Over the last years, the endovascular approach to the management of the acute and chronic deep vein thrombosis (DVT) has gained more and more attention from the scientific community. DVT is the third ...most common cardiovascular disease after coronary heart disease and stroke, with classic treatment based on anticoagulation. Recent evidences have highlighted the risk of postthrombotic syndrome as high as 30%–50% in proximal ilio‐femoral lesions, with irreversible clinical symptoms and impact on the quality of life of the population. Since 2000s, the new concept of thrombus removal in the acute phase has been supported by the introduction of different techniques based on the endovascular ablation of the clot by in‐situ fibrinolysis and, more recently, fragmentation and aspiration. In the chronic phase, recanalization of the thrombosed segment is recommended by stent placement to remove the obstruction and eventually reduce the congestion. Immediate technical success of these procedures is widely satisfying, whereas the long‐term clinical benefits are still debated. This paper presents an overview of the modern management of the DVT by endovascular approach with regard to the clinical contexts, interventional strategies and clinical outcomes. Endovascular specialist needs to be aware of this incoming challenge, as local expertise is demanded for the modern management of these patients in multidisciplinary theaters.
To assess the radiation dose and image quality of cardiac computed tomography angiography (CCTA) in an acute stroke imaging protocol using a deep learning reconstruction (DLR) method compared to a ...hybrid iterative reconstruction algorithm.
Retrospective analysis of 296 consecutive patients admitted to the emergency department for stroke suspicion. All patients underwent a stroke CT imaging protocol including a non-enhanced brain CT, a brain perfusion CT imaging if necessary, a CT angiography (CTA) of the supra-aortic vessels, a CCTA and a post-contrast brain CT. The CCTA was performed with a prospectively ECG-gated volume acquisition. Among all CT scans performed, 143 were reconstructed with an iterative reconstruction algorithm (AIDR 3D, adaptive iterative dose reduction three dimensional) and 146 with a DLR algorithm (AiCE, advanced intelligent clear-IQ engine). Image noise, signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and subjective image quality (IQ) scored from 1 to 4 were assessed. Dose-length product (DLP), volume CT dose index (CTDIvol) and effective dose (ED) were obtained.
The radiation dose was significantly lower with AiCE than with AIDR 3D (DLP =106.4±50.0
176.1±37.1 mGy·cm, CTDIvol =6.9±3.2
11.5±2.2 mGy, and ED =1.5±0.7
2.5±0.5 mSv) (P<0.001). The median SNR and CNR were higher 9.9 (IQR, 8.1-12.3); and 12.6 (IQR, 10.5-15.5), respectively, with AiCE than with AIDR 3D 6.5 (IQR, 5.2-8.5); and 8.4 (IQR, 6.7-11.0), respectively (P<0.001). SNR and CNR were increased by 51% and 49%, respectively, with AiCE compared to AIDR 3D. The image quality was significantly better with AiCE (mean IQ score =3.4±0.7) than with AIDR 3D (mean IQ score =3±0.9) (P<0.001).
The use of a DLR algorithm for cardiac CTA in an acute stroke imaging protocol reduced the radiation dose by about 40% and improved the image quality by about 50% compared to an iterative reconstruction algorithm.
•On third of patients with ischemic stroke (IS) have atrial fibrillation (AF).•The prevalence of prestroke cognitive impairment is greater in patients with AF.•Prior mild cognitive impairment and ...dementia are independently associated with AF.•Preexisting brain lesions do not fully account for this association.
Atrial Fibrillation (AF) is a common cause of ischemic stroke (IS), and is associated with cognitive impairment in the general population. We aimed to compare the prevalence of preexisting cognitive impairment between IS patients with and without AF, and to assess whether prior brain damage could contribute to the observed differences.
Patients with acute IS were prospectively identified from the population-based Dijon Stroke Registry, France. Patients who had a CT-scan as brain imaging modality were included in this analysis to assess the presence of preexisting leukoaraiosis, old vascular brain lesions, and cerebral atrophy. Characteristics of patients including prior-to-stroke cognitive status (normal cognition, mild cognitive impairment (MCI), or dementia) were compared between those with and without AF.
