Effect of Intravenous Alteplase Treatment on First-Line Stent Retriever Versus Aspiration Alone During Endovascular Treatment.

BACKGROUND: We aimed to assess whether the effect of intravenous alteplase treatment (IVT) before endovascular treatment (EVT) on outcome is modified by first-line technique during EVT in IVT eligible patients. METHODS: This was a post hoc analysis from MR CLEAN-NO IV (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands - Intravenous Treatment Followed by Intra-Arterial Treatment Versus Direct Intra-Arterial Treatment for Acute Ischemic Stroke Caused by a Proximal Intracranial Occlusion), a randomized trial of IVT followed by EVT versus EVT alone in patients presenting directly to EVT-capable centers. We included data from all patients who underwent EVT with a thrombectomy attempt. We compared patients treated with stent retriever (with or without aspiration) to aspiration alone as first-line EVT technique and assessed the interaction of first-line EVT technique with IVT treatment. Primary outcome was the 90-day modified Rankin Scale score, analyzed with mixed model ordinal regression for a shift towards better outcome. Secondary outcomes included successful reperfusion (extended Thrombolysis in Cerebral Infarction score 2b-3). RESULTS: Of 473 included patients, 102 (21.6%) were treated with aspiration alone as first-line technique. In the full population, functional outcome was similar for patients treated with stent retriever versus aspiration only (adjusted common odds ratio [acOR]' 1.07 [95% CI, 0.69-1.66]). We observed a significant interaction between IVT and first-line EVT technique (P=0.03). In the aspiration-only group, patients treated with EVT alone had worse functional outcome compared to those treated with IVT and EVT (acOR, 0.44 [95% CI, 0.21-0.90]). In the stent retriever group, functional outcome did not differ between patients treated with or without IVT (acOR, 1.08 [95% CI, 0.74-1.57]). There was no statistically significant interaction for successful reperfusion. CONCLUSIONS: In MR CLEAN-NO IV, the treatment effect of IVT was modified by first-line EVT technique. Patients treated with aspiration only as first-line technique had worse clinical outcomes if they did not receive IVT. No such difference was observed in patients treated with stent retrievers. Confirmation by pooling with results from other trials is needed to confirm these findings.

Impact of PTV margin reduction (2 mm to 0 mm) on pseudoprogression in stereotactic radiotherapy of solitary brain metastases.

PURPOSE: To determine the influence of PTV-margin (0 mm versus 2 mm) on the incidence of pseudoprogression (PP) and local tumour control (LC) in patients treated with stereotactic radiotherapy (SRT) for solitary brain metastases. METHODS: Patients were treated on Novalis LINAC. Three dose schedules were used depending on the PTV-size. The PTV-margin was 2-mm prior to 2015 and 0-mm thereafter. MRI-scans were made every three months including a perfusion MRI-scan when pseudoprogression was suspected. We examined the relation of pseudoprogression and local control with the size of PTV-margin. Besides this, the association of dose-volume data of the whole brain (minus GTV) and pseudoprogression was investigated. RESULTS: 121 patients were analyzed (2-mm margin in 84 patients; 0-mm margin in 37 patients). There was no difference in GTV (7.6 cc versus 9.1 cc p = 0.2). At 24 months there was no difference in incidence of pseudoprogression (49% and versus 33%, p = 0.5) and local control in the 2-mm and 0-mm group (82% and versus 79%, p = 1.0). The size of PTV-margin was not associated with PP. Both margin and volume of brain receiving 12 Gy (V12) were not associated with pseudoprogression in patients treated with single fraction. CONCLUSIONS: PTV-margin reduction did not reduce the incidence of pseudoprogression in LINAC-based-SRT for single brain metastases. We did not find a significant association of GTV-PTV margin or V12Gy with the incidence of pseudoprogression in solitary metastases treated with a single fraction. LC rates were similar, indicating margin reduction seems to be safe.

Ruptured Bilobed Basilar Artery Fenestration Aneurysm Treated with a WEB Device.

Objective: To describe the technique of using a Woven Endo Bridge (WEB) device to treat a ruptured bilobed blister-like aneurysm (BLA) at the basilar artery (BA) fenestration. Case Presentation: A previously healthy 66-year-old female presented at the emergency room with subarachnoid hemorrhage (SAH), centered around the brainstem. Unenhanced CT and CT angiography showed a BLA of a basilar fenestration limb. The angiogram confirmed the diagnosis. A WEB device was chosen to treat this rare and challenging aneurysm. Conclusion: In this article, we describe the successful endovascular treatment of a SAH patient with a ruptured BLA at the basilar artery fenestration using a WEB device. And an overview of treatment options is provided.

