Georg Bohner

Purpose Surface modifications may improve procedural safety of flow diverter (FD) treatment, but larger studies are rare. This multicenter study aims to evaluate the safety and efficacy of unruptured aneurysm treatment with surface-modified and coated FDs. Methods Patients treated with the following FDs at 8 neurovascular centers were retrospectively reviewed: Pipeline Vantage Embolization Device, Pipeline Flex with Shield Technology, FRED X, p48/64 HPC, Derivo Embolization Device (DED), and DED 2heal. Aneurysm characteristics, procedural details, and angiographic results were evaluated in detail. Results A total of 511 patients with 545 aneurysms were included (mean aneurysm size: 8.2 ± 5.5 mm, 12% posterior circulation, 14% non-saccular morphology). Multiple FDs were used in 26/515 (5%) procedures and adjunctive coiling in 76 (15%). Thromboembolic events occurred in 40 (7.8%) cases, including 9 (1.7%) major ischemic events, 20 (3.9%) minor ischemic events and 11 (2.1%) asymptomatic/technical events. Non-saccular aneurysm morphology (p = 0.014) and use of multiple FDs (p = 0.025) favored thromboembolic events. Hemorrhagic events occurred in 5 (1.0%) cases, of which 3 were symptomatic. The combined morbidity and mortality rate was 11/515 (2.1%). Complete and adequate occlusion rates were 66% (196/297) and 80% (238/297) at 6 months, respectively, and 70% (64/92) and 85% (78/92) at 12 months, respectively. Conclusion The present study demonstrates high safety and efficacy for coated or surface-modified FDs. Whether the surface modifications confer a clinical benefit needs to be addressed in comparative studies.

Background/Objectives: This study evaluates whether convolutional neural networks (CNNs) can be trained to determine the primary tumor origin from MRI images alone in patients with metastatic brain lesions. Methods: This retrospective, monocentric study involved the segmentation of 1175 brain lesions from MRI scans of 436 patients with histologically confirmed primary tumor origins. The four most common tumor types—lung adenocarcinoma, small cell lung cancer, breast cancer, and melanoma—were selected, and a class-balanced dataset was created through under-sampling. This resulted in 276 training datasets and 88 hold-out test datasets. Bayesian optimization was employed to determine the optimal CNN architecture, the most relevant imaging sequences, and whether the masking of images was necessary. We compared the performance of the CNN with that of two expert radiologists specializing in neuro-oncological imaging. Results: The best-performing CNN from the Bayesian optimization process used masked images across all available MRI sequences. It achieved Area-Under-the-Curve (AUC) values of 0.75 for melanoma, 0.65 for small cell lung cancer, 0.64 for breast cancer, and 0.57 for lung adenocarcinoma. Masked images likely improved performance by focusing the CNN on relevant regions and reducing noise from surrounding tissues. In comparison, Radiologist 1 achieved AUCs of 0.55, 0.52, 0.45, and 0.51, and Radiologist 2 achieved AUCs of 0.68, 0.55, 0.64, and 0.43 for the same tumor types, respectively. The CNN consistently showed higher accuracy, particularly for melanoma and breast cancer. Conclusions: Bayesian optimization enabled the creation of a CNN that outperformed expert radiologists in classifying the primary tumor origin of brain metastases from MRI.

Background/Objectives: This study aimed to research the potential association between brain atrophy and hematoma expansion (HE) in intracerebral hemorrhage (ICH). Methods: A retrospective analysis was conducted using data from patients with primary ICH in our stroke database. ICH volumes from initial and follow-up CT scans were manually segmented. Total brain and intracranial volumes were quantified using an automated head CT segmentation method. Normalized brain volume (NBV) was calculated by dividing the total brain volume by the total intracranial volume to account for individual head size differences. The relationship between the NBV and hematoma expansion was assessed using linear regression, adjusting for other variables influencing hematoma expansion. Results: Our final analysis included 420 patients. Brain atrophy (lower NBV) was associated with hematoma growth (>0 mL) in patients not on oral anticoagulants (β = −0.159, p = 0.032). A strong association was observed in patients using vitamin K antagonists (β = −0.667, p = 0.006) but not in those on direct oral anticoagulants (DOACs; (β = −0.159, p = 0.436)). Results remained significant in patients not on oral anticoagulants and in those on VKAs when hematoma expansion was defined as a volume increase >6 mL or >33%. Conclusions: This research provides initial evidence that brain atrophy is a risk factor for hematoma expansion, depending on the patient’s coagulation status. These findings could enhance risk stratification for acute clinical management and deepen understanding of the biological mechanisms behind hematoma expansion.