Among 916 IS patients, 288 (31.4 %) had AF, of whom 88 had newly diagnosed AF. AF patients had more frequent prior MCI (17.8 % versus 10.2 %) or dementia (22.4 % versus 13.1 %) (p = 0.001), vascular risk factors, and preexisting brain damage. In unadjusted model, preexisting cognitive impairment was associated with AF (OR=2.24; 95 % CI: 1.49–3.37, p < 0.001 for MCI; OR=2.20; 95 % CI: 1.52–3.18, p < 0.001 for dementia). After adjustment for clinical and imaging variables, preexisting mild cognitive impairment (OR=1.87; 95 % CI: 1.06–3.32, p = 0.032) and dementia (OR=1.98; 95 % CI: 1.15–3.40, p = 0.013) were independently associated with AF.
AF is a common condition in IS patients and is associated with preexisting cognitive impairment. Brain lesions visible on imaging did not seem to fully account for this association that may involve other mechanisms yet to be elucidated.
The aim of this study is to evaluate the image quality and diagnostic performance of angiographic images reconstructed from whole-brain CT perfusion (CTP) using temporal averaging compared to CT ...angiography (CTA) for the detection of vasospasm.
39 CT studies in 28 consecutive patients who underwent brain CTA with CTP for suspected vasospasm between September 2020 and May 2021 were retrospectively evaluated. The image quality of these two vascular imaging techniques was assessed either quantitatively (image noise, vascular enhancement, signal-to-noise (SNR) and contrast-to-noise (CNR) ratios,) and qualitatively (4 criteria assessed on a 5-point scale).
Intra and interobserver agreements and a diagnostic confidence score on the diagnosis of vasospasm were measured. Radiation dose parameters (volume CT dose index (CTDIvol) and dose-length product (DLP)) were recorded.
Both SNR and CNR were significantly higher with temporal averaging compared to CTA, increasing by 104% and 113%, respectively (p<0.001).
The qualitative assessment found no significant difference in overall image quality between temporal averaging (4.33 ± 0.48) and brain CTA (4.19 ± 0.52) (p = 0.12).There was a significant improvement in intravascular noise and arterial contrast enhancement with temporal averaging.
The evaluation of intra and interobserver agreements showed a robust concordance in the diagnosis of vasospasm between the two techniques.
Temporal averaging appeared as a feasible and reliable imaging technique for the detection of vasospasm. The use of temporal averaging, replacing brain CTA, could represent a new strategy of radiation and contrast material doses reduction in these patients.
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•Patients hospitalized for aneurysmal subarachnoid hemorrhage frequently receive a high cumulative radiation dose.•Temporal averaging reconstruction technique from brain CT perfusion appeared as an effective vascular imaging technique for the vasospasm assessment.•The use of temporal averaging instead of brain CTA could represent a new strategy of contrast agent and radiation dose reduction in patients with suspected vasospasm following subarachnoid hemorrhage.
PURPOSEThe aim of this study was to investigate the presence and chemical forms of residual gadolinium (Gd) in rat brain after a single dose of Gd-based contrast agent.
METHODSFour groups of healthy ...rats (2 sacrifice time-points, n = 10/group, 80 rats in total) were randomized to receive a single intravenous injection of 1 of the 3 Gd-based contrast agents (GBCAs) (gadoterate meglumine, gadobenate dimeglumine, or gadodiamide) or the same volume of 0.9% saline solution. The injected concentration was 0.6 mmol/kg, corresponding to a concentration of 0.1 mmol/kg in humans after body surface normalization between rats and humans (according to the US Food and Drug Administration recommendations). Animals were sacrificed at 2 washout times1 (M1) and 5 (M5) months after the injection. Total Gd concentrations were determined in cerebellum by inductively coupled plasma mass spectrometry. Gadolinium speciation was analyzed by size-exclusion chromatography coupled to inductively coupled plasma mass spectrometry after extraction from cerebellum.
