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European Stroke Organization Guidelines for the Management of Intracranial Aneurysms and Subarachnoid Haemorrhage
Background: Intracranial aneurysm with and without subarachnoid haemorrhage (SAH) is a relevant health problem: The overall incidence is about 9 per 100,000 with a wide range, in some countries up to 20 per 100,000. Mortality rate with conservative treatment within the first months is 50–60%. About one third of patients left with an untreated aneurysm will die from recurrent bleeding within 6 months after recovering from the first bleeding. The prognosis is further influenced by vasospasm, hydrocephalus, delayed ischaemic deficit and other complications. The aim of these guidelines is to provide comprehensive recommendations on the management of SAH with and without aneurysm as well as on unruptured intracranial aneurysm. Methods: We performed an extensive literature search from 1960 to 2011 using Medline and Embase. Members of the writing group met in person and by teleconferences to discuss recommendations. Search results were graded according to the criteria of the European Federation of Neurological Societies. Members of the Guidelines Committee of the European Stroke Organization reviewed the guidelines. Results: These guidelines provide evidence-based information on epidemiology, risk factors and prognosis of SAH and recommendations on diagnostic and therapeutic methods of both ruptured and unruptured intracranial aneurysms. Several risk factors of aneurysm growth and rupture have been identified. We provide recommendations on diagnostic work up, monitoring and general management (blood pressure, blood glucose, temperature, thromboprophylaxis, antiepileptic treatment, use of steroids). Specific therapeutic interventions consider timing of procedures, clipping and coiling. Complications such as hydrocephalus, vasospasm and delayed ischaemic deficit were covered. We also thought to add recommendations on SAH without aneurysm and on unruptured aneurysms. Conclusion: Ruptured intracranial aneurysm with a high rate of subsequent complications is a serious disease needing prompt treatment in centres having high quality of experience of treatment for these patients. These guidelines provide practical, evidence-based advice for the management of patients with intracranial aneurysm with or without rupture. Applying these measures can improve the prognosis of SAH.
Journal Article
Nusinersen in adults with 5q spinal muscular atrophy: a non-interventional, multicentre, observational cohort study
Nusinersen is approved for the treatment of 5q spinal muscular atrophy of all types and stages in patients of all ages. Although clinical trials have shown improvements in motor function in infants and children treated with the drug, data for adults are scarce. We aimed to assess the safety and efficacy of nusinersen in adults with 5q spinal muscular atrophy.
We did an observational cohort study at ten academic clinical sites in Germany. Patients with genetically confirmed 5q spinal muscular atrophy (age 16–65 years) with a homozygous deletion of exons 7, 8, or both, or with compound heterozygous mutations were eligible for inclusion and received nusinersen treatment in accordance with the label for a minimum treatment time of 6 months to a follow-up of up to 14 months. The primary outcome was the change in the total Hammersmith Functional Motor Scale Expanded (HFMSE) score, assessed at months 6, 10, and 14, and based on pre–post comparisons. This study is registered with the German Clinical Trials Register (number DRKS00015702).
Between July 13, 2017, and May 1, 2019, 173 patients were screened, of whom 139 (80%) were eligible for data analysis. Of these, 124 (89%) were included in the 6-month analysis, 92 (66%) in the 10-month analysis, and 57 (41%) in the 14-month analysis; patients with missing baseline HFMSE scores were excluded from these analyses. Mean HFMSE scores were significantly increased compared with baseline at 6 months (mean difference 1·73 [95% CI 1·05–2·41], p<0·0001), 10 months (2·58 [1·76–3·39], p<0·0001), and 14 months (3·12 [2·06–4·19], p<0·0001). Clinically meaningful improvements (≥3 points increase) in HFMSE scores were seen in 35 (28%) of 124 patients at 6 months, 33 (35%) of 92 at 10 months, and 23 (40%) of 57 at 14 months. To 14-month follow-up, the most frequent adverse effects among 173 patients were headache (61 [35%] patients), back pain (38 [22%]), and nausea (19 [11%]). No serious adverse events were reported.
Despite the limitations of the observational study design and a slow functional decline throughout the natural disease course, our data provide evidence for the safety and efficacy of nusinersen in the treatment of adults with 5q spinal muscular atrophy, with clinically meaningful improvements in motor function in a real-world cohort.
None.
Journal Article
Information extraction from weakly structured radiological reports with natural language queries
Objectives
Provide physicians and researchers an efficient way to extract information from weakly structured radiology reports with natural language processing (NLP) machine learning models.
