Finnish flow diverter study : 8 years of experience in the treatment of acutely ruptured intracranial aneurysms

Background Flow diversion of acutely ruptured intracranial aneurysms (IAs) is controversial due to high treatment-related complication rates and a lack of supporting evidence. We present clinical and radiological results of the largest series to date. Methods This is a nationwide retrospective study of acutely ruptured IAs treated with flow diverters (FDs). The primary outcome was the modified Rankin Scale (mRS) score at the last available follow-up time. Secondary outcomes were treatment-related complications and the aneurysm occlusion rate. Results 110 patients (64 females; mean age 55.7 years; range 12-82 years) with acutely ruptured IAs were treated with FDs between 2012 and 2020 in five centers. 70 acutely ruptured IAs (64%) were located in anterior circulation, and 47 acutely ruptured IAs (43%) were blister-like. A favorable functional outcome (mRS 0-2) was seen in 73% of patients (74/102). Treatment-related complications were seen in 45% of patients (n=49). Rebleeding was observed in 3 patients (3%). The data from radiological follow-ups were available for 80% of patients (n=88), and complete occlusion was seen in 90% of aneurysms (79/88). The data from clinical follow-ups were available for 93% of patients (n=102). The overall mortality rate was 18% (18/102). Conclusions FD treatment yields high occlusion for acutely ruptured IAs but is associated with a high risk of complications. Considering the high mortality rate of aneurysmal subarachnoid hemorrhage, the prevention of rebleeding is crucial. Thus, FD treatment may be justified as a last resort option.Peer reviewe

Finnish flow diverter study : 8 years of experience in the treatment of acutely ruptured intracranial aneurysms

Background Flow diversion of acutely ruptured intracranial aneurysms (IAs) is controversial due to high treatment-related complication rates and a lack of supporting evidence. We present clinical and radiological results of the largest series to date. Methods This is a nationwide retrospective study of acutely ruptured IAs treated with flow diverters (FDs). The primary outcome was the modified Rankin Scale (mRS) score at the last available follow-up time. Secondary outcomes were treatment-related complications and the aneurysm occlusion rate. Results 110 patients (64 females; mean age 55.7 years; range 12-82 years) with acutely ruptured IAs were treated with FDs between 2012 and 2020 in five centers. 70 acutely ruptured IAs (64%) were located in anterior circulation, and 47 acutely ruptured IAs (43%) were blister-like. A favorable functional outcome (mRS 0-2) was seen in 73% of patients (74/102). Treatment-related complications were seen in 45% of patients (n=49). Rebleeding was observed in 3 patients (3%). The data from radiological follow-ups were available for 80% of patients (n=88), and complete occlusion was seen in 90% of aneurysms (79/88). The data from clinical follow-ups were available for 93% of patients (n=102). The overall mortality rate was 18% (18/102). Conclusions FD treatment yields high occlusion for acutely ruptured IAs but is associated with a high risk of complications. Considering the high mortality rate of aneurysmal subarachnoid hemorrhage, the prevention of rebleeding is crucial. Thus, FD treatment may be justified as a last resort option.Peer reviewe

Real-time monitoring of human blood-brain barrier disruption

Chemotherapy aided by opening of the blood-brain barrier with intra-arterial infusion of hyperosmolar mannitol improves the outcome in primary central nervous system lymphoma. Proper opening of the blood-brain barrier is crucial for the treatment, yet there are no means available for its real-time monitoring. The intact blood-brain barrier maintains a mV-level electrical potential difference between blood and brain tissue, giving rise to a measurable electrical signal at the scalp. Therefore, we used direct-current electroencephalography ( DC-EEG) to characterize the spatiotemporal behavior of scalp-recorded slow electrical signals during blood-brain barrier opening. Nine anesthetized patients receiving chemotherapy were monitored continuously during 47 blood-brain barrier openings induced by carotid or vertebral artery mannitol infusion. Left or right carotid artery mannitol infusion generated a strongly lateralized DC-EEG response that began with a 2 min negative shift of up to 2000 mu V followed by a positive shift lasting up to 20 min above the infused carotid artery territory, whereas contralateral responses were of opposite polarity. Vertebral artery mannitol infusion gave rise to a minimally lateralized and more uniformly distributed slow negative response with a posterior-frontal gradient. Simultaneously performed near-infrared spectroscopy detected a multiphasic response beginning with mannitol-bolus induced dilution of blood and ending in a prolonged increase in the oxy/deoxyhemoglobin ratio. The pronounced DC-EEG shifts are readily accounted for by opening and sealing of the blood-brain barrier. These data show that DC-EEG is a promising real-time monitoring tool for bloodbrain barrier disruption augmented drug delivery.Peer reviewe