Spectrum of Vascular Involvement in Coronavirus Disease 2019 Pneumonia-Findings on CT Perfusion.

OBJECTIVES: There is accumulating evidence of a distinct coagulopathy in severe acute respiratory syndrome coronavirus 2 infection which is associated with poor prognosis in coronavirus disease 2019. Coagulation abnormalities in blood samples resemble systemic coagulopathies in other severe infections but demonstrate specific features such as a very high d-dimer. These clinical observations are consistent with histopathologic findings of locally disturbed pulmonary microvascular thrombosis and angiopathy in end-stage coronavirus disease 2019. However, exact underlying processes and the sequence of events are not fully understood. DATA SOURCES: CT perfusion may provide insight in the dynamic aspect of the vascularity in pulmonary lesions in coronavirus disease 2019 infection as, in contrast to dual energy CT, a multiphase perfusion pattern is displayed. STUDY SELECTION: In six patients with coronavirus disease 2019 pneumonia, findings on additional CT perfusion series were correlated with known histopathologic vascular patterns upon pulmonary autopsy of patients who had died of coronavirus disease 2019. DATA EXTRACTION: In this case series, we were able to show perfusion changes on CT scans in typical pulmonary lesions illustrating diverse patterns. DATA SYNTHESIS: We demonstrated hyperperfusion in areas with ground glass and a severely decreased perfusion pattern in more consolidated areas often seen later in the course of disease. A combination was also observed, illustrating temporal heterogeneity. CONCLUSIONS: These findings provide new insights into the pathophysiology of coronavirus disease 2019 pneumonia and further understanding of the mechanisms that lead to respiratory failure in these patients.

Endovascular salvage of non-maturing autogenous arteriovenous fistulas by using angioplasty and competitive vein embolization.

INTRODUCTION: The aim of this study is to evaluate the maturation and patency rates after endovascular treatment of non-maturing arteriovenous fistulas with percutaneous transluminal angioplasty, embolization of competitive veins, or a combination of both in a series of consecutive patients. MATERIAL AND METHODS: Retrospective evaluation of patients with non-matured arteriovenous fistulas treated in our hospital was performed. Fistulography and ultrasonography was performed in all patients to evaluate the presence of stenosis and competitive veins. Significant stenoses (> 50%) were treated with balloon angioplasty and competitive veins (accessory and collateral veins) with coil embolization. RESULTS: A total of 78 fistulas were treated. Angioplasty and coil embolization were performed in 73 and 51 patients, respectively. No major complications occurred. In 65 out of 78 arteriovenous fistulas (83%), successful cannulation with two needles was possible after endovascular treatment. Sixty-three arteriovenous fistulas (81%) were used successfully for at least 3 months. Accessory veins were the only lesion present in 14% of the arteriovenous fistulas; coil embolization of these accessory veins resulted in 100% successful maturation. The estimated 3, 6, and 12 months postintervention assisted primary patency rates were, respectively, 73%, 55%, and 45%. The estimated 3, 6, and 12 months postintervention secondary patency rates were, respectively, 81%, 78%, and 73%. CONCLUSION AND DISCUSSION: Angioplasty and coil embolization are successful and safe procedures that can convert a non-mature fistula into a mature one in more than 80% of patients. Accessory vein embolization may be more important than collateral vein embolization in the presence of stenosis.

Total bolus extraction method improves arterial image quality in dynamic CTAs derived from whole-brain CTP data.

Background and Purposes. The 320-detector row CT scanner enables visualization of whole-brain hemodynamic information (dynamic CT angiography (CTA) derived from CT perfusion scans). However, arterial image quality in dynamic CTA (dCTA) is inferior to arterial image quality in standard CTA. This study evaluates whether the arterial image quality can be improved by using a total bolus extraction (ToBE) method. Materials and Methods. DCTAs of 15 patients, who presented with signs of acute cerebral ischemia, were derived from 320-slice CT perfusion scans using both the standard subtraction method and the proposed ToBE method. Two neurointerventionalists blinded to the scan type scored the arterial image quality on a 5-point scale in the 4D dCTAs in consensus. Arteries were divided into four categories: (I) large extradural, (II) intradural (large, medium, and small), (III) communicating arteries, and (IV) cerebellar and ophthalmic arteries. Results. Quality of extradural and intradural arteries was significantly higher in the ToBE dCTAs than in the standard dCTAs (extradural P = 0.001, large intradural P < 0.001, medium intradural P < 0.001, and small intradural P < 0.001). Conclusion. The 4D dCTAs derived with the total bolus extraction (ToBE) method provide hemodynamic information combined with improved arterial image quality as compared to standard 4D dCTAs.