEB), the Luna Aneurysm Embolization System, the Medina Embolic Device (Medtronic), and the Contour Neurovascular System. The aim of this article is to provide an overview of these devices and to summarize the evidence in the literature pertaining to the treatment of intracranial aneurysms with them.
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Aneurisma/diagnóstico por imagen , Aneurisma/cirugía , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/normas , Diseño de Prótesis/normas , Sistemas de Liberación de Medicamentos/métodos , Sistemas de Liberación de Medicamentos/normas , Embolización Terapéutica/instrumentación , Embolización Terapéutica/normas , Europa (Continente) , Humanos , Aneurisma Intracraneal/diagnóstico por imagen , Aneurisma Intracraneal/cirugía , Resultado del TratamientoRESUMEN
Correction to: Clin Neuroradiol 2019 https://doi.org/10.1007/s00062-019-00776-2 The original version of this article unfortunately contained a mistake. The Acknowledgements were missing. The correct information is given .
RESUMEN
BACKGROUND: Cerebral vasospasm (CVS) following subarachnoid hemorrhage occurs in up to 70% of patients. Recently, stents have been used to successfully treat CVS. This implies that the force required to expand spastic vessels and resolve vasospasm is lower than previously thought. OBJECTIVE: We develop a mechanistic model of the spastic arterial wall to provide insight into CVS and predict the forces required to treat it. MATERIAL AND METHODS: The arterial wall is modelled as a cylindrical membrane using a constrained mixture theory that accounts for the mechanical roles of elastin, collagen and vascular smooth muscle cells (VSMC). We model the pressure diameter curve prior to CVS and predict how it changes following CVS. We propose a stretch-based damage criterion for VSMC and evaluate if several commercially available stents are able to resolve vasospasm. RESULTS: The model predicts that dilatation of VSMCs beyond a threshold of mechanical failure is sufficient to resolve CVS without damage to the underlying extracellular matrix. Consistent with recent clinical observations, our model predicts that existing stents have the potential to provide sufficient outward force to successfully treat CVS and that success will be dependent on an appropriate match between stent and vessel. CONCLUSION: Mathematical models of CVS can provide insights into biological mechanisms and explore treatment approaches. Improved understanding of the underlying mechanistic processes governing CVS and its mechanical treatment may assist in the development of dedicated stents.