Vesivoimalla tuotettu sähköenergia

Tämän opinnäytetyön aiheena oli ”Vesivoimalla tuotettu sähköenergia”, ja opinnäytetyön tavoitteena oli selvittää Suomessa olevien vesivoimalaitoksien toimintaperiaatetta, rakennetta sekä tekniikkaa. Opinnäytetyö tehtiin Metropolia AMK:lle kartoittamaan tämän päivän tilannette siitä, miksi vesivoimalat ovat niin tärkeä osa säätövoimaa. Opinnäytetyöstä tehtiin tutkielma, jossa käsiteltiin Suomessa olevia vesivoimalaitoksia kokonaisuuteta. Opinnäytetyössä käsiteltiin myös sitä, miten vesivoimalaitokset ovat kehittyneet vuosisatojen aikana nykyisten kaltaisiksi vesivoimalaitoksiksi. sekä tästä työstä käy ilmi myös se, minkälaisia vesivoimalaitostyyppejä on olemassa ja miksi, sekä työstä käy ilmi Suomessa olevien vesivoimalaitosten teknisten laitteistojen rakenne sekä syy, miksi ne ovat vesivoimalaitoksessa. Työssä käsiteltiin myös lähinnä vesivoimalaitoksilla, tuotetun sähköenergian määrää, erilaisia tuotantotapoja, tuotantolaitosten teknisiä ominaisuuksia rakenteineen sekä sitä, miksi vesivoima on tärkeä tuotantotapa, mitä haasteita vuodenaikojen kanssa on sekä miten vesivoimalat vaikuttavat jokien kalakantoihin. Tässä opinnäytetyössä käydään myös se läpi, kuinka paljon vesivoimalat tuottavat sähköä valtakunnan sähköverkkoon ja paljonko tuotanto on koko Suomen sähköntuotantokapasiteetista, voidaanko vesivoimaa säädellä, ja onko siitä apua silloin, kun Suomessa tarvitaan paljon sähköenergiaa. Opinnäytetyössä tietolähteinä oli vesivoimalayhtiöiden asiantuntijat ja ammattilaiset, eri viranomaistahot sekä puolueettomat asiantuntijat niin puhelimitse sekä painetun ja sähköisen tiedon avulla. Työn tuloksena opinnäytetyöstä tuli varsin kattava selvitys 2000-luvun vesivoimalaitosten tilasta sekä siitä, miten vesivoimalaitokset toimivat. Työn tuloksiin voidaan laskea myös se, että minkälainen laitteisto on vesivoimalaitoksen sisällä ja se, minkälaiseksi asiantuntijat odottavat vesivoimalaitoksien tulevaisuuden muuttuvan

Endovascular treatment of 467 consecutive intracranial aneurysms in Oulu University Hospital:angiographic and clinical results

