Usefulness of Spectral Cardiac Computed Tomography for the Evaluation of Thrombotic Complications in Patients with Ischemic Stroke

Objetivo: Evaluar la utilidad de la angiotomografía computada (TC) espectral cardíaca en pacientes con ataque cerebrovascular isquémico (ACVi). Material y métodos: En el contexto de pandemia de COVID-19 incorporamos la utilización de la TC espectral cardíaca en pacientes con ACVi para descartar en una única sesión, tanto fuentes cardioembólicas (FCE) como la presencia de complicaciones trombóticas o daño miocárdico. A partir de julio de 2020 incorporamos una adquisición tardía a las TC cardíacas en contexto de ACVi. Se presentan cuatro casos representativos sobre su utilidad y hallazgos cardiovasculares. Resultados: Se presentan cuatro casos registrados en un lapso de 40 días. Dos pacientes con FCE (aorta y orejuela izquierda) y dos con ACVi de origen indeterminado donde se evidenció miocardiopatía (isquémica y no isquémica). Conclusiones: En el contexto del ACVi, la TC espectral cardíaca, que incluía adquisición tardía, permitiría, eventualmente, descartar la presencia de FCE e identificar la etiología subyacente.Objective: The aim of this study was to evaluate the usefulness of spectral cardiac computed tomography (CT) angiography in patients with ischemic stroke. Methods: In the setting of COVID-19 pandemic, we incorporated the use of spectral cardiac CT in patients with ischemic stroke to rule out the presence of cardioembolic sources, thrombotic complications or myocardial damage in a single session. Since July 2020, a delayed-phase image acquisition was incorporated to cardiac CT scans in the context of ischemic stroke. We describe four representative cases of the usefulness of the method and the cardiovascular findings. Results: We present four cases recorded recorded within a 40-day period. Two patients with patients with cardioembolic source (aorta and left atrial appendage) and two with ischemic stroke of undetermined source with evidence of cardiomyopathy (ischemic and non-ischemic). Conclusions: In the setting of ischemic stroke, spectral cardiac CT with delayed acquisition could be useful to rule out the presence of cardioembolic sources and identify the underlying etiology.Fil: Rodriguez Granillo, Gaston Alfredo. Clinica la Sagrada Familia; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Houssay. Instituto Alberto C. Taquini de Investigaciones en Medicina Traslacional - Universidad de Buenos Aires. Facultad de Medicina. Instituto de Investigaciones Cardiológicas "Prof. Dr. Alberto C. Taquini". Instituto Alberto C. Taquini de Investigaciones en Medicina Traslacional; ArgentinaFil: Cirio, Juan. Clinica la Sagrada Familia; ArgentinaFil: Ciardi, Celina. Clinica la Sagrada Familia; ArgentinaFil: Ceron, Marcos. Clinica la Sagrada Familia; ArgentinaFil: Rubilar, Bibiana. Clinica la Sagrada Familia; ArgentinaFil: Bleise, Carlos. Clinica la Sagrada Familia; ArgentinaFil: Ingino, Carlos. Clinica la Sagrada Familia; ArgentinaFil: Lylyk, Pedro. Clinica la Sagrada Familia; Argentin

Usefulness of Spectral Cardiac Computed Tomography for the Evaluation of Thrombotic Complications in Patients with Ischemic Stroke

