Assoziierte Begleiterkrankungen beim abdominalen Aortenaneurysma

Einleitung: Das abdominale Aortenaneurysma (AAA) ist eine Erkrankung des älteren Menschen. In Zeiten des demografischen Wandels gewinnt diese Erkrankung zunehmend an Bedeutung. Mit AAA werden bereits einige Erkrankungen in Verbindung gesetzt, u. a. Cholecystolithiasis (CCL), Nierenzysten, chronisch obstruktive Lungenerkrankung (COPD) und Hernien. Das Ziel dieser Arbeit ist es, neben bereits bekannten, auch neue mögliche assoziierte Begleiterkrankungen zum Krankheitsbild des AAA zu erfassen. Methoden: Die vorhandenen klinischen Daten von 100 AAA-Patienten wurden mit 100 Kontrollpatienten (gematcht nach Geschlecht und Alter) verglichen. Computertomographische Aufnahmen wurden von zwei unabhängigen Untersuchern auf das Vorhandensein von Nierenzysten, Leberzysten, Hernien, Divertikulose, CCL, A. lusoria und anderen Erkrankungen, wie z. B. Milzzysten, Pankreaszysten, Hiatushernie und Nephrolithiasis untersucht. Die Krankenakten wurden zur Ergänzung des Nebenerkrankungsprofils analysiert. Die statistische Auswertung erfolgte mittels univariater Analyse (Kreuztabellierung und Chi-Quadrat-Test) und multipler logistischer Regression. Ergebnisse: Die AAA-Patienten litten signifikant häufiger an Nierenzysten (p = 0,008) und Divertikulose (p = 0,008) und hatten häufiger eine Hernie in der Vorgeschichte (p = 0,005). Es wurde kein signifikanter Unterschied im Auftreten der Leberzysten (p = 0,609) und CCL (p = 1,000) festgestellt. Die AAA-Patienten litten ebenfalls häufiger an koronarer Herzkrankheit (KHK; p < 0,001), peripherer arterieller Verschlusskrankheit (pAVK; p = 0,037), Herzinsuffizienz (p < 0,001), chronischer Niereninsuffizienz (p < 0,001) und COPD (p < 0,001). Bei den AAA-Patienten wurde häufiger ein koronarer Bypass implantiert (p = 0,011), sie waren mit höherer Wahrscheinlichkeit ehemalige (p = 0,034) oder aktuelle (p = 0,006) Raucher und hatten eine signifikant höhere Zahl an pack years (p < 0,001). Diabetes mellitus trat in fortgeschrittenen Stadien häufiger in der Kontrollgruppe auf (p < 0,001). AAA-Patienten hatten eine signifikant niedrigere forcierte Einsekundenkapazität (p = 0,003), niedrigere Thrombozytenzahl (p = 0,030) und höhere Kreatininwerte (p = 0,032). In der multivariaten Analyse wurde eine direkte Assoziation von AAA mit folgenden Faktoren nachgewiesen: COPD (OR = 12,242; p = 0,002), chronischer Niereninsuffizienz (OR = 5,655; p = 0,003), aktuellem Nikotinabusus (OR = 4,141; p = 0,002), KHK (OR = 2,603; p = 0,020), Divertikulose (OR = 1,844; p = 0,075) und Thrombozyten (OR = 0,994; p = 0,023). Schlussfolgerung: Das Krankheitsbild des AAA ist bis zum heutigen Zeitpunkt leider immer noch nicht ausreichend genug untersucht worden. Umfassende Kenntnisse über das Krankheitsbild bilden die Basis für die zukünftige Entwicklung einer kurativen pharmakologischen Therapie. Durch eine weitere Erkennung neuer Risikofaktoren könnte das AAA in der Zukunft besser und früher erkannt werden. Eine Einführung eines gesetzlichen Screeningprogramms sollte in Erwägung gezogen werden.Background: Abdominal aortic aneurysm (AAA) is a disease of elderly people. In times of demographic change, this disease becomes increasingly important. There are some diseases that seem to be associated with AAA, e.g. cholelithiasis, renal cysts, chronic obstructive pulmonary disease (COPD), and hernia. The goal of the study is to assess diseases associated with AAA. Methods: Clinical data of 100 AAA-patients were compared with 100 controls (matched to sex and age). Computer tomographic scans were analysed by two independent examiners for the presence of simple renal cysts, liver cysts, hernia, diverticulosis, cholelithiasis, A. lusoria, and other diseases, e.g. spleen cysts, pancreas cysts, hiatus hernia, and nephrolithiasis. In addition, the patient data were analysed to complete the comorbidity profile. The statistical analysis included a univariate analysis (cross tabulation and Chi-Square-Test) and multiple logistic regression. Results: AAA-patients had higher prevalence of renal cysts (p = 0.008), diverticulosis (p = 0.008), and hernia (p = 0.005). There were no significant differences in prevalence of liver cysts (p = 0.609) and cholelithiasis (p = 1.000). AAA-patients had higher prevalence of coronary artery disease (CAD; p < 0.001), peripheral artery disease (p = 0.037), heart failure (p < 0.001), chronic kidney disease (CKD, p < 0.001), COPD (p < 0.001), and had a higher presence of coronary bypass (p = 0.011). AAA-patients were more frequent ex- (p = 0.034) or present smokers (p = 0.006) and had a significantly higher number of pack years (p < 0.001). Controls had higher prevalence of diabetes mellitus in advanced stadium (p < 0.001). AAA-patients had a significantly lower forced expiratory volume in 1 second (p = 0.003), a lower count of blood platelet (p = 0.030) and a higher creatinine level (p = 0.032). Multivariate analysis showed following independent associations with AAA: COPD (OR = 12.242; p = 0.002), CKD (OR = 5.655; p = 0.003), present smoking (OR = 4.141; p = 0.002), CAD (OR = 2.603; p = 0.020), diverticulosis (OR = 1.844; p = 0.075), and blood platelet count (OR = 0.994; p = 0.023). Conclusions: Our knowledge about the pathophysiology of AAA is still not sufficient. Deep understanding of the disease builds a basis for a future pharmacological therapy. Knowing all risk factors of this disease could help early detection of the AAA. Establishing a screening for AAA should be taken into consideration

