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Highly time-resolved 4D MR angiography using golden-angle radial sparse parallel (GRASP) MRI
Goldman-Yassen, Adam E; Raz, Eytan; Borja, Maria J; Chen, Duan; Derman, Anna; Dogra, Siddhant; Block, Kai Tobias; Dehkharghani, Seena
Current dynamic MRA techniques are limited by temporal resolution and signal-to-noise penalties. GRASP, a fast and flexible MRI technique combining compressed-sensing, parallel imaging, and golden-angle radial sampling, acquires volumetric data continuously and can be reconstructed post hoc for user-defined applications. We describe a custom pipeline to retrospectively reconstruct ultrahigh temporal resolution, dynamic MRA from GRASP imaging obtained in the course of routine practice. GRASP scans were reconstructed using a custom implementation of the GRASP algorithm and post-processed with MeVisLab (MeVis Medical Solutions AG, Germany). Twenty consecutive examinations were scored by three neuroradiologists for angiographic quality of specific vascular segments and imaging artifacts using a 4-point scale. Unsubtracted images, baseline-subtracted images, and a temporal gradient dataset were available in 2D and 3D reconstructions. Distinct arterial and capillary phases were identified in all reconstructions, with a median of 2 frames (IQR1-3 and 2-3, respectively). Median rating for vascular segments was 3 (excellent) in all reconstructions and for nearly all segments, with excellent intraclass correlation (range 0.91-1.00). No cases were degraded by artifacts. GRASP-MRI obtained in routine practice can be seamlessly repurposed to produce high quality 4D MRA with 1-2-s resolved isotropic cerebrovascular angiography. Further exploration into diagnostic accuracy in disease-specific applications is warranted.
PMCID:9445093
PMID: 36064872
ISSN: 2045-2322
CID: 5332362
Preoperative flow analysis of arteriovenous malformations and obliteration response after stereotactic radiosurgery
Alzate, Juan Diego; Berger, Assaf; Bernstein, Kenneth; Mullen, Reed; Qu, Tanxia; Silverman, Joshua S; Shapiro, Maksim; Nelson, Peter K; Raz, Eytan; Jafar, Jafar J; Riina, Howard A; Kondziolka, Douglas
OBJECTIVE:Morphological and angioarchitectural features of cerebral arteriovenous malformations (AVMs) have been widely described and associated with outcomes; however, few studies have conducted a quantitative analysis of AVM flow. The authors examined brain AVM flow and transit time on angiograms using direct visual analysis and a computer-based method and correlated these factors with the obliteration response after Gamma Knife radiosurgery. METHODS:A retrospective analysis was conducted at a single institution using a prospective registry of patients managed from January 2013 to December 2019: 71 patients were analyzed using a visual method of flow determination and 38 were analyzed using a computer-based method. After comparison and validation of the two methods, obliteration response was correlated to flow analysis, demographic, angioarchitectural, and dosimetric data. RESULTS:The mean AVM volume was 3.84 cm3 (range 0.64-19.8 cm3), 32 AVMs (45%) were in critical functional locations, and the mean margin radiosurgical dose was 18.8 Gy (range 16-22 Gy). Twenty-seven AVMs (38%) were classified as high flow, 37 (52%) as moderate flow, and 7 (10%) as low flow. Complete obliteration was achieved in 44 patients (62%) at the time of the study; the mean time to obliteration was 28 months for low-flow, 34 months for moderate-flow, and 47 months for high-flow AVMs. Univariate and multivariate analyses of factors predicting obliteration included AVM nidus volume, age, and flow. Adverse radiation effects were identified in 5 patients (7%), and 67 patients (94%) remained free of any functional deterioration during follow-up. CONCLUSIONS:AVM flow analysis and categorization in terms of transit time are useful predictors of the probability of and the time to obliteration. The authors believe that a more quantitative understanding of flow can help to guide stereotactic radiosurgery treatment and set accurate outcome expectations.
