Detection of monoclonal protein by capillary zone electrophoresis can be challenged by iodinated contrast agent interference: a case report

The detection of monoclonal immunoglobulins is a key element in the diagnosis of monoclonal gammopathy. In clinical practice, screening and measurement of monoclonal proteins are commonly performed using capillary zone electrophoresis (CZE). Some exogenous substances, such as iodinated contrast agents, absorb incident UV light at the same wavelengths as the peptide bonds and may therefore interfere with the detection of proteins in CZE. We herein use the description of a case to illustrate that iodinated contrast agents can mask the presence of monoclonal immunoglobulins in CZE and we discuss the strategy needed to confirm this interference. Performing immunofixation, immunosubtraction, or a second CZE at a distance from the first blood sample is not only necessary to confirm the presence of an iodinated contrast media interference but also to ensure the absence of monoclonal proteins

Model-Based Iterative Reconstruction (MBIR) for ASPECT Scoring in Acute Stroke Patients Selection: Comparison to rCBV and Follow-Up Imaging

Background: To compare a model-based iterative reconstruction (MBIR) versus a hybrid iterative reconstruction (HIR) for initial and final Alberta Stroke Program Early Ct Score (ASPECT) scoring in acute ischemic stroke (AIS). We hypothesized that MBIR designed for brain computed tomography (CT) could perform better than HIR for ASPECT scoring. Methods: Among patients who had undergone CT perfusion for AIS between April 2018 and October 2019 with a follow-up imaging within 7 days, we designed a cohort of representative ASPECTS. Two readers assessed regional-cerebral-blood-volume-ASPECT (rCBV-ASPECTS) on the initial exam and final-ASPECTS on the follow-up non-contrast-CT (NCCT) in consensus. Four readers performed independently MBIR and HIR ASPECT scoring on baseline NCCT. Results: In total, 294 hemispheres from 147 participants (average age of 69.59 ± 15.63 SD) were analyzed. Overall raters’ agreement between rCBV-map and MBIR and HIR ranged from moderate to moderate (κ = 0.54 to κ = 0.57) with HIR and moderate to substantial (κ = 0.52 to κ = 0.74) with MBIR. Overall raters’ agreement between follow-up imaging and HIR/MBIR ranged from moderate to moderate (κ = 0.55 to κ = 0.59) with HIR and moderate to almost perfect (κ = 0.48 to κ = 0.82) with MBIR. Conclusions: ASPECT scoring with MBIR more closely matched with initial and final infarct extent than classical HIR NCCT reconstruction

Four-dimensional computed tomography angiography analysis of internal carotid arteries opacification at the skull base to detect delayed cerebral ischemia: a feasibility study

International audiencePurposeDelayed cerebral ischemia represents a significant cause of poor functional outcome for patients with vasospasm after subarachnoid hemorrhage. We investigated whether delayed cerebral ischemia could be detected by the arterial opacification of internal carotid artery at the level of the skull base.MethodsIn this exploratory, nested retrospective cohort diagnostic accuracy study, patients with clinical and/or transcranial Doppler suspicion of vasospasm who underwent four-dimensional computed tomography angiography were included. They were split into two groups for the main endpoint analysis, according to the actually adopted morphological (cerebral infarction) and clinical criteria (neurologic deterioration) of delayed cerebral ischemia. Opacification with a temporal resolution of 0.15 s of both internal carotid arteries at the skull base level was obtained through a semi-automated segmentation method based on skeletonization, and analyzed by a wavelet transform (rbio2.2, level 1). The results obtained by k-means clustering were analyzed with regard to the state of delayed cerebral infarction.ResultsOver ten patients included and analyzed, five patients presented a delayed cerebral ischemia, two of them in both side. The semi-automated processing and analysis clustered two different types of opacification curves. The obtaining of a nonlinear opacification pattern was associated (p < 0.001) with delayed cerebral ischemia.ConclusionsThe analysis of arterial opacification of internal carotid arteries at skull base by the proposed processing is feasible and leads to cluster two types of opacification that may help to early detect and prevent delayed cerebral ischemia, in particularly when examinations are artifacted by aneurysm treatment materials

