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PurposeArterio-ureteral fistula (AUF) is an uncommon diagnosis, but potentially lethal. Although the number of reports has increased over the past two decades, the true incidence and contemporary urologists’ experience and approach in clinical practice remains unknown. This research is conducted to provide insight in the incidence of AUF in The Netherlands, and the applied diagnostic tests and therapeutic approaches in modern practice.MethodsA nationwide cross-sectional questionnaire analysis was performed by sending a survey to all registered Dutch urologists. Data collection included information on experience with patients with AUF; and their medical history, diagnostics, treatment, and follow-up, and were captured in a standardized template by two independent reviewers. Descriptive statistics were used.ResultsResponse rate was 62% and 56 AUFs in 53 patients were reported between 2003 and 2018. The estimated incidence of AUF in The Netherlands in this time period is 3.5 AUFs per year. Hematuria was observed in all patients; 9% intermittent microhematuria, and 91% presenting with, or building up to massive hematuria. For the final diagnosis, angiography was the most efficient modality, confirming diagnosis in 58%. Treatment comprised predominantly endovascular intervention.ConclusionThe diagnosis AUF should be considered in patients with persistent intermittent or massive hematuria.

Purpose: To evaluate if there are any differences in duplex ultrasound velocity measurements between native and stented carotid arteries using duplex ultrasound in an animal model. Methods: The common carotid artery of 5 pigs was exposed bilaterally (10 arteries). Diameters and velocities were measured by ultrasound in the proximal, mid, and distal native artery at the intended site of stent implantation. Measurements were repeated after bilateral stent placement (Wallstent versus Precise) under angiographic control. Outcomes of native versus stented arteries and Wallstent versus Precise were statistically compared. Results: Angiographic measurements matched well with duplex-measured diameters. The mean proximal stent diameter (3.5±0.5 mm) was significantly smaller than the native proximal artery diameter (4.2±0.4 mm, p=0.004), mostly due to narrowing of the Wallstent diameter to 3.2±0.5 mm (p=0.009). Proximal, mid, and distal segments of the Wallstents were narrower than those of the Precise stent, and associated peak systolic velocities (PSV) were higher at the 3 locations versus the Precise stent, although the differences were not statistically significant. Wallstent PSVs were higher than in the native artery at the proximal, mid, and distal segments, respectively; again, the differences were not statistically significant. Conclusion: Stent placement caused anatomical and hemodynamic alterations. Narrowings and associated increased velocities were noted. Such alterations, however, were stent-type dependent and did not justify a general approach to new velocity criteria indiscriminately applied to all stents.

Introduction: Endovascular thrombectomy (EVT) procedures and workflow have evolved over the years. We examined trends in patient characteristics, EVT techniques and outcomes over 5 years in the Netherlands. Patients and methods: Data from the MR CLEAN Registry (2014–2018) were analysed, including patients treated with EVT for anterior circulation acute ischaemic stroke (AIS). Patients were grouped by year of inclusion except for the linear regression analysis where the inclusion date was used. Baseline predicted probability of poor outcome (modified Rankin Scale (mRS) score 3–6) was calculated using a validated prediction model. Primary outcome was mRS score at 90 days. Secondary outcomes included workflow times, EVT techniques, successful reperfusion (eTICI ⩾ 2B) and symptomatic intracranial haemorrhage (sICH). Time trends were analysed using multivariable regression models (adjusted common odds ratios (acOR) per year). Results: 5193 patients were included. Median age increased (from 66 in 2014 to 74 years in 2018 [p < 0.001]). Proportion of patients with pre-stroke dependence (mRS ⩾ 3) increased from 2014 through 2018 (9% to 16%, p < 0.001). Baseline predicted probability of poor outcome did not change (60% vs 66%, p = 0.06). Over time, functional outcomes improved (acOR 1.14 per year, 95%CI: 1.09–1.20); mortality decreased (aOR 0.88 per year, 95%CI: 0.83–0.94). EVT under local anaesthesia increased (from 46% in 2014 to 70% in 2018; aOR 1.15, 95%CI: 1.10–1.22), as did use of direct aspiration (13%–36%; aOR 1.43, 95%CI: 1.35–1.53). Successful reperfusion became more frequent (aOR 1.32 per year, 95%CI: 1.25–1.40), despite needing more attempts (1 in 2014 vs 2 in 2018, aOR 0.93 per year, 95%CI: 0.89–0.98). Incidence of sICH remained unchanged (5% vs 5%, aOR 0.99 per year, 95%CI: 0.89–1.09). Time from emergency room to groin puncture reduced by 7 min per year (95%CI: 5–8). Discussion and conclusion: Enhanced workflow and increased EVT experience may have led to shorter time to treatment and more frequent successful reperfusion, with better functional outcomes over 5 years, despite treating older, more dependent patients. Graphical abstract