PMID: 36057117
ISSN: 1933-0693
CID: 5337952
Retro Jugular, Retro Sternocleidomastoid Approach for Subclavian Artery to Common Carotid Artery Bypass Using a Radial Artery Interposition Graft: 2-Dimensional Operative Video
Haynes, Joseph; Sadek, Mikel; Raz, Eytan; Levine, Jamie; Shapiro, Maksim; Delavari, Nader; Riina, Howard A; Nelson, Peter Kim; Favate, Albert; Nossek, Erez
PMID: 35972106
ISSN: 2332-4260
CID: 5299872
Tumor Embolization through Meningohypophyseal and Inferolateral Trunks is Safe and Effective
Raz, E; Cavalcanti, D D; Sen, C; Nossek, E; Potts, M; Peschillo, S; Lotan, E; Narayan, V; Ali, A; Sharashidze, V; Nelson, P K; Shapiro, M
BACKGROUND AND PURPOSE/OBJECTIVE:Skull base tumors are commonly supplied by dural branches of the meningohypophyseal and inferolateral trunks. Embolization through these arteries is often avoided due to technical challenges and inherent risks; however, successful embolization can be a valuable surgical adjunct. We aimed to review the success and complications in our series of tumor embolizations through the meningohypophyseal and inferolateral trunks. MATERIALS AND METHODS/METHODS:We performed a retrospective review of patients with tumor treated with preoperative embolization at our institution between 2010 and 2020. We reviewed the following data: patients' demographics, tumor characteristics, endovascular embolization variables, and surgical results including estimated blood loss, the need for transfusion, and operative time. RESULTS:= 4) trunk. In this group of patients, on average, 79% of tumors were embolized. No mortality or morbidity from the embolization procedure was observed in this subgroup of patients. The average estimated blood loss in the operation was 395 mL (range, 200-750 mL). None of the patients required a transfusion, and the average operative time was 7.3 hours. CONCLUSIONS:Some skull base tumors necessitate embolization through ICA branches such as the meningohypophyseal and inferolateral trunks. Our series demonstrates that an effective and safe embolization may be performed through these routes.
PMID: 35902121
ISSN: 1936-959x
CID: 5276862
Intrasaccular Flow Disruptor-Assisted Coiling of Intracranial Aneurysms Using the Novel Contour Neurovascular Systems and NEQSTENT: A Single-Center Safety and Feasibility Study
Diana, Francesco; de Dios Lascuevas, Marta; Peschillo, Simone; Raz, Eytan; Yoshimura, Shinichi; Requena Ruiz, Manuel; Morales, David Hernández; Tomasello, Alejandro
PMID: 35892432
ISSN: 2076-3425
CID: 5276562
Thrombectomy for secondary distal, medium vessel occlusions of the posterior circulation: seeking complete reperfusion
Meyer, Lukas; Stracke, Christian Paul; Wallocha, Marta; Broocks, Gabriel; Sporns, Peter B; Piechowiak, Eike I; Kaesmacher, Johannes; Maegerlein, Christian; Dorn, Franziska; Zimmermann, Hanna; Naziri, Weis; Abdullayev, Nuran; Kabbasch, Christoph; Behme, Daniel; Jamous, Ala; Maus, Volker; Fischer, Sebastian; Möhlenbruch, Markus; Weyland, Charlotte Sabine; Langner, Soenke; Meila, Dan; Miszczuk, Milena; Siebert, Eberhard; Lowens, Stephan; Krause, Lars Udo; Yeo, Leonard Ll; Tan, Benjamin Yq; Gopinathan, Anil; Gory, Benjamin; Arenillas, Juan F; Navia, Pedro; Raz, Eytan; Shapiro, Maksim; Arnberg, Fabian; Zeleňák, Kamil; Martínez-Galdámez, Mario; Kastrup, Andreas; Papanagiotou, Panagiotis; Kemmling, Andre; Psychogios, Marios N; Andersson, Tommy; Chapot, René; Fiehler, Jens; Hanning, Uta