BACKGROUND AND PURPOSE: The Pipeline Embolization Device is a safe and effective treatment option for intracranial aneurysms. The newer Pipeline generations have received structural refinements and a surface modification to improve deliverability, procedural safety, and angiographic outcomes. This multicenter study evaluated the clinical safety and efficacy of the 2 surface-modified Pipeline iterations, Pipeline Vantage and Pipeline Flex with Shield Technology (PFS). MATERIALS AND METHODS: Consecutive patients treated between 2017 and 2023 were retrospectively reviewed for aneurysm characteristics, procedural details, complications, and angiographic outcomes. The safety end point was the rate of procedural and postprocedural major neurologic events occurring during the hospital stay. The efficacy end point was the rate of complete occlusion at last follow-up. RESULTS: One hundred forty-one patients underwent 112 Pipeline Vantage procedures and 32 PFS procedures for 147 aneurysms with a mean size of 8.0 (SD, 5.9) mm (11% ruptured, 16% posterior circulation, 18% nonsaccular morphology). All procedures were technically successful with a mean of 1.2 devices implanted. Balloon angioplasty was required in 20/144 (13.9%) procedures. Major neurologic adverse events occurred in 6/144 (4.2%) procedures (all ischemic stroke), resulting in death in 2 (1.4%) patients. There were no hemorrhagic complications. At a mean of 11 months, complete occlusion was achieved in 85/112 (75.9%) aneurysms, 15/112 (13.4%) had an entry remnant, and 12/112 (10.7%) had an aneurysm remnant. CONCLUSIONS: The results demonstrate high feasibility, procedural safety, and efficacy of the surface-modified Pipeline flow diverters.

Introduction Many studies demonstrated that endovascular embolization is an effective and safe technique for the occlusion of cranial dural arteriovenous fistulas (DAVFs). However, the quality of life (QoL) of the treated patients was not yet addressed before. Aim of Study In this post-hoc analysis of the LIQUID study we aimed to systematically investigate the QoL of patients with high-grade DAVFs treated with endovascular embolization. Methods The LIQUID study was a prospective multi-center study on the endovascular embolization of high-grade DAVF with the embolic agent Squid. EQ5D-3L was used for the assessment of the QoL. Patients were interviewed before and after treatment. Results Pre-interventional EQ5D was available for 39 and post-interventional EQ5D for 46 patients. Patients with unruptured DAVFs mainly suffered from “pain and discomfort’ (50%) before treatment, while in case of ruptured DAVFs, complains were most frequently reported for “mobility’ and “usual activities’ (57.1%, respectively). After treatment, according to EQ5D, QoL improved in most patients across all items (e.g., EQ5D for “usual activities’: 2 or 3 in 55.9% before treatment vs. 23.5% after treatment). Deterioration of QoL was most frequently observed for “mobility’ which was reported to be worse in 26.5%. Non-improvement or worsening of the QoL was associated with treatment-related complications but not with the degree of occlusion after the treatment. Conclusion After the embolization of high-grade DAVFs, the QoL of most of the treated patients improves substantially. However, especially in terms of mobility, non-improvement or worsening is regularly observed. The degree of occlusion does not influence the QoL. Funding This is an investigator-initiated study. The Department of Neuroradiology, Heidelberg University Hospital received a scientific grant from Balt (Montmorency, France). The contributing centers received a case fee for each patient who was included in the study. Balt did not have an influence on the study design, data collection, analysis, and writing of the manuscript.

Purpose: To evaluate a commercially available mobile device for the highly specialized task of detection of intracranial arterial aneurysm in telemedicine. Methods: Six radiologists with three different levels of experience retrospectively interpreted 60 computed tomography (CT) angiographies for the presence of intracranial arterial aneurysm, among them 30 cases with confirmed positive findings. Each radiologist reviewed the angiography datasets twice: once on a dedicated medical-grade workstation and on a commercially available mobile consumer-grade tablet with an interval of 3 months. Diagnostic performance, reading efficiency and subjective scorings including diagnostic confidence were analyzed and compared. Results: Diagnostic performance was comparable on both devices regardless of readers’ experience, and no significant differences in sensitivity (66–87.5%) and specificity (79.4–87%) were found. Results obtained with tablets and medical workstations were also comparable in terms of subjective assessment across all reader groups. Conclusions: There was no significant difference between tablet and workstation readings of angiography datasets for the presence of intracranial arterial aneurysm. Sensitivity, specificity, efficiency and subjective scorings were similar with the two devices for all three reader groups. While medical workstations are 10 times more expensive, tablets allow higher mobility especially for radiologists on call.