Methods
We evaluate seven different German bidirectional encoder representations from transformers (BERT) models on a dataset of 857,783 unlabeled radiology reports and an annotated reading comprehension dataset in the format of SQuAD 2.0 based on 1223 additional reports.
Results
Continued pre-training of a BERT model on the radiology dataset and a medical online encyclopedia resulted in the most accurate model with an F1-score of 83.97% and an exact match score of 71.63% for answerable questions and 96.01% accuracy in detecting unanswerable questions. Fine-tuning a non-medical model without further pre-training led to the lowest-performing model. The final model proved stable against variation in the formulations of questions and in dealing with questions on topics excluded from the training set.
Conclusions
General domain BERT models further pre-trained on radiological data achieve high accuracy in answering questions on radiology reports. We propose to integrate our approach into the workflow of medical practitioners and researchers to extract information from radiology reports.
Clinical relevance statement
By reducing the need for manual searches of radiology reports, radiologists’ resources are freed up, which indirectly benefits patients.
Key Points
• BERT models pre-trained on general domain datasets and radiology reports achieve high accuracy (83.97% F1-score) on question-answering for radiology reports.
• The best performing model achieves an F1-score of 83.97% for answerable questions and 96.01% accuracy for questions without an answer.
• Additional radiology-specific pretraining of all investigated BERT models improves their performance.
Graphical Abstract
Journal Article
Perimesencephalic non-aneurysmal subarachnoid hemorrhage: is there a need for repeat digital subtraction angiography?
PurposeTo assess the diagnostic yield and clinical relevance of repeated digital subtraction angiography (DSA) in patients with spontaneous perimesencephalic non-aneurysmal subarachnoid hemorrhage (PMSAH) and to evaluate DSA-related complication rates.MethodsRetrospective analysis of 82 patients with PMSAH confirmed by non-contrast CT between March 2002 and February 2025. All patients underwent initial computed tomography angiography (CTA) and first DSA on average within 24 h. If no bleeding source was identified, a second DSA was performed after 10–14 days. Clinical data, radiological findings, and complications were evaluated.ResultsThe initial DSA showed no vascular abnormality in 76/82 patients (92.7%). A second DSA was performed in 60/76 cases (78.9%) and identified two small basilar artery aneurysms (3.3%) that were not visible on the initial CTA or DSA but were detectable on repeat 3D rotational angiography (3DRA). Procedure-related complications occurred in three DSAs (2%), including a cerebellar infarct, supratentorial embolism, and local puncture site complication. Most patients had a benign clinical course, and only one in-hospital death was documented.ConclusionThe diagnostic benefit of repeat DSA in typical PMSAH is low, with no clear therapeutic impact and a relevant risk of complications. Given the benign course of PMSAH and the availability of high-resolution non-invasive imaging such as dual-source, photon-counting CTA, or vessel wall MRI, repeat DSA should be reserved for selected cases with atypical features or clinical deterioration.
Journal Article
Cardiac computed tomography-derived epicardial fat volume and attenuation independently distinguish patients with and without myocardial infarction
Epicardial adipose tissue (EAT) volume is associated with coronary plaque burden and adverse events. We aimed to determine, whether CT-derived EAT attenuation in addition to EAT volume distinguishes patients with and without myocardial infarction.
In 94 patients with confirmed or suspected coronary artery disease (aged 66.9±14.7years, 61%male) undergoing cardiac CT imaging as part of clinical workup, EAT volume was retrospectively quantified from non-contrast cardiac CT by delineation of the pericardium in axial images. Mean attenuation of all pixels from EAT volume was calculated. Patients with type-I myocardial infarction (n = 28) had higher EAT volume (132.9 ± 111.9ml vs. 109.7 ± 94.6ml, p = 0.07) and CT-attenuation (-86.8 ± 5.8HU vs. -89.0 ± 3.7HU, p = 0.03) than patients without type-I myocardial infarction, while EAT volume and attenuation were only modestly inversely correlated (r = -0.24, p = 0.02). EAT volume increased per standard deviation of age (18.2 [6.2-30.2] ml, p = 0.003), BMI (29.3 [18.4-40.2] ml, p<0.0001), and with presence of diabetes (44.5 [16.7-72.3] ml, p = 0.0002), while attenuation was higher in patients with lipid-lowering therapy (2.34 [0.08-4.61] HU, p = 0.04). In a model containing volume and attenuation, both measures of EAT were independently associated with the occurrence of type-I myocardial infarction (OR [95% CI]: 1.79 [1.10-2.94], p = 0.02 for volume, 2.04 [1.18-3.53], p = 0.01 for attenuation). Effect sizes remained stable for EAT attenuation after adjustment for risk factors (1.44 [0.77-2.68], p = 0.26 for volume; 1.93 [1.11-3.39], p = 0.02 for attenuation).