BackgroundArteriovenous malformations (AVMs) in the pediatric population are rare, yet they form the most frequent cause of hemorrhagic stroke in children. Compared to adults, children have been suggested to have beneficial neurological outcomes. However, few studies have focused on other variables than neurological outcomes. This study aims to assess the long-term functional and educational outcomes of children after multimodality approach of treatment for intracranial AVMs.MethodsAll children treated in our center between 1998 and 2016 for intracranial AVMs were reviewed. Patient characteristics, as well as AVM specifics, were collected. Functional outcomes were compared using the modified Rankin scale (mRs). Educational levels, using the International Standard Classification of Education (ISCED), were compared to the age-matched general population of the Netherlands.ResultsIn total, 25 children were included at mean age of 10 years (range 2–16 years). Nineteen patients (76%) presented with intracranial bleeding. Mean follow-up was 11.5 ± 5.3 years (range 4.1–24.4). Four (16%) of patients were treated with embolization, three (12%) with microsurgery, and 18 patients (72%) received a combination of different treatment modalities. Altogether, 21 (84%) were embolized, 14 (56%) were treated with microsurgery, and eight (32%) received stereotactic radiosurgery. One child had a worse mRs at discharge compared to admission; all others improved (n = 11) or were stable (n = 13). At follow-up, all patients scored a stable or improved mRs compared to discharge, with 23 children (92%) scoring mRs 0 or 1. These 23 children followed regular education during follow-up without specialized or adapted schooling. No significant differences in educational level with the age-matched general population were found.ConclusionThis retrospective review shows positive long-term results of both functional and educational outcomes after multidisciplinary treatment of pediatric brain AVMs.

Trials involving Asian patients with acute stroke have suggested that endovascular treatment alone is not inferior to the usual practice of thrombolysis before endovascular treatment. This trial involving European patients did not show noninferiority or superiority of endovascular treatment alone.

In a randomized trial involving 300 patients with basilar-artery stroke, endovascular thrombectomy was not significantly different from medical therapy with respect to a favorable functional outcome (modified Rankin scale score of 0 to 3) at 90 days, but a clinically significant benefit could not be excluded.

Endovascular treatment for anterior circulation ischaemic stroke is effective and safe within a 6 h window. MR CLEAN-LATE aimed to assess efficacy and safety of endovascular treatment for patients treated in the late window (6–24 h from symptom onset or last seen well) selected on the basis of the presence of collateral flow on CT angiography (CTA). MR CLEAN-LATE was a multicentre, open-label, blinded-endpoint, randomised, controlled, phase 3 trial done in 18 stroke intervention centres in the Netherlands. Patients aged 18 years or older with ischaemic stroke, presenting in the late window with an anterior circulation large-vessel occlusion and collateral flow on CTA, and a neurological deficit score of at least 2 on the National Institutes of Health Stroke Scale were included. Patients who were eligible for late-window endovascular treatment were treated according to national guidelines (based on clinical and perfusion imaging criteria derived from the DAWN and DEFUSE-3 trials) and excluded from MR CLEAN-LATE enrolment. Patients were randomly assigned (1:1) to receive endovascular treatment or no endovascular treatment (control), in addition to best medical treatment. Randomisation was web based, with block sizes ranging from eight to 20, and stratified by centre. The primary outcome was the modified Rankin Scale (mRS) score at 90 days after randomisation. Safety outcomes included all-cause mortality at 90 days after randomisation and symptomatic intracranial haemorrhage. All randomly assigned patients who provided deferred consent or died before consent could be obtained comprised the modified intention-to-treat population, in which the primary and safety outcomes were assessed. Analyses were adjusted for predefined confounders. Treatment effect was estimated with ordinal logistic regression and reported as an adjusted common odds ratio (OR) with a 95% CI. This trial was registered with the ISRCTN, ISRCTN19922220. Between Feb 2, 2018, and Jan 27, 2022, 535 patients were randomly assigned, and 502 (94%) patients provided deferred consent or died before consent was obtained (255 in the endovascular treatment group and 247 in the control group; 261 [52%] females). The median mRS score at 90 days was lower in the endovascular treatment group than in the control group (3 [IQR 2–5] vs 4 [2–6]), and we observed a shift towards better outcomes on the mRS for the endovascular treatment group (adjusted common OR 1·67 [95% CI 1·20–2·32]). All-cause mortality did not differ significantly between groups (62 [24%] of 255 patients vs 74 [30%] of 247 patients; adjusted OR 0·72 [95% CI 0·44–1·18]). Symptomatic intracranial haemorrhage occurred more often in the endovascular treatment group than in the control group (17 [7%] vs four [2%]; adjusted OR 4·59 [95% CI 1·49–14·10]). In this study, endovascular treatment was efficacious and safe for patients with ischaemic stroke caused by an anterior circulation large-vessel occlusion who presented 6–24 h from onset or last seen well, and who were selected on the basis of the presence of collateral flow on CTA. Selection of patients for endovascular treatment in the late window could be primarily based on the presence of collateral flow. Collaboration for New Treatments of Acute Stroke consortium, Dutch Heart Foundation, Stryker, Medtronic, Cerenovus, Top Sector Life Sciences & Health, and the Netherlands Brain Foundation.