A 50 year old man is described with hepatic dysfunction and chronic pancreatitis in whom greatly increased concentrations of the pancreatic tumour marker CA 19-9 combined with an abnormal appearance at endoscopic retrograde cholangiopancreatography lead to the false suspicion of pancreatic carcinoma. CA 19-9 concentrations should be interpreted with caution in patients with intrinsic liver disease or biliary obstruction.

Purpose COVID-19 has a variable, but well-described course. However, some patients additionally present with neurological symptoms. Recent studies also show a broad range of neuroimaging features. The purpose of this study was to perform a snapshot analysis to approximate the frequency and types of neuroimaging findings on CT and MRI scans in a large cohort of SARS-CoV-2-positive patients in a level I COVID-19 center, both in general and in critically ill patients. Materials and Methods We retrospectively analyzed brain CT and MRI scans of 34 hospitalized COVID-19 patients at our level I COVID-19 center between March 15 and April 24 with regard to pathological neuroimaging findings. In addition, clinical parameters such as neurological symptoms, comorbidities, and type of ventilation therapy were also documented. A descriptive statistical analysis was performed. Results Pathological findings were detected in 38.2 % of patients in the study cohort. Based on the weekly institutional SARS-CoV-2 report of all positively tested patients in our clinic at the time of data collection, neuroimaging findings could be found in 6 % of all patients (34/565). The most common findings were microbleeds (20.6 %) and signs of hypoxic brain injury (11.8 %). Furthermore, cortical subarachnoid hemorrhage, typical and atypical cerebral hematomas, ischemic strokes, and generalized brain edema were documented. All neuroimaging findings occurred in patients who were either intubated or treated by ECMO. Conclusion Based on the analysis of this large cohort of SARS-CoV-2-positive patients, pathological neuroimaging findings seem to be relatively rare in general but do occur in a substantial proportion of patients with severe COVID-19 disease needing intubation or ECMO. Key Points: Citation Format

Background: Functional outcome post-stroke depends on time to recanalization. Effect of in-hospital delay may differ in patients directly admitted to a comprehensive stroke center and patients transferred via a primary stroke center. We analyzed the current door-to-groin time in Germany and explored its effect on functional outcome in a real-world setting. Methods: Data were collected in 25 stroke centers in the German Stroke Registry-Endovascular Treatment a prospective, multicenter, observational registry study including stroke patients with large vessel occlusion. Functional outcome was assessed at three months by modified Rankin Scale. Association of door-to-groin time with outcome was calculated using binary logistic regression models. Results: Out of 4340 patients, 56% were treated primarily in a comprehensive stroke center and 44% in a primary stroke center and then transferred to a comprehensive stroke center (“drip-and-ship” concept). Median onset-to-arrival at comprehensive stroke center time and door-to-groin time were 103 and 79 min in comprehensive stroke center patients and 225 and 44 min in primary stroke center patients. The odds ratio for poor functional outcome per hour of onset-to-arrival-at comprehensive stroke center time was 1.03 (95%CI 1.01–1.05) in comprehensive stroke center patients and 1.06 (95%CI 1.03–1.09) in primary stroke center patients. The odds ratio for poor functional outcome per hour of door-to-groin time was 1.30 (95%CI 1.16–1.46) in comprehensive stroke center patients and 1.04 (95%CI 0.89–1.21) in primary stroke center patients. Longer door-to-groin time in comprehensive stroke center patients was associated with admission on weekends (odds ratio 1.61; 95%CI 1.37–1.97) and during night time (odds ratio 1.52; 95%CI 1.27–1.82) and use of intravenous thrombolysis (odds ratio 1.28; 95%CI 1.08–1.50). Conclusion: Door-to-groin time was especially relevant for outcome of comprehensive stroke center patients, whereas door-to-groin time was much shorter in primary stroke center patients. Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT03356392 . Unique identifier NCT03356392