CT perfusion as a selection tool for mechanical thrombectomy, a single-centre study

Background: Recently, CT perfusion (CTP) has been proposed as a selection tool for stroke patients to be treated with endovascular thrombectomy. We investigated whether functional outcome following endo-vascular treatment was improved after the introduction of CTP. Methods: This retrospective single-centre study includes all patients with a major vessel occlusion in the anterior circulation that received a CTP and underwent a mechanical thrombectomy from 2014 up to 2015. CTP were visually evaluated. Demographics, stroke and time data, procedural data, functional outcomes as measured by the modified Rankin Scale (mRS) and the association between these variables were studied. A comparison was made with the results of a similar local retrospective study from before the CTP "era". Results: Eighty-nine patients were included in this study. Median National Institutes of Health Stroke Scale (NIHSS) was 16 (Interquartile range 6). At three months, good functional outcome (GFO; mRS 0-2) was achieved in 48.4% and excellent functional outcome (EFO; mRS 0-1) in 34.4% of patients. The mortality rate at three months was 14.5%. GFO at one year was 44.8%, EFO was 31.3% and mortality 21.1%. The duration of the thrombectomy procedure and the EFO were associated (p = 0.032). The outcome improvement achieved with CTP was higher compared to the reference study (GFO 48.4% versus 44%; EFO 34.4% versus 29%) but remained below the statistical significance. Conclusions: Mechanical thrombectomy for anterior circulation strokes based on CTP did not result in a significant functional outcome improvement. The duration of the thrombectomy procedure was the sole time-interval related to improved functional outcome

Intracranial dural arteriovenous fistula successfully treated by combined open-endovascular procedure

Intracranial dural arteriovenous fistulas constitute a rare though potentially devastating disease. Because the arterial (high-pressure) blood flow drains directly into the low-pressure venous system, there is a high risk of bleeding and associated neurological deficit. The classifications by Borden and Cognard underline the correlation between bleeding risk and venous drainage pattern of the fistula. There are different treatment options for this vascular pathology, which always poses a challenge for the physicians involved to offer the optimal treatment for an individual patient. This case report illustrates how combining forces between the neurosurgical and endovascular team benefits outcome. Simultaneously, this contributes to the growing amount of evidence that a new endovascular technique with transarterial ONYX embolisation enables complete obliteration of the vascular malformation

Cerebral Proliferative Angiopathy in a Child, Five Years after an Intraventricular Hemorrhage and Negative Catheter Angiography

Cerebral proliferative angiopathy (CPA) is a rare cerebrovascular disease comprised of a diffuse network of blood vessels, often spread over several lobes. Due to the presence of normal brain tissue within the malformation, complete resection is not desirable. Several imaging characteristics help to distinguish CPA from brain arteriovenous malformations. We report the case of a patient diagnosed with CPA five years after a spontaneous intraventricular hemorrhage and an initial negative angiogram. Teaching Point: The radiologist should be able to differentiate CPA from brain AVM to prevent potentially harmful treatment

Unruptured brain arteriovenous malformations : primary ONYX embolization in ARUBA (A Randomized Trial of Unruptured Brain Arteriovenous Malformations)-eligible patients

Background and Purpose: In light of evidence from ARUBA (A Randomized Trial of Unruptured Brain Arteriovenous Malformations), neurovascular specialists had to reconsider deliberate treatment of unruptured brain arteriovenous malformations (uBAVMs). Our objective was to determine the outcomes of uBAVM treated with primary embolization using ethylene vinyl alcohol (ONYX). Methods: Patients with uBAVM who met the inclusion criteria of ARUBA and were treated with primary Onyx embolization were assigned to this retrospective study. The primary outcome was the modified Rankin Scale score. Secondary outcomes were stroke or death because of uBAVM or intervention and uBAVM obliteration. Results: Sixty-one patients (mean age, 38 years) were included. The median observation period was 60 months. Patients were treated by embolization alone (41.0%), embolization and radiosurgery (57.4%), or embolization and excision (1.6%). Occlusion was achieved in 44 of 57 patients with completed treatment (77.2%). Forty-seven patients (77.1%) had no clinical impairment at the end of observation (modified Rankin Scale score of <2). Twelve patients (19.7%) reached the outcome of stroke or death because of uBAVM or intervention. Treatment-related mortality was 6.6% (4 patients). Conclusions: In uBAVM, Onyx embolization alone or combined with stereotactic radiosurgery achieves a high occlusion rate. Morbidity remains a challenge, even if it seems lower than in the ARUBA trial

Transarterial RAdioembolization versus ChemoEmbolization for the treatment of hepatocellular carcinoma (TRACE) : study protocol for a randomized controlled trial

Background: Hepatocellular carcinoma is a primary malignant tumor of the liver that accounts for an important health problem worldwide. Only 10 to 15% of hepatocellular carcinoma patients are suitable candidates for treatment with curative intent, such as hepatic resection and liver transplantation. A majority of patients have locally advanced, liver restricted disease (Barcelona Clinic Liver Cancer (BCLC) staging system intermediate stage). Transarterial loco regional treatment modalities offer palliative treatment options for these patients; transarterial chemoembolization (TACE) is the current standard treatment. During TACE, a catheter is advanced into the branches of the hepatic artery supplying the tumor, and a combination of embolic material and chemotherapeutics is delivered through the catheter directly into the tumor. Yttrium-90 radioembolization (Y-90-RE) involves the transarterial administration of minimally embolic microspheres loaded with Yttrium-90, a beta-emitting isotope, delivering selective internal radiation to the tumor. Y-90-RE is increasingly used in clinical practice for treatment of intermediate stage hepatocellular carcinoma, but its efficacy has never been prospectively compared to that of the standard treatment (TACE). In this study, we describe the protocol of a multicenter randomized controlled trial aimed at comparing the effectiveness of TACE and Y-90-RE for treatment of patients with unresectable (BCLC intermediate stage) hepatocellular carcinoma. Methods/design: In this pragmatic randomized controlled trial, 140 patients with unresectable (BCLC intermediate stage) hepatocellular carcinoma, with Eastern Cooperative Oncology Group performance status 0 to 1 and Child-Pugh A to B will be randomly assigned to either Y-90-RE or TACE with drug eluting beads. Patients assigned to Y-90-RE will first receive a diagnostic angiography, followed by the actual transarterial treatment, which can be divided into two sessions in case of bilobar disease. Patients assigned to TACE will receive a maximum of three consecutive transarterial treatment sessions. Patients will undergo structural follow-up for a timeframe of two years post treatment. Post procedural magnetic resonance imaging (MRI) will be performed at one and three months post trial entry and at three-monthly intervals thereafter for two years to assess tumor response. Primary outcome will be time to progression. Secondary outcomes will be overall survival, tumor response according to the modified RECIST criteria, toxicities/adverse events, treatment related effect on total liver function, quality of life, treatment-related costs and cost-effectiveness