Comorbidities Associated with Large Abdominal Aortic Aneurysms

BACKGROUND: Abdominal aortic aneurysm has become increasingly important owing to demographic changes. Some other diseases, for example, cholecystolithiasis, chronic obstructive pulmonary disease, and hernias, seem to co-occur with abdominal aortic aneurysm. The aim of this retrospective analysis was to identify new comorbidities associated with abdominal aortic aneurysm. METHODS: We compared 100 patients with abdominal aortic aneurysms and 100 control patients. Their preoperative computed tomographic scans were examined by two investigators independently, for the presence of hernias, diverticulosis, and cholecystolithiasis. Medical records were also reviewed. Statistical analysis was performed using univariate analysis and multiple logistic regression analysis. RESULTS: The aneurysm group had a higher frequency of diverticulosis (p = 0.008). There was no significant difference in the occurrence of hernia (p = 0.073) or cholecystolithiasis (p = 1.00). Aneurysm patients had a significantly higher American Society of Anesthesiology score (2.84 vs. 2.63; p = 0.015) and were more likely to have coronary artery disease (p < 0.001), congestive heart failure (p < 0.001), or chronic obstructive pulmonary disease (p < 0.001). Aneurysm patients were more likely to be former (p = 0.034) or current (p = 0.006) smokers and had a significantly higher number of pack years (p < 0.001). Aneurysm patients also had a significantly poorer lung function. In multivariate analysis, the following factors were associated with aneurysms: chronic obstructive pulmonary disease (odds ratio, OR = 12.24; p = 0.002), current smoking (OR = 4.14; p = 0.002), and coronary artery disease (OR = 2.60; p = 0.020). CONCLUSIONS: Our comprehensive analysis identified several comorbidities associated with abdominal aortic aneurysms. These results could help to recognize aneurysms earlier by targeting individuals with these comorbidities for screening