Outcomes Following Mechanical Thrombectomy in Different Etiological Subtypes of Acute Basilar Artery Occlusion

International audienceBackground and purpose: Vertebrobasilar occlusion stroke (VBOS) is innately associated with high morbimortality despite advances in endovascular thrombectomy (EVT). Nonetheless, notable outcome dissimilarities exist between angiographically categorized stroke subtypes. We aim to evaluate potential differences concerning clinical angiographic outcomes among etiological subtypes of VBOS based on the Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria.Methods: We retrospectively reviewed prospective EVT databases at two tertiary care stroke centers for consecutive patients with VBOS who had preinterventional MRI and underwent EVT from January 2015 to December 2019. We identified three groups: large artery atherosclerosis (LAA), cardioembolic stroke (CES), and embolic stroke of undetermined source (ESUS). The primary endpoints were the rates of poor outcome (identified as 90-day modified Rankin scale score of 3-6) and mortality, while the secondary endpoint included the rates of incomplete reperfusion (identified as modified treatment in cerebral infarction scale mTICI 0-2b), and periprocedural symptomatic intracranial hemorrhage. We evaluated the association between the etiology and clinical angiographic outcomes through stepwise logistic regression analysis.Results: Out of 1823 patients, 139 (91 men; median age, 69 (61-76) years) with VBOS were qualified for the final analysis with incidence as follows: LAA (41%, n = 57), CES (35%, n = 48), and ESUS (24%, n = 34). Overall, incomplete reperfusion was realized in 41% (57/139) of the patients, a poor outcome in 65% (90/139), and mortality in 40% (55/139). Longer puncture to reperfusion interval (aOR 1.0182 [95% CI: 1.008-1.029]; p < 0.001) and utilization of combined aspiration-retriever technique (aOR 0.1998 [95% CI: 0.066-0.604]; p = 0.004) were associated with a greater likelihood of incomplete reperfusion (mTICI 0-2b) irrespective of the stroke etiology. After adjustment for confounding factors in the regression analysis, ESUS was an independent predictor of poor outcome (aOR 5.315 [95% CI: 1.646-17.163]; p = 0.005) and mortality (aOR 4.667 [95% CI: 1.883-11.564]; p < 0.001) at 90 days following EVT.Conclusion: The functional outcome following EVT for VBOS might depend on stroke etiology. According to our results, ESUS seems to be associated with the worst outcome, which needs further investigation to tailor the appropriate therapeutic plan

Negative susceptibility vessel sign might be predictive of complete reperfusion in patients with acute basilar artery occlusion managed with thrombectomy

International audienceObjectives: Negative susceptibility vessel sign (SVS) on pre-thrombectomy MRI has been linked to fibrin-rich thrombus and difficult retrieval in anterior ischemic stroke. However, its impact in posterior circulation-large vessel occlusion stroke (PC-LVOS) has not yet been elucidated. We aim to investigate the relationship of SVS parameters with stroke subtypes and their influence on angiographic and functional outcomes.Methods: Prospective thrombectomy registries at two-comprehensive stroke centers were retrospectively reviewed between January 2015 and December 2019 for consecutive MRI-selected patients with PC-LVOS. Two groups were assigned by two independent readers, based on the presence or absence of the SVS (SVS +, SVS -) on MRI-GRE sequence. Multivariate logistic regression analysis was utilized to study primarily the impact of the SVS on the rate of complete recanalization (defined as mTICI 2c/3) at the final series following endovascular thrombectomy (EVT) and whether or not it might influence the efficacy of the frontline EVT strategy. Secondarily, we studied whether the absence of the SVS was predictive of the rate of 90-day functional independence (defined as mRS score < 2). Lastly, both qualitative (SVS +, SVS-) and quantitative (SVS length and diameter) parameters of the SVS were analyzed in association with the puncture to recanalization interval and various stroke etiological subtypes based on TOAST criteria.Results: Among 1823 patients, 116 were qualified for final analysis (median age, 68 (59-75) years; male, 65%); SVS was detected in 62.9% (73/116) of cases. SVS length was an independent predictor of procedural duration (p = .01) whilst two-layered SVS was inversely associated with the atherosclerosis etiological subtype (aOR = 0.27, 95% CI 0.08-0.89; p = .03). Successful recanalization was achieved in 82% (60/73) vs. 86% (37/43), p = .80 of patients with SVS (+, -) respectively. Only in SVS (+), stentriever (RR 0.59 (0.4-0.88), p = .009), and contact-aspiration (RR 0.82 (0.7-0.96), p = .01) achieved a lower rate of successful recanalization compared to combined technique. SVS (-) was significantly associated with a higher rate of mTICI 2c/3 (aOR = 4.444; 95% CI 1.466-13.473; p = .008) and showed an indirect effect of 9% towards functional independence mediated by mTICI 2c/3.Conclusion: SVS parameters in PC-LVOS might predict stroke subtype and indirectly influence the functional outcome by virtue of complete recanalization.Key points: • Negative susceptibility vessel sign (SVS) in patients with basilar occlusion independently predict complete recanalization that indirectly instigated a 3-month favorable outcome following thrombectomy. • The longer the SVS, the higher likelihood of large artery atherosclerosis and the longer the thrombectomy procedure. • Two-layered SVS might be negatively associated with the presence of atherosclerosis, yet already-known limitations of TOAST classification and the absence of pathological analysis should be taken into consideration