BACKGROUND:Whether to approach distal occlusions endovascularly or not in medium-sized vessels secondary to proximal large vessel occlusion stroke remains unanswered. OBJECTIVE:To investigates the technical feasibility and safety of thrombectomy for secondary posterior circulation distal, medium vessel occlusions (DMVO). METHODS:TOPMOST (Treatment fOr Primary Medium vessel Occlusion STroke) is an international, retrospective, multicenter, observational registry of patients treated for distal cerebral artery occlusions. This study subanalysis endovascularly treated occlusions of the posterior cerebral artery in the P2 and P3 segment secondary preprocedural or periprocedural thrombus migration between January 2014 and June 2020. Technical feasibility was evaluated with the modified Thrombolysis in Cerebral Infarction (mTICI) scale. Procedural safety was assessed by the occurrence of symptomatic intracranial hemorrhage (sICH) and intervention-related serious adverse events. RESULTS:Among 71 patients with secondary posterior circulation DMVO who met the inclusion criteria, occlusions were present in 80.3% (57/71) located in the P2 segment and in 19.7% (14/71) in the P3 segment. Periprocedural migration occurred in 54.9% (39/71) and preprocedural migration in 45.1% (32/71) of cases. The first reperfusion attempt led in 38% (27/71) of all cases to mTICI 3. On multivariable logistic regression analysis, increased numbers of reperfusion attempts (adjusted odds ratio (aOR)=0.39, 95% CI 0.29 to 0.88, p=0.009) and preprocedural migration (aOR=4.70, 95% CI,1.35 to 16.35, p=0.015) were significantly associated with mTICI 3. sICH occurred in 2.8% (2/71). CONCLUSION/CONCLUSIONS:Thrombectomy for secondary posterior circulation DMVO seems to be safe and technically feasible. Even though thrombi that have migrated preprocedurally may be easier to retract, successful reperfusion can be achieved in the majority of patients with secondary DMVO of the P2 and P3 segment.
PMID: 34272260
ISSN: 1759-8486
CID: 4937602
Characteristics of a COVID-19 Cohort With Large Vessel Occlusion: A Multicenter International Study
Jabbour, Pascal; Dmytriw, Adam A; Sweid, Ahmad; Piotin, Michel; Bekelis, Kimon; Sourour, Nader; Raz, Eytan; Linfante, Italo; Dabus, Guilherme; Kole, Max; Martínez-Galdámez, Mario; Nimjee, Shahid M; Lopes, Demetrius K; Hassan, Ameer E; Kan, Peter; Ghorbani, Mohammad; Levitt, Michael R; Escalard, Simon; Missios, Symeon; Shapiro, Maksim; Clarençon, Frédéric; Elhorany, Mahmoud; Vela-Duarte, Daniel; Tahir, Rizwan A; Youssef, Patrick P; Pandey, Aditya S; Starke, Robert M; El Naamani, Kareem; Abbas, Rawad; Hammoud, Bassel; Mansour, Ossama Y; Galvan, Jorge; Billingsley, Joshua T; Mortazavi, Abolghasem; Walker, Melanie; Dibas, Mahmoud; Settecase, Fabio; Heran, Manraj K S; Kuhn, Anna L; Puri, Ajit S; Menon, Bijoy K; Sivakumar, Sanjeev; Mowla, Ashkan; D'Amato, Salvatore; Zha, Alicia M; Cooke, Daniel; Goyal, Mayank; Wu, Hannah; Cohen, Jake; Turkel-Parrella, David; Xavier, Andrew; Waqas, Muhammad; Tutino, Vincent M; Siddiqui, Adnan; Gupta, Gaurav; Nanda, Anil; Khandelwal, Priyank; Tiu, Cristina; Portela, Pere C; Perez de la Ossa, Natalia; Urra, Xabier; de Lera, Mercedes; Arenillas, Juan F; Ribo, Marc; Requena, Manuel; Piano, Mariangela; Pero, Guglielmo; De Sousa, Keith; Al-Mufti, Fawaz; Hashim, Zafar; Nayak, Sanjeev; Renieri, Leonardo; Aziz-Sultan, Mohamed A; Nguyen, Thanh N; Feineigle, Patricia; Patel, Aman B; Siegler, James E; Badih, Khodr; Grossberg, Jonathan A; Saad, Hassan; Gooch, M Reid; Herial, Nabeel A; Rosenwasser, Robert H; Tjoumakaris, Stavropoula; Tiwari, Ambooj