Retinal diffusion restrictions in acute branch retinal arteriolar occlusion

This study sought to investigate the occurrence of retinal diffusion restrictions (RDR) in branch retinal arteriolar occlusion (BRAO) using standard brain diffusion-weighted imaging (DWI). Two radiologists assessed DWI MRI scans of BRAO patients for RDR in a retrospective cohort study. Inter- and intrarater reliability were calculated using Kappa statistics. Detection rates of RDR were compared among MRI scans with varying field strength, sequence type and onset-to-DWI time intervals. 85 BRAO patients (63.1 +/- 16.5 years) and 89 DWI scans were evaluated. Overall sensitivity of RDR in BRAO was 46.1% with visually correlating low ADC signal in 56.1% of cases. Localization of RDR matched distribution of fundoscopic retinal edema in 85% of patients. Inter- and intra-rater agreement for RDR in BRAO was kappa(inter) = 0.64 (95% CI 0.48-0.80) and kappa(intra) = 0.87 (95% CI 0.76-0.96), respectively. RDR detection rate tended to be higher for 3T, when compared to 1.5T MRI scans (53.7% vs. 34.3%%; p = 0.07). RDR were identified within 24 h up to 2 weeks after onset of visual impairment. RDR in BRAO can be observed by means of standard stroke DWI in a substantial proportion of cases, although sensitivity and interrater reliability were lower than previously reported for complete central retinal artery occlusion

Direct puncture of the carotid artery as a bailout vascular access technique for mechanical thrombectomy in acute ischemic stroke—the revival of an old technique in a modern setting

Purpose: To describe our single-center experience of mechanical thrombectomy (MTE) via a direct carotid puncture (DCP) with regard to indication, time metrics, procedural details, as well as safety and efficacy aspects. Methods: DCP thrombectomy cases performed at our center were retrospectively identified from a prospectively maintained institutional MTE database. Various patient (age, sex, stroke cause, comorbidities), clinical (NIHSS, mRS), imaging (occlusion site, ASPECT score), procedural (indication for DCP, time from DCP to reperfusion, materials used, technical nuances), and outcome data (NIHSS, mRS) were tabulated. Results: Among 715 anterior circulation MTEs, 12 DCP-MTEs were identified and analyzed. Nine were left-sided M1 occlusions, one right-sided M1 occlusion, and two right-sided M2 occlusions. DCP was successfully carried out in 91.7%; TICI 2b/3-recanalization was achieved in 83.3% via direct lesional aspiration and/or stent-retrieval techniques. Median time from DCP to reperfusion was 23 min. Indications included futile transfemoral catheterization attempts of the cervical target vessels as well as iliac occlusive disease. Neck hematoma occurred in 2 patients, none of which required further therapy. Conclusion: MTE via DCP in these highly selected patients was reasonably safe, fast, and efficient. It thus represents a valuable technical extension of MTE, especially in patients with difficult access

Association of simple renal cysts and chronic kidney disease with large abdominal aortic aneurysm

Background: Abdominal aortic aneurysms (AAA) primarily affect men over 65 years old who often have many other diseases, with similar risk factors and pathobiological mechanisms to AAA. The aim of this study was to assess the prevalence of simple renal cysts (SRC), chronic kidney disease (CKD), and other kidney diseases (e.g. nephrolithiasis) among patients presenting with AAA. Methods: Two groups of patients (97 AAA and 100 controls), with and without AAA, from the Surgical Clinic Charité, Berlin, Germany, were selected for the study. The control group consisted of patients who were evaluated for a kidney donation (n = 14) and patients who were evaluated for an early detection of a melanoma recurrence (n = 86). The AAA and control groups were matched for age and sex. Medical records were analyzed and computed tomography scans were reviewed for the presence of SRC and nephrolithiasis. Results: SRC (74% vs. 57%; p<0.016) and CKD (30% vs. 8%; p<0.001) were both more common among AAA than control group patients. On multivariate analysis, CKD, but not SRC, showed a strong association with AAA. Conclusions: Knowledge about pathobiological mechanisms and association between CKD and AAA could provide better diagnostic and therapeutic approaches for these patients