Abstract The purpose of the study was to analyze the angiographic and clinical results of endovascularly treated intracranial aneurysms in Oulu University Hospital, Finland. The study population consisted of 416 consecutive patients (467 aneurysms, 332 ruptured), who were referred for endovascular treatment of intracranial aneurysm(s) between December 1993 and July 2004. Technical failures were analyzed for an assesment of technical feasibility. Angiographic results were assessed using modified Raymond Classification. Clinical results were analyzed from patient files using the Glasgow Outcome Scale (GOS). Patient, aneurysm, and procedure related variables were tested with an intention to find the predictors of the angiographic and clinical outcome. The clinical effects on presenting symptoms were analyzed for a subgroup of patients with a symptomatic unruptured aneurysm (n = 30). The mean results on technical feasibility, complications, and angiographic results were separately assessed for three time periods (1993–1997, 1998–2000 and 2001–2004) to demonstrate potential significant changes in outcome. Endovascular treatment of saccular aneurysms was technically feasible in 91.4% of the treatments. Initially, 25.7% of the aneurysms were completely occluded, 57.9% had a neck remnant, and 16.3% remained incompletely occluded. In follow-up, the rates for complete occlusions, neck remnants and incomplete occlusions were 37.6%, 49.7% and 12.7%, respectively. Small aneurysm size predicted complete aneurysm occlusion, while a wide aneurysm neck and location in the posterior circulation predicted incomplete occlusion. In follow-up (mean 38.2 months), 78.1% of the patients with a ruptured aneurysm and 92.3% of the patients with an unruptured aneurysm had resumed independent life (GOS 4-5). The predictors of good outcome were young age, good preprocedural clinical condition, small amount of blood in CT scan, and uncomplicated procedure. Ten of the treated aneurysms involved intracranial bleeding in follow-up, and the annual risk for bleeding after endovascular treatment was 0.95% among the patients with ruptured aneurysms and 0.33% among those with unruptured aneurysms. The risk of bleeding was associated with larger aneurysm size and lower occlusion grade. In the subgroup of symptomatic unruptured aneurysms, 53.4% of the patients showed either resolution or improvement of the symptoms after treatment. The rates of procedural complications, morbidity, and mortality were 16.5%, 6.7%, and 1.7%, respectively. The risk for procedural complications was higher when the balloon remodeling technique was used and lower in retreatments. Technical feasibility (85.6%, 90.6%, and 95.7%, respectively) and the percentage of complete occlusions (initially 16.5%, 23.0%, and 32.9%, respectively) were significantly improved by increased experience, while no statistical difference was detected in the total procedural complication rates (15.4%, 15.7%, and 18.3%, respectively) or the combined procedural morbidity and mortality rates (8.0%, 8.3%, and 9.1%, respectively). All six dissecting aneurysms treated with parent artery occlusion or the stent remodeling technique resulted in complete occlusions. The present results confirmed endovascular treatment of intracranial aneurysms as a feasible, safe, and effective method in preventing further bleeding of aneurysms. Increased experience in a single center improved the feasibility of the treatment as well as the angiographic results

Aivoinfarktin liuotushoito ja trombektomia käytännössä

Teema : aivoinfarkti. English summaryPeer reviewe

Medical complications and outcome after endovascular therapy for acute ischemic stroke

Abstract Aim: Endovascular therapy (EVT) in acute stroke is an effective but invasive treatment which is frequently followed by various complications. The aim of the present study was to examine the rate of medical complications and other adverse events following EVT. Methods: Retrospective single-center study of 380 consecutive stroke patients who received EVT between the years 2015–2019. Results: A total of 234 (61.6%) patients had at least one recorded medical complication. The most common complication was pneumonia in 154 (40.5%) patients, followed by acute cardiac insufficiency in 134 (35.3%), and myocardial infarction in 22 (5.8%) patients. In multivariate analysis, the need for general anesthesia (OR 3.8 (1.9–7.7)), Charlson Comorbidity Index >3 (OR 1.3 (1.1–1.5)), male gender (1.9 (1.1–1.3)) and high National Institutes of Health Stroke Scale (NIHSS) score at admission (1.1 (1.0–1.2)) were associated with medical complications. Conclusion: Medical complications are common among unselected stroke patients undergoing EVT. Both comorbidity and stroke severity have an influence on medical complications. Early recognition of complications is essential, because vast majority of patients encountering medical complications have a poor short-term outcome