BACKGROUND:The mechanisms and outcomes in coronavirus disease (COVID-19)-associated stroke are unique from those of non-COVID-19 stroke. OBJECTIVE:To describe the efficacy and outcomes of acute revascularization of large vessel occlusion (LVO) in the setting of COVID-19 in an international cohort. METHODS:We conducted an international multicenter retrospective study of consecutively admitted patients with COVID-19 with concomitant acute LVO across 50 comprehensive stroke centers. Our control group constituted historical controls of patients presenting with LVO and receiving a mechanical thrombectomy between January 2018 and December 2020. RESULTS:The total cohort was 575 patients with acute LVO; 194 patients had COVID-19 while 381 patients did not. Patients in the COVID-19 group were younger (62.5 vs 71.2; P < .001) and lacked vascular risk factors (49, 25.3% vs 54, 14.2%; P = .001). Modified thrombolysis in cerebral infarction 3 revascularization was less common in the COVID-19 group (74, 39.2% vs 252, 67.2%; P < .001). Poor functional outcome at discharge (defined as modified Ranklin Scale 3-6) was more common in the COVID-19 group (150, 79.8% vs 132, 66.7%; P = .004). COVID-19 was independently associated with a lower likelihood of achieving modified thrombolysis in cerebral infarction 3 (odds ratio [OR]: 0.4, 95% CI: 0.2-0.7; P < .001) and unfavorable outcomes (OR: 2.5, 95% CI: 1.4-4.5; P = .002). CONCLUSION/CONCLUSIONS:COVID-19 was an independent predictor of incomplete revascularization and poor outcomes in patients with stroke due to LVO. Patients with COVID-19 with LVO were younger, had fewer cerebrovascular risk factors, and suffered from higher morbidity/mortality rates.
PMID: 35238817
ISSN: 1524-4040
CID: 5174582
Aspiration Versus Stent Retriever Thrombectomy for Distal, Medium Vessel Occlusion Stroke in the Posterior Circulation: A Subanalysis of the TOPMOST Study
Meyer, Lukas; Stracke, Paul; Wallocha, Marta; Broocks, Gabriel; Sporns, Peter; Piechowiak, Eike I; Kaesmacher, Johannes; Maegerlein, Christian; Hernandez Petzsche, Moritz Roman; Dorn, Franziska; Zimmermann, Hanna; Naziri, Weis; Abdullayev, Nuran; Kabbasch, Christoph; Behme, Daniel; Jamous, Ala; Maus, Volker; Fischer, Sebastian; Möhlenbruch, Markus; Weyland, Charlotte S; Langner, Sönke; Meila, Dan; Miszczuk, Milena; Siebert, Eberhard; Lowens, Stephan; Krause, Lars Udo; Yeo, Leonard; Tan, Benjamin; Gopinathan, Anil; Gory, Benjamin; Galván-Fernández, Jorge; Schüller, Miguel; Navia, Pedro; Raz, Eytan; Shapiro, Maksim; Arnberg, Fabian; Zeleňák, Kamil; Martínez-Galdámez, Mario; Kastrup, Andreas; Papanagiotou, Panagiotis; Kemmling, André; Psychogios, Marios; Andersson, Tommy; Chapot, Rene; Fiehler, Jens; Hanning, Uta
BACKGROUND:The optimal endovascular strategy for reperfusing distal medium-vessel occlusions (DMVO) remains unknown. This study evaluates angiographic and clinical outcomes of thrombectomy strategies in DMVO stroke of the posterior circulation. METHODS:TOPMOST (Treatment for Primary Medium Vessel Occlusion Stroke) is an international, retrospective, multicenter, observational registry of patients treated for DMVO between January 2014 and June 2020. This study analyzed endovascularly treated isolated primary DMVO of the posterior cerebral artery in the P2 and P3 segment. Technical feasibility was evaluated with the first-pass effect defined as a modified Thrombolysis in Cerebral Infarction Scale score of 3. Rates of early neurological improvement and functional modified Rankin Scale scores at 90 days were compared. Safety was assessed by the occurrence of symptomatic intracranial hemorrhage and intervention-related serious adverse events. RESULTS:<0.025). Symptomatic intracranial hemorrhage occurred in 2.8% (4) of all cases. CONCLUSIONS:Both first-pass aspiration and stent retriever thrombectomy for primary isolated posterior circulation DMVO seem to be safe and technically feasible leading to similar favorable rates of angiographic and clinical outcome.