Objetivo: Evaluar la utilidad de la angiotomografía computada (TC) espectral cardíaca en pacientes con ataque cerebrovascular isquémico (ACVi). Material y métodos: En el contexto de pandemia de COVID-19 incorporamos la utilización de la TC espectral cardíaca en pacientes con ACVi para descartar en una única sesión, tanto fuentes cardioembólicas (FCE) como la presencia de complicaciones trombóticas o daño miocárdico. A partir de julio de 2020 incorporamos una adquisición tardía a las TC cardíacas en contexto de ACVi. Se presentan cuatro casos representativos sobre su utilidad y hallazgos cardiovasculares. Resultados: Se presentan cuatro casos registrados en un lapso de 40 días. Dos pacientes con FCE (aorta y orejuela izquierda) y dos con ACVi de origen indeterminado donde se evidenció miocardiopatía (isquémica y no isquémica). Conclusiones: En el contexto del ACVi, la TC espectral cardíaca, que incluía adquisición tardía, permitiría, eventualmente, descartar la presencia de FCE e identificar la etiología subyacente.Objective: The aim of this study was to evaluate the usefulness of spectral cardiac computed tomography (CT) angiography in patients with ischemic stroke. Methods: In the setting of COVID-19 pandemic, we incorporated the use of spectral cardiac CT in patients with ischemic stroke to rule out the presence of cardioembolic sources, thrombotic complications or myocardial damage in a single session. Since July 2020, a delayed-phase image acquisition was incorporated to cardiac CT scans in the context of ischemic stroke. We describe four representative cases of the usefulness of the method and the cardiovascular findings. Results: We present four cases recorded recorded within a 40-day period. Two patients with patients with cardioembolic source (aorta and left atrial appendage) and two with ischemic stroke of undetermined source with evidence of cardiomyopathy (ischemic and non-ischemic). Conclusions: In the setting of ischemic stroke, spectral cardiac CT with delayed acquisition could be useful to rule out the presence of cardioembolic sources and identify the underlying etiology.Fil: Rodriguez Granillo, Gaston Alfredo. Clinica la Sagrada Familia; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Houssay. Instituto Alberto C. Taquini de Investigaciones en Medicina Traslacional - Universidad de Buenos Aires. Facultad de Medicina. Instituto de Investigaciones Cardiológicas "Prof. Dr. Alberto C. Taquini". Instituto Alberto C. Taquini de Investigaciones en Medicina Traslacional; ArgentinaFil: Cirio, Juan. Clinica la Sagrada Familia; ArgentinaFil: Ciardi, Celina. Clinica la Sagrada Familia; ArgentinaFil: Ceron, Marcos. Clinica la Sagrada Familia; ArgentinaFil: Rubilar, Bibiana. Clinica la Sagrada Familia; ArgentinaFil: Bleise, Carlos. Clinica la Sagrada Familia; ArgentinaFil: Ingino, Carlos. Clinica la Sagrada Familia; ArgentinaFil: Lylyk, Pedro. Clinica la Sagrada Familia; Argentin

Discriminación de trombos mediante evaluación cuantitativa de mapas de yodo e imágenes monoenergéticas de baja energía en realce tardío

In the past decade, spectral computed tomography (CT) has emerged as a useful means to improve tissue characterization. However, few studies have explored its potential usefulness for the detection of cardiac and aortic thrombi.1–3 Furthermore, although delayed-phase imaging typically provides the most valuable datasets aimed at ruling out thrombi, there are scarce reports regarding threshold values for thrombotic sources.4 With the advent of dual-layer scanners that enable spectral routine acquisitions without protocol modifications, and in the context of acute ischemic stroke imaging, there is an expected increase in the number of scans with incidental thrombi. These scanners enable the availability of simultaneous multiparametric data including conventional CT images, monoenergetic imaging ranging from low (40keV) to high (200 keV) energy levels, and iodine density maps among others. Accordingly, we sought to evaluate the incremental value of monoenergetic and iodine density maps over conventional CT for the discrimination of thrombi in patients with acute ischemic stroke (AIS)...Fil: Rodriguez Granillo, Gaston Alfredo. Clínica La Sagrada Familia; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Houssay. Instituto Alberto C. Taquini de Investigaciones en Medicina Traslacional - Universidad de Buenos Aires. Facultad de Medicina. Instituto de Investigaciones Cardiológicas "Prof. Dr. Alberto C. Taquini". Instituto Alberto C. Taquini de Investigaciones en Medicina Traslacional; ArgentinaFil: Cirio, Juan J.. Clínica La Sagrada Familia; ArgentinaFil: Bleise, Carlos. Clínica La Sagrada Familia; ArgentinaFil: Fontana, Lucía. Clínica La Sagrada Familia; ArgentinaFil: Lylyk, Pedro. Clínica La Sagrada Familia; Argentin

Early Triage of Cardioembolic Sources Using Chest Spectral Computed Tomography in Acute Ischemic Stroke