Long-term mortality after endovascular thrombectomy for stroke

Abstract Objectives: Endovascular thrombectomy (EVT) has become the standard treatment for large vessel occlusion (LVO) in acute ischemic stroke. Stroke trials typically report clinical outcome at the three-month time point but there is a lack of studies focusing on the long-term outcome after EVT. The aim of this study is to assess the long-term mortality after EVT for stroke and to determine the factors that are associated with mortality. Methods: Retrospective single-center analysis of 323 patients who underwent EVT for stroke between the years 2015–2019 and survived at least 30 days. Patients were followed up until the end of the year 2020. Cox regression analysis was used to identify the factors associated with mortality. Results: A total of 53 (16.4%) of the 30-day survivors died during the follow-up. According to the Cox regression analysis, mortality was associated with functional dependence (modified Rankin Scale (mRS) <2, HR 2.7 (95% CI 1.2–5.9), p=0.013), comorbidity (Charlson Comorbidity Index (CCI) ≥3, HR 2.7 (95% CI 1.4–5.5), p=0.004), stroke severity at baseline (National Institutes of Health Stroke Scale (NIHSS) <8, HR 1.9 (95% CI 1.1–3.3), p=0.026), and medical complications (HR 2.4 (95% CI 1.2–4.8), p=0.011). Procedural variables did not have an impact on mortality. Conclusions: Functional dependence, stroke severity, comorbidity, and medical complications during the hospital stay were associated with the long-term mortality after EVT for stroke

Case report: chemotherapy in conjunction with blood–brain barrier disruption for a patient with germ cell tumor with multiple brain metastases

Clinical practice points Testicular cancer with brain metastases is related to poor prognosis because the penetration of chemotherapeutic agents is decreased by the blood–brain barrier. The standard treatment of brain metastases—whole brain radiation therapy combined with chemotherapy—is related to a limited increase in survival and considerable deleterious cognitive effects. The blood–brain barrier can be transiently disrupted using hyperosmolar intra-arterial mannitol injection. When combined with intra-arterial chemotherapy, therapeutic intratumoral concentrations can be attained. In experienced centers, blood–brain barrier disruption therapy is relatively safe with a low incidence of catheter-related complications. Blood–brain barrier disruption therapy is a promising treatment modality for brain metastases as an alternative to whole brain radiation therapy

Physiological instability is linked to mortality in primary central nervous system lymphoma:a case–control fMRI study

Abstract Primary central nervous system lymphoma (PCNSL) is an aggressive brain disease where lymphocytes invade along perivascular spaces of arteries and veins. The invasion markedly changes (peri)vascular structures but its effect on physiological brain pulsations has not been previously studied. Using physiological magnetic resonance encephalography (MREGBOLD) scanning, this study aims to quantify the extent to which (peri)vascular PCNSL involvement alters the stability of physiological brain pulsations mediated by cerebral vasculature. Clinical implications and relevance were explored. In this study, 21 PCNSL patients (median 67y; 38% females) and 30 healthy age-matched controls (median 63y; 73% females) were scanned for MREGBOLD signal during 2018–2021. Motion effects were removed. Voxel-by-voxel Coefficient of Variation (CV) maps of MREGBOLD signal was calculated to examine the stability of physiological brain pulsations. Group-level differences in CV were examined using nonparametric covariate-adjusted tests. Subject-level CV alterations were examined against control population Z-score maps wherein clusters of increased CV values were detected. Spatial distributions of clusters and findings from routine clinical neuroimaging were compared [contrast-enhanced, diffusion-weighted, fluid-attenuated inversion recovery (FLAIR) data]. Whole-brain mean CV was linked to short-term mortality with 100% sensitivity and 100% specificity, as all deceased patients revealed higher values (n = 5, median 0.055) than surviving patients (n = 16, median 0.028) (p < .0001). After adjusting for medication, head motion, and age, patients revealed higher CV values (group median 0.035) than healthy controls (group median 0.024) around arterial territories (p ≤ .001). Abnormal clusters (median 1.10 × 10₅mm₃) extended spatially beyond FLAIR lesions (median 0.62 × 10₅mm₃) with differences in volumes (p = .0055)