PMID: 35443785
ISSN: 1524-4628
CID: 5218362
Salvage Superficial Temporal Artery to Middle Cerebral Artery Direct Bypass Using an Interposition Graft for Failed Encephaloduroarteriosynangiosis in Moyamoya Disease
Kim, Nora C; Raz, Eytan; Shapiro, Maksim; Riina, Howard A; Nelson, Peter K; Levine, Jamie P; Nossek, Erez
BACKGROUND:Moyamoya disease may present with either hemorrhagic or ischemic strokes. Surgical bypass has previously demonstrated superiority when compared to natural history and medical treatment alone. The best bypass option (direct vs. indirect), however, remains controversial in regard to adult ischemic symptomatic moyamoya disease. Multiple studies have demonstrated clinical as well as angiographic effectiveness of direct bypass in adult hemorrhagic moyamoya disease. In particular, there are limited data regarding strategies in the setting of failed indirect bypass with recurrent hemorrhagic strokes. Here, we describe a salvage procedure. METHODS:We describe a case of a 52-year-old man who presented with hemorrhagic moyamoya disease and failed previous bilateral encephaloduroarteriosynangiosis (EDAS) procedures at an outside institution. On a 3-year follow-up diagnostic cerebral angiogram, no synangiosis was noted on the right side and only minimal synangiosis was present on the left. The left hemisphere was significant for a left parietal hypoperfusion state. We performed a salvage left proximal superficial temporal artery to distal parietal M4 middle cerebral artery bypass using the descending branch of the lateral circumflex artery as an interposition graft with preservation of the existing EDAS sites. RESULTS:The patient underwent the procedure successfully and recovered well with resolution of headaches and no further strokes or hemorrhages on the 1-year follow-up magnetic resonance imaging of the brain. CONCLUSIONS:This case presents the use of a salvage direct bypass technique for recurrent symptomatic hemorrhagic moyamoya disease after failed EDAS. The strategy, approach, and technical nuances of this unique case have implications for revascularization options.
PMID: 35421586
ISSN: 1878-8769
CID: 5219102
Microsurgical clipping versus newer endovascular techniques in treatment of unruptured anterior communicating artery-complex aneurysms: a meta-analysis and systematic review
Diana, F; Pesce, A; Toccaceli, G; Muralidharan, V; Raz, E; Miscusi, M; Raco, A; Missori, P; Peschillo, S
The aim of this study is to compare occlusion rate, complication rate, and clinical outcome of microsurgical clipping (MC) and advanced endovascular techniques (EVT) in unruptured anterior communicating artery-complex aneurysms (ACoCAs). We reviewed the scientific literature reporting occlusion rate, time of occlusion assessment, and clinical outcome of MC and EVT in patients with unruptured ACoCAs, from January 2009 to December 2019. We included in our analysis 25 studies and 872 patients with unruptured ACoCAs (434 treated with endovascular techniques and 438 with MC). Ninety-three (10.7%), 320 (36.7%), 21 (2.4%), and 438 (50.2%) were treated with flow diverter (FD), stent-assisted coiling (SAC), endosaccular devices (ES), and microsurgical clipping (MC) respectively. FD, SAC, ES, and MC subgroups presented minor complications in 11.8%, 3.8%, 14.3%, and 7.1% of cases (p=.016), and major complications in 3.2%, 4.4%, 0%, and 7.1% (p=.136) of patients. A total occlusion rate post-treatment has been achieved in 4.3%, 87.1%, 47.6%, and 98.2% of cases (p=.000), while at 12 months' follow-up in 50%, 66%, 83.3%, and 80% of patients (p=.001). FD, SAC, ES, and MC subgroups had a good clinical outcome at 12 months in 93.5%, 90.5%, 100%, and 67.8% of cases. MC is associated with higher post-treatment total occlusion rate, but higher complication and lower good clinical outcome rates. EVT are promising in treating unruptured anterior cerebral artery aneurysms with high margin of safety and good clinical outcome, despite the lower total occlusion rate.
PMID: 34622332
ISSN: 1437-2320
CID: 5067822