Objectives: The present study investigated the potential usefulness of delayed-phase, low-dose, non-gated, chest spectral CT scans (DSCT) for the early triage of cardioembolic (CE) sources in patients admitted with acute ischemic stroke (AIS), and for the simultaneous detection of myocardial disease and thrombotic complications. Material and methods: Since July 2020 and promoted by the COVID-19 pandemic, we implemented the use of DSCT after cerebrovascular CT angiography (CTA) among patients with AIS using a dual-layer spectral CT. We explored the presence of CE sources, as well as late myocardium iodine enhancement (LIE) and pulmonary thromboembolism. Among patients further undergoing transesophageal echocardiogram (TEE) or cardiac CTA, we explored the diagnostic performance. Results: Fifty consecutive patients with AIS who underwent DSCT after cerebrovascular CTA comprised the patient population. The confidence degree for excluding cardiac thrombi was significantly higher than for LIE (4.4±0.8 vs. 3.4±1.3, p<0.0001). DSCT identified a CE source in 4 (8%) and LIE in 24 (48%) patients. The iodine ratio of CE sources was significantly lower compared to the left atrial appendage of patients with no CE sources (0.25±0.1 mg/mL vs. 0.91±0.2 mg/mL, p<0.0001). TEE/cardiac CT, performed in 20 (40%) patients, identified a CE source in 5 (25%) cases, whereas DSCT identified 4 (20%), leading to a sensitivity and specificity of 80% (95% CI 28–99%) and 100% (95% CI 78–100%) respectively (kappa 0.86). Conclusions: In this pilot study, we identified DSCT as a potential unsophisticated approach for the early triage of CE sources among patients with AIS undergoing CTA upon admission.Fil: Rodriguez Granillo, Gaston Alfredo. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Houssay. Instituto Alberto C. Taquini de Investigaciones en Medicina Traslacional - Universidad de Buenos Aires. Facultad de Medicina. Instituto de Investigaciones Cardiológicas "Prof. Dr. Alberto C. Taquini". Instituto Alberto C. Taquini de Investigaciones en Medicina Traslacional; ArgentinaFil: Cirio, Juan J.. No especifíca;Fil: Ciardi, Celina. No especifíca;Fil: Caballero, Maria Laura. No especifíca;Fil: Ceron, Marcos. No especifíca;Fil: Bleise, Carlos. No especifíca;Fil: Diluca, Pablo. No especifíca;Fil: Lylyk, Pedro. No especifíca

Abstract Number ‐ 12: First‐In‐Human Endovascular Treatment of Idiopathic Intracranial Hypertension Using a Miniature Biomimetic Transdural Shunt.

Introduction Successful percutaneous transvenous deployment of a miniature valved biomimetic transdural endovascular shunt (CereVasc eShunt, Auburndale, MA, USA) via an inferior petrosal sinus approach was recently described for treatment of post‐subarachnoid hemorrhage communicating hydrocephalus.The endovascular shunt replicates the function of the arachnoid granulation by draining cerebrospinal fluid (CSF) from the cerebello‐pontine angle cistern to the ipsilateral internal jugular vein. Idiopathic intracranial hypertension (IIH), usually resulting from venous transverse sinus stenosis, can be treated with pharmacological inhibition of CSF production, surgical ventriculoperitoneal shunting, or using venous stent angioplasty. In IIH, elevated CSF pressure can act to exacerbate venous sinus stenosis, resulting in worsening CSF reabsorption, thereby perpetuating a vicious cycle. The authors sought to evaluate the role of the minimally invasive eShunt approach in IIH management. Methods A 50‐year‐old male patient with history of dyslipidemia and IIH initially presented 6 years ago with diplopia initially treated with poorly tolerated acetazolamide and periodic lumbar punctures with subsequent symptom improvement. The patient was admitted following rapid evolution of sudden onset horizontal diplopia and headache. Brain magnetic resonance revealed flattening of the posterior sclera, partially empty Sella Turcica, enhancement of the prelaminar optic nerves and enlarged Meckel´s cave. Lumbar puncture was performed with opening pressure of 28 cmH2O. Cerebral angiography with 3D venography confirmed bilateral transverse sinus stenosis, though without a significant pressure gradient. Results The patient declined surgical ventriculoperitoneal shunting and was approved for compassionate use of eShunt by regulatory and bioethics committees.He underwent successful endovascular transdural deployment of the eShunt, which he tolerated well and was discharged at 48 hours post‐procedure with rapid symptomatic headache relief. Upon 30‐day follow‐up repeat brain MRI showed improvement of the prominent subarachnoid space around both optic nerves and sustained improvement of his pre‐procedural headache and diplopia.A repeat lumbar puncture revealed a lowed opening pressure of 20 cmH2O and MRI cisternography confirmed maintained patency of the biomimetic valve with accumulation of Gadolinium‐enhanced CSF drainage through the eShunt into the jugular bulb. Conclusions The current report describes the first‐in‐human use of the eShunt device for treatment of IIH resulting in sustained symptomatic relief along with decrease in CSF pressure and pre‐laminar optic nerve edema. The current results, which require confirmation in a larger cohort with longer follow‐up, are encouraging and suggest a possible role for minimally invasive endovascular transdural eshunt placement in the management of IIH