CT-derived EAT attenuation, in addition to volume, distinguishes patients with vs. without myocardial infarction and is increased in patients with lipid-lowering therapy. Our results suggest that assessment of EAT attenuation could render complementary information to EAT volume regarding coronary risk burden.
Journal Article
Current use of percutaneous image-guided tumor ablation for the therapy of liver tumors: lessons learned from the registry of the German Society for Interventional Radiology and Minimally Invasive Therapy (DeGIR) 2018–2022
Objectives
Percutaneous image-guided tumor ablation of liver malignancies has become an indispensable therapeutic procedure. The aim of this evaluation of the prospectively managed multinational registry of the voluntary German Society for Interventional Radiology and Minimally Invasive Therapy (DeGIR) was to analyze its use, technical success, and complications in clinical practice.
Materials and methods
All liver tumor ablations from 2018 to 2022 were included. Technical success was defined as complete ablation of the tumor with an ablative margin.
Results
A total of 7228 liver tumor ablations from 136 centers in Germany and Austria were analyzed. In total, 31.4% (2268/7228) of patients were female. Median age was 67 years (IQR 58–74 years). Microwave ablation (MWA) was performed in 65.1% (4703/7228), and radiofrequency ablation (RFA) in 32.7% (2361/7228). Of 5229 cases with reported tumor etiology, 60.3% (3152/5229) of ablations were performed for liver metastases and 37.3% (1950/5229) for hepatocellular carcinoma. The median lesion diameter was 19 mm (IQR 12–27 mm). In total, 91.8% (6636/7228) of ablations were technically successful. The rate of technically successful ablations was significantly higher in MWA (93.9%, 4417/4703) than in RFA (87.3%, 2061/2361) (
p
< 0.0001). The total complication rate was 3.0% (214/7228) and was significantly higher in MWA (4.0%, 189/4703) than in RFA (0.9%, 21/2361,
p
< 0.0001). Additional needle track ablation did not increase the rate of major complications significantly (24.8% (33/133) vs. 28.4% (23/81),
p
= 0.56)).
Conclusion
MWA is the most frequent ablation method. Percutaneous image-guided liver tumor ablations have a high technical success rate, which is higher for MWA than RFA. The complication rate is generally low but is higher for MWA than RFA.
Clinical relevance statement
Percutaneous image-guided liver ablation using microwave ablation and radiofrequency ablation are effective therapeutic procedures with low complication rates for the treatment of primary and secondary liver malignancies.
Key Points
• Percutaneous image-guided liver tumor ablations have a high technical success rate, which is higher for microwave ablation than radiofrequency ablation.
• Microwave ablation is the most frequent ablation method ahead of radiofrequency ablation.
• The complication rate is generally low but is higher for microwave ablation than radiofrequency ablation.
Journal Article
Pediatric age estimation from radiographs of the knee using deep learning
Objectives
Age estimation, especially in pediatric patients, is regularly used in different contexts ranging from forensic over medicolegal to clinical applications. A deep neural network has been developed to automatically estimate chronological age from knee radiographs in pediatric patients.
Methods
In this retrospective study, 3816 radiographs of the knee from pediatric patients from a German population (acquired between January 2008 and December 2018) were collected to train a neural network. The network was trained to predict chronological age from the knee radiographs and was evaluated on an independent validation cohort of 423 radiographs (acquired between January 2019 and December 2020) and on an external validation cohort of 197 radiographs.
Results
The model showed a mean absolute error of 0.86 ± 0.72 years and 0.9 ± 0.71 years on the internal and external validation cohorts, respectively. Separating age classes (< 14 years from ≥ 14 years and < 18 years from ≥ 18 years) showed AUCs between 0.94 and 0.98.
Conclusions
The chronological age of pediatric patients can be estimated with good accuracy from radiographs of the knee using a deep neural network.
Key Points
•
Radiographs of the knee can be used for age estimations in pediatric patients using a standard deep neural network.
•
The network showed a mean absolute error of 0.86 ± 0.72 years in an internal validation cohort and of 0.9 ± 0.71 years in an external validation cohort.
•
The network can be used to separate the age classes < 14 years from
≥
14 years with an AUC of 0.97 and < 18 years from
≥
18 years with an AUC of 0.94.
Journal Article
Locoregional tumour evaluation of squamous cell carcinoma in the head and neck area: a comparison between MRI, PET/CT and integrated PET/MRI
Purpose
To evaluate the accuracy of integrated
18
F-FDG PET/MR imaging for locoregional tumour evaluation compared to
18
F-FDG PET/CT and MR imaging in initial tumour and recurrence diagnosis in histopathologically confirmed head and neck squamous cell carcinoma (HNSCC).