Surgical treatment of brain arteriovenous malformations: clinical outcomes of patients included in the registry of a pragmatic randomized trial

International audienceOBJECTIVE The Treatment of Brain Arteriovenous Malformations Study (TOBAS) is a pragmatic study that includes 2 randomized trials and registries of treated or conservatively managed patients. The authors report the results of the surgical registry. METHODS TOBAS patients are managed according to an algorithm that combines clinical judgment and randomized allocation. For patients considered for curative treatment, clinicians selected from surgery, endovascular therapy, or radiation therapy as the primary curative method, and whether observation was a reasonable alternative. When surgery was selected and observation was deemed unreasonable, the patient was not included in the randomized controlled trial but placed in the surgical registry. The primary outcome of the trial was mRS score > 2 at 10 years (at last follow-up for the current report). Secondary outcomes include angiographic results, perioperative serious adverse events, and permanent treatment-related complications leading to mRS score > 2. RESULTS From June 2014 to May 2021, 1010 patients were recruited at 30 TOBAS centers. Surgery was selected for 229/512 patients (44%) considered for curative treatment; 77 (34%) were included in the surgery versus observation randomized trial and 152 (66%) were placed in the surgical registry. Surgical registry patients had 124/152 (82%) ruptured and 28/152 (18%) unruptured arteriovenous malformations (AVMs), with the majority categorized as low-grade Spetzler-Martin grade I–II AVM (118/152 [78%]). Thirteen patients were excluded, leaving 139 patients for analysis. Embolization was performed prior to surgery in 78/139 (56%) patients. Surgical angiographic cure was obtained in 123/139 all-grade (89%, 95% CI 82%–93%) and 105/110 low-grade (95%, 95% CI 90%–98%) AVM patients. At the mean follow-up of 18.1 months, 16 patients (12%, 95% CI 7%–18%) had reached the primary safety outcome of mRS score > 2, including 11/16 who had a baseline mRS score ≥ 3 due to previous AVM rupture. Serious adverse events occurred in 29 patients (21%, 95% CI 15%–28%). Permanent treatment-related complications leading to mRS score > 2 occurred in 6/139 patients (4%, 95% CI 2%–9%), 5 (83%) of whom had complications due to preoperative embolization. CONCLUSIONS The surgical treatment of brain AVMs in the TOBAS registry was curative in 88% of patients. The participation of more patients, surgeons, and centers in randomized trials is needed to definitively establish the role of surgery in the treatment of unruptured brain AVMs. Clinical trial registration no.: NCT02098252 ( ClinicalTrials.gov

Patient Selection in a Pragmatic Study on the Management of Patients with Brain Arteriovenous Malformations

The Treatment of Brain Arteriovenous Malformations Study (TOBAS) is an all-inclusive pragmatic study comprising 2 randomized clinical trials (RCTs). Patients excluded from the RCTs are followed in parallel treatment and observation registries, allowing a comparison between RCT and registry patients