RESULTSA single injection of a clinically relevant dose of GBCA resulted in the detectable presence of Gd in the cerebellum 1 and 5 months after injection. The cerebellar total Gd concentrations after administration of the least stable GBCA (gadodiamide) were significantly higher at both time-points (M10.280 ± 0.060 nmol/g; M50.193 ± 0.023 nmol/g) than those observed for macrocyclic gadoterate (M10.019 ± 0.004 nmol/g, M50.004 ± 0.002 nmol/g; P < 0.0001). Gadolinium concentrations after injection of gadobenate were significantly lower at both time-points (M10.093 ± 0.020 nmol/g; M50.067 ± 0.013 nmol/g; P < 0.05) than the Gd concentration measured after injection of gadodiamide. At the 5-month time-point, the Gd concentration in the gadoterate group was also significantly lower than the Gd concentration in the gadobenate group (P < 0.05). Gadolinium speciation analysis of the water-soluble fraction showed that, after injection of the macrocyclic gadoterate, Gd was still detected only in its intact, chelated form 5 months after injection. In contrast, after a single dose of linear GBCAs (gadobenate and gadodiamide), 2 different forms were detectedintact GBCA and Gd bound to soluble macromolecules (above 80 kDa). Elimination of the intact GBCA form was also observed between the first and fifth month, whereas the amount of Gd present in the macromolecular fraction remained constant 5 months after injection.
CONCLUSIONSA single injection of a clinically relevant dose of GBCA is sufficient to investigate long-term Gd retention in the cerebellar parenchyma. Administration of linear GBCAs (gadodiamide and gadobenate) resulted in higher residual Gd concentrations than administration of the macrocyclic gadoterate. Speciation analysis of the water-soluble fraction of cerebellum confirmed washout of intact GBCA over time. The quantity of Gd bound to macromolecules, observed only with linear GBCAs, remained constant 5 months after injection and is likely to represent a permanent deposition.
BACKGROUND AND PURPOSE:Because of several methodological limitations, previous studies focusing on the prevalence of large vessel occlusion in ischemic stroke (IS) patients provided conflicting ...results. We evaluated the incidence of IS with a visible arterial occlusion using a comprehensive population-based registry.
METHODS:Patients with acute IS were prospectively identified among residents of Dijon, France, using a population-based registry (2013–2017). All arterial imaging exams were reviewed to assess arterial occlusion. Annual incidence rates of IS (first-ever and recurrent events) and IS with a visible occlusion were calculated.
RESULTS:One thousand sixty cases of IS were recorded (mean age76.0±15.8 years, 53.9% women). Information about arterial imaging was available in 971 (91.6%) of them, and only preexisting dementia was independently associated with having missing information (odds ratio=0.34 95% CI, 0.18–0.65, P=0.001). Among these patients, 284 (29.2%) had a visible arterial occlusion. Occlusion site was the anterior circulation in 226 patients (23.3% of overall patients with available data) and the posterior circulation in 58 patients (6.0%). A proximal occlusion of the anterior circulation was observed in 167 patients (17.2%). The crude annual incidence rate of total IS per 100 000 was 138 (95% CI, 129–146). Corresponding standardized rates were 66 (95% CI, 50–82) to the World Health Organization and 141 (95% CI, 118–164) to the 2013 European populations. The crude annual incidence rate of IS with a visible arterial occlusion per 100 000 was 37 (95% CI, 33–41) and that of IS with a proximal occlusion of the anterior circulation was 22 (95% CI, 18–25). Corresponding standardized rates were 18 (95% CI, 10–26) and 10 (95% CI, 8–13) to the World Health Organization population, and 38 (95% CI, 26–50) and 23 (95% CI, 19–26) to the 2013 European population, respectively.
CONCLUSIONS:These results will be helpful to plan the need for thrombectomy-capable stroke center resources.
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