The effect of anesthetic management (general anesthesia [GA], conscious sedation, or local anesthesia) on functional outcome and the role of blood pressure management during endovascular treatment (EVT) for acute ischemic stroke is under debate. We aimed to determine whether hypotension during EVT under GA is associated with functional outcome at 90 days. We retrospectively collected data from patients with a proximal intracranial occlusion of the anterior circulation treated with EVT under GA. The primary outcome was the distribution on the modified Rankin Scale at 90 days. Hypotension was defined using two thresholds: a mean arterial pressure (MAP) of 70 mm Hg and a MAP 30% below baseline MAP. To quantify the extent and duration of hypotension, the area under the threshold (AUT) was calculated using both thresholds. Of the 366 patients included, procedural hypotension was observed in approximately half of them. The occurrence of hypotension was associated with poor functional outcome (MAP <70 mm Hg: adjusted common odds ratio [acOR], 0.57; 95% confidence interval [CI], 0.35-0.94; MAP decrease [greater than or equal to]30%: acOR, 0.76; 95% CI, 0.48-1.21). In addition, an association was found between the number of hypotensive periods and poor functional outcome (MAP <70 mm Hg: acOR, 0.85 per period increase; 95% CI, 0.73-0.99; MAP decrease [greater than or equal to]30%: acOR, 0.90 per period; 95% CI, 0.78-1.04). No association existed between AUT and functional outcome (MAP <70 mm Hg: acOR, 1.000 per 10 mm Hg*min increase; 95% CI, 0.998-1.001; MAP decrease [greater than or equal to]30%: acOR, 1.000 per 10 mm Hg*min; 95% CI, 0.999-1.000). Occurrence of procedural hypotension and an increase in number of procedural hypotensive periods were associated with poor functional outcome, whereas the extent and duration of hypotension were not. Randomized clinical trials are needed to confirm our hypothesis that hypotension during EVT under GA has detrimental effects.

BackgroundApproximately one-third of patients with ischemic stroke treated with endovascular treatment do not recover to functional independence despite rapid and successful recanalization. We aimed to quantify the importance of predictors of poor functional outcome despite successful reperfusion.MethodsWe analyzed patients from the MR CLEAN Registry between March 2014 and November 2017 with successful reperfusion (extended Thrombolysis In Cerebral Infarction ≥2B). First, predictors were selected based on expert opinion and were clustered according to acquisition over time (ie, baseline patient factors, imaging factors, treatment factors, and postprocedural factors). Second, several models were constructed to predict 90-day functional outcome (modified Rankin Scale (mRS)). The relative importance of individual predictors in the most extensive model was expressed by the proportion of unique added χ2 to the model of that individual predictor.ResultsOf 3180 patients, 1913 (60%) had successful reperfusion. Of these 1913 patients, 1046 (55%) were functionally dependent at 90 days (mRS >2). The most important predictors for mRS were baseline patient factors (ie, pre-stroke mRS, added χ2 0.16; National Institutes of Health Stroke Scale score at baseline, added χ2 0.12; age, added χ2 0.10), and postprocedural factors (ie, symptomatic intracranial hemorrhage (sICH), added χ2 0.12; pneumonia, added χ2 0.09). The probability of functional independence for a typical stroke patient with sICH was 54% (95% CI 36% to 72%) lower compared with no sICH, and 21% (95% CI 4% to 38%) for pneumonia compared with no pneumonia.ConclusionBaseline patient factors and postprocedural adverse events are important predictors of poor functional outcome in successfully reperfused patients with ischemic stroke. This implies that prevention of postprocedural adverse events has the greatest potential to further improve outcomes in these patients.

Background and purposeCT perfusion (CTP) might support decision making in patients with acute ischemic stroke by providing perfusion maps of ischemic tissue. Currently, the reliability of CTP is hampered by varying results between different post-processing software packages. The purpose of this study is to compare ischemic core volumes estimated by IntelliSpace Portal (ISP) and syngo.via with core volumes as estimated by RAPID.MethodsThirty-five CTP datasets from patients in the MR CLEAN trial were post-processed. Core volumes were estimated with ISP using default settings and with syngo.via using three different settings: default settings (method A); additional smoothing filter (method B); and adjusted settings (method C). The results were compared with RAPID. Agreement between methods was assessed using Bland–Altman analysis and intraclass correlation coefficient (ICC). Accuracy for detecting volumes up to 25 mL, 50 mL, and 70 mL was assessed. Final infarct volumes were determined on follow-up non-contrast CT.ResultsMedian core volume was 50 mL with ISP, 41 mL with syngo.via method A, 20 mL with method B, 36 mL with method C, and 11 mL with RAPID. Agreement ranged from poor (ISP: ICC 0.41; method A: ICC 0.23) to good (method B: ICC 0.83; method C: ICC 0.85). The bias (1.8 mL) and limits of agreement (−27, 31 mL) were the smallest with syngo.via with additional smoothing (method B). Agreement for detecting core volumes ≤25 mL with ISP was 54% and 57%, 85% and 74% for syngo.via methods A, B, and C, respectively.ConclusionBest agreement with RAPID software is provided by syngo.via default settings with additional smoothing. Moreover, this method has the highest agreement in categorizing patients with small core volumes.