Comparison of diagnostic value of 68 Ga-DOTATOC PET/MRI and standalone MRI for the detection of intracranial meningiomas

To evaluate the diagnostic performance of magnetic resonance imaging (MRI) alone in comparison to positron emission tomography/ magnetic resonance imaging (PET/MRI) in patients with meningiomas. 57 patients with a total of 112 meningiomas of the brain were included. PET/MRI, including a fully diagnostic contrast enhanced MRI and PET, were acquired. PET/MRI was used as reference standard. The size and location of meningiomas was recorded. Likelihood-ratio chi-square tests were used to calculate p-values within logistic regression in order to compare different models. A multi-level logistic regression was applied to comply the hierarchical data structure. Multi-level regression adjusts for clustering in data was performed. The majority (n=103) of meningiomas could be identified based on standard MRI sequences compared to PET/MRI. MRI alone achieved a sensitivity of 95% (95% CI 0.78, 0.99) and specificity of 88% (95% CI 0.58, 0.98). Based on intensity of contrast medium uptake, 97 meningiomas could be diagnosed with intense uptake (93.75%). Sensitivity was lowest with 74% for meningiomas2cm(3) and highest with 100% for meningiomas 0.5-1.0 cm(3). Petroclival meningiomas showed lowest sensitivity with 88% compared to sphenoidal meningiomas with 94% and orbital meningiomas with 100%. Specificity of meningioma diagnostic with MRI was high with 100% for sphenoidal and hemispherical-dural meningiomas and meningiomas with 0.5-1.0 and 1.0-2.0 cm(3). Overall MRI enables reliable detection of meningiomas compared to PET/MRI. PET/MRI imaging offers highest sensitivity and specificity for small or difficult located meningiomas

Do Hernias Contribute to Increased Severity of Aneurysmal Disease among Abdominal Aortic Aneurysm Patients?

Background: Connective tissue disorders could contribute to the pathogenesis of both abdominal aortic aneurysms (AAA) and hernias. We tested the hypothesis that hernias in AAA patients contribute to increased severity of the aneurysmal disease. Methods: A questionnaire was used to collect information from 195 AAA patients divided into four groups: (1) survivors (n = 22) of ruptured AAA, (2) patients (n = 90) after elective open repair, (3) patients (n = 43) after elective endovascular repair (EVAR), and (4) patients (n = 40) under surveillance of AAA. The control group consisted of 100 patients without AAA whose abdominal computed tomography (CT) scans were examined for the presence of hernias. Mann-Whitney U-test, Chi-squared (χ 2) test, or Fisher's exact test (as appropriate) were used for statistical analyses. Multivariate logistic regression was used to control for potential confounding variables such as sex and age. Results: The prevalence of inguinal hernias was significantly higher in the AAA than the control group (25 vs. 9%, p = 0.001) and did not differ between the AAA subgroups (9, 24, 35, and 23% in subgroups 1 through 4, respectively, p = 0.15) based on univariate analysis. The prevalence of inguinal hernias did not differ (p = 0.15) between the two open surgery groups (groups 1 and 2), or when comparing all three operative procedures as a combined group to group 4 (p = 0.73). The prevalences of incisional hernias were 18 and 24% for groups 1 and 2, respectively, with no significant difference (p = 0.39). Inguinal hernia demonstrated a significant association with AAA on multivariate analysis (p = 0.006; odds ratio [OR] = 4.00; 95% confidence interval [CI] = 1.49-10.66). Conclusions: Our study confirms previous observations that patients with AAA have a high prevalence of hernias. Our results suggest that hernias do not contribute to increased severity of the aneurysmal disease