Results of the pToWin Study: Using the pCONUS Device for the Treatment of Wide-Neck Intracranial Aneurysms

Coil embolization has become a well-established option for the treatment of intracranial aneurysms. Yet, wide-neck bifurcation aneurysms (WNBAs) remain a challenge. The pCONUS is the first generation of a stent-like implant for the bridging of WNBAs to enable coiling. The pToWin study was a prospective, single-arm, multicenter study conducted to analyze the safety and efficacy of the pCONUS in the treatment of WNBAs. The primary effectiveness endpoint was the rate of adequate occlusion of the aneurysm at 3&ndash;6 and 7&ndash;12 months. The primary safety endpoint was the occurrence of major ipsilateral stroke or neurological death during the follow-up. A total of 115 patients were included. Aneurysm locations were the middle cerebral artery in 52 (45.2%), the anterior communicating artery in 35 (30.4%), the basilar artery in 23 (20%), the internal carotid artery terminus in three (2.6%), and the pericallosal artery in two (1.7%) patients. Treatment was successfully performed in all but one patient. The morbi-mortality rate was 1.9% and 2.3% at 3&ndash;6 and 7&ndash;12 months, respectively. Of the aneurysms, 75.0% and 65.6% showed adequate occlusion at 3&ndash;6 and 7&ndash;12 months, respectively. pCONUS offers a safe and reasonably effective treatment of WNBAs, demonstrated by acceptable adequate aneurysm occlusion and low rates of adverse neurologic events

Diversion-p64: results from an international, prospective, multicenter, single-arm post-market study to assess the safety and effectiveness of the p64 flow modulation device

International audienceBackground: The use of flow diversion to treat intracranial aneurysms has increased in recent years.Objective: To assess the safety and angiographic efficacy of the p64 flow modulation device.Methods: Diversion-p64 is an international, prospective, multicenter, single-arm, study conducted at 26 centers. The p64 flow modulation device was used to treat anterior circulation aneurysms between December 2015 and January 2019. The primary safety endpoint was the incidence of major stroke or neurologic death at 3-6 months, with the primary efficacy endpoint being complete aneurysm occlusion (Raymond-Roy Occlusion Classification 1) on follow-up angiography.Results: A total of 420 patients met the eligibility criteria and underwent treatment with the p64 flow modulation device (mean age 55±12.0 years, 86.2% female). Mean aneurysm dome width was 6.99±5.28 mm and neck width 4.47±2.28 mm. Mean number of devices implanted per patient was 1.06±0.47, with adjunctive coiling performed in 14.0% of the cases. At the second angiographic follow-up (mean 375±73 days), available for 343 patients (81.7%), complete aneurysm occlusion was seen in 287 (83.7%) patients. Safety data were available for 413 patients (98.3%) at the first follow-up (mean 145±43 days) with a composite morbidity/mortality rate of 2.42% (n=10).Conclusions: Diversion-p64 is the largest prospective study using the p64 flow modulation device. The results of this study demonstrate that the device has a high efficacy and carries a low rate of mortality and permanent morbidity