Methods
18
F-FDG PET/CT and integrated
18
F-FDG PET/MR imaging were performed for initial tumour staging or recurrence diagnosis in 25 patients with HNSCC. MR, fused
18
F-FDG PET/CT and fused
18
F-FDG PET/MR images were analysed by two independent readers in separate sessions in random order. In initial tumour staging, T and N staging was performed while individual lesions were analysed in patients with suspected cancer recurrence. In T and N staging, histopathological results after tumour resection served as the reference standard while histopathological sampling as well as cross-sectional and clinical follow-up were accepted in cancer recurrence diagnosis. The diagnostic accuracy of each modality was calculated separately for T and N staging as well as for tumour recurrence, and compared using McNemar’s test. Values of
p
<0.017 were considered statistically significant after Bonferroni correction.
Results
In 12 patients undergoing
18
F-FDG PET/CT and
18
F-FDG PET/MR for initial tumour staging, T staging was accurate in 50 % with MRI, in 59 % with PET/CT and in 75 % with PET/MR while N staging was accurate in 75 % with MRI, in 77 % with PET/CT and in 71 % with PET/MR in relation to the reference standard. No significant differences were observed in T and N staging among the three modalities (
p
> 0.017). In 13 patients undergoing hybrid imaging for cancer recurrence diagnosis, diagnostic accuracy was 57 % with MRI and in 72 % with
18
F-FDG PET/CT and
18
F-FDG PET/MR, respectively. Again, no significant differences were found among the three modalities (
p
> 0.017).
Conclusion
In this initial study, no significant differences were found among
18
F-FDG PET/MR,
18
F-FDG PET/CT and MRI in local tumour staging and cancer recurrence diagnosis.
Journal Article
Current use of percutaneous ablation in renal tumors: an analysis of the registry of the German Society for Interventional Radiology and Minimally Invasive Therapy
Objective
To evaluate the success and complications of thermal ablation (TA) based on the voluntary, prospective registry of the German Society for Interventional Radiology and Minimally Invasive Therapy (DeGIR) with 303 participating centers from Germany, Austria, and Switzerland.
Materials and methods
Registry data from 2018 until 2023 of 1102 patients with small renal tumors (age: 72.5 ± 11.6 years; female: 33.6%, 370/1102) were analyzed. Hospitals with ≥ 20 TAs were considered high-volume centers. Technical success and complication rates between different parameters were compared using the chi-square or Fisher’s exact test,
p
< 0.05 was considered statistically significant.
Results
Patients were most frequently treated with radiofrequency ablation (RFA, 43.6%, 481/1102), then microwave ablation (MWA, 41.9%, 462/1102) or cryoablation (13.3%, 147/1102). Technical success for heat-based TA (RFA&MWA) was 94.3% (893/947), for cryoablation 97.3% (143/147). RFA&MWA was significantly more successful in lesions ≤ 3 cm (96.1%, 567/590) compared to 3–4 cm lesions (89.8%, 97/108;
p
= 0.005). In patients treated with cryoablation, no significant differences between sizes could be found (≤ 3 cm: 97.9%, 94/96; 3–4 cm: 85.7%, 12/14;
p
= 0.078). Complication rate was significantly higher in RFA&MWA of lesions 3–4 cm compared to ≤ 3 cm (≤ 3 cm: 3.9%, 23/590; 3–4 cm: 11.1%, 12/108,
p
= 0.002), while no significant differences were seen regarding cryoablation (≤ 3 cm: 1.0%, 1/96; 3–4 cm: 0.0%, 0/14;
p
= 1.000).
Conclusions
In this exploratory analysis of the DeGIR registry, percutaneous TA of small renal masses is technically feasible with low complication rates. Heat-based TAs seem to have lower success rates and higher complication rates in larger tumors. Cryoablation could potentially be a safe alternative for 3- to 4-cm-sized tumors.
Key Points
Question
How effective is renal thermal ablation (TA) in terms of treatment success and complication rates?
Findings
In contrast to cryoablation, heat-based thermal ablation has lower success and higher complication rates in tumors measuring 3–4 cm compared to tumors < 3 cm
.
Clinical relevance
Thermal ablation is not influenced by the need for additional techniques such as cooling, protective organ displacement, or temporary vessel occlusion. For small renal tumors, TA is an effective and safe treatment option. Cryoablation could be beneficial in larger tumors.
Graphical Abstract
Journal Article