Mechanical thrombectomy of acute distal posterior cerebral artery occlusions

To describe our experience with mechanical thrombectomy (MTE) of acute distal posterior cerebral artery (PCA) occlusions, either isolated or in combination with more proximal vessel occlusions regarding recanalization rates, MTE techniques, and procedural safety. From the prospectively maintained stroke thrombectomy databases of two institutions, all consecutive patients subjected to MTE of acute distal PCA occlusion (P2 and 3 segments) between July 2013 and May 2020 were retrospectively identified. Imaging data and angiographic features, as well as patients' demographic and clinical data were evalu-ated. 35 consecutive patients were included in the study. In 17 patients MTE of isolated acute distal PCA occlusion was performed. 9 patients had combined basilar artery (BA) and distal PCA occlusion on stroke imaging and 3 had embolic distal PCA occlusion following MTE for BA occlusion. 6 patients har -bored distal PCA occlusions in combination with carotid-T occlusion and a dominant posterior commu-nicating artery. The median NIHSS at presentation was 14 (IQR 8 - 27). 25 patients (71.4%) had occlusions of the P2 and 10 patients (28.6%) of the P3 segment. Successful recanalization (TICI 2b/3) was achieved in 31 patients (88.6%). 10 patients (28.6%) were treated with a direct contact aspiration technique, while a stent retriever was used in 25 patients (71.4%). No complication attributable to distal PCA MTE occurred. Good outcome (mRS < 2) was achieved in 14 patients (46.7%) and mortality was 22.9%. MTE for acute distal PCA occlusion in the setting of different occlusion patterns appears both safe and angiographically effective. Yet, clinical effectiveness remains to be determined. (c) 2021 Elsevier Ltd. All rights reserved

Endovascular versus medical therapy in posterior cerebral artery stroke: role of baseline NIHSS and occlusion site.

Background: Acute ischemic stroke (AIS) with isolated posterior cerebral artery occlusion (iPCAO) lacks management evidence from randomized trials. We aimed to evaluate whether the association between endovascular treatment (EVT) and outcomes in iPCAO-AIS is modified by initial stroke severity (baseline NIHSS) and arterial occlusion site. Methods: Based on the multicenter, retrospective, case-control study of consecutive iPCAO-AIS patients (PLATO study), we assessed the heterogeneity of EVT outcomes compared to medical management (MM) for iPCAO, according to baseline NIHSS (≤6 vs. >6) and occlusion site (P1 vs. P2), using multivariable regression modelling with interaction terms. The primary outcome was the favorable shift of 3-month mRS. Secondary outcomes included excellent outcome (mRS 0-1), functional independence (mRS 0-2), symptomatic intracranial hemorrhage (sICH) and mortality. Results: From 1344 patients assessed for eligibility, 1,059 were included (median age 74 years, 43.7% women, 41.3% had intravenous thrombolysis), 364 receiving EVT and 695 MM. Baseline stroke severity did not modify the association of EVT with 3-month mRS distribution (pint=0.312), but did with functional independence (pint=0.010), with a similar trend on excellent outcome (pint=0.069). EVT was associated with more favorable outcomes than MM in patients with baseline NIHSS>6 (mRS 0-1: 30.6% vs. 17.7%, aOR=2.01, 95%CI=1.22-3.31; mRS 0-2: 46.1% vs. 31.9%, aOR=1.64, 95%CI=1.08-2.51), but not in those with NIHSS≤6 (mRS 0-1: 43.8% vs. 46.3%, aOR=0.90, 95%CI=0.49-1.64; mRS 0-2: 65.3% vs. 74.3%, aOR=0.55, 95%CI=0.30-1.0). EVT was associated with more sICH regardless of baseline NIHSS (pint=0.467), while the mortality increase was more pronounced in patients with NIHSS≤6 (pint=0.044, NIHSS≤6: aOR=7.95,95%CI=3.11-20.28, NIHSS>6: aOR=1.98,95%CI=1.08-3.65). Arterial occlusion site did not modify the association of EVT with outcomes compared to MM. Conclusion: Baseline clinical stroke severity, rather than the occlusion site, may be an important modifier of the association between EVT and outcomes in iPCAO. Only severely affected patients with iPCAO (NIHSS>6) had more favorable disability outcomes with EVT than MM, despite increased mortality and sICH