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Background: Acute ischemic stroke (AIS) due to anterior circulation tandem lesion (TL) remains a technical and clinical challenge for endovascular treatment (EVT). Conflicting results from observational studies and missing evidence from the randomized trials led us to report a recent real-world multicenter clinical experience and evaluate possible predictors of good outcome after EVT., Methods: We analyzed all AIS patients with TL enrolled in the prospective national study METRICS (Mechanical Thrombectomy Quality Indicators Study in Czech Stroke Centers). A good 3-month clinical outcome was scored as 0-2 points in modified Rankin Scale (mRS), achieved recanalization using the Thrombolysis In Cerebral Infarction (TICI) scale and symptomatic intracerebral hemorrhage (sICH) according to the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST) criteria., Results: Of 1178 patients enrolled in METRICS, 194 (19.2%) (59.8% males, mean age 68.7±11.5 years) were treated for TL. They did not differ in mRS 0-2 (48.7% vs 46.7%; p=0.616), mortality (17.3% vs 22.7%; p=0.103) and sICH (4.7% vs 5.1%; p=0.809) from those with single occlusion (SO). More TL patients with prior intravenous thrombolysis (IVT) reached TICI 3 (70.3% vs 50.8%; p=0.012) and mRS 0-2 (55.4% vs 34.4%; p=0.007) than those without IVT. No difference was found in the rate of sICH (6.2% vs 1.6%; p=0.276). Multivariate logistic regression analysis showed prior IVT as a predictor of mRS 0-2 after adjustment for potential confounders (OR 3.818, 95% CI 1.614 to 9.030, p=0.002)., Conclusion: Patients with TL did not differ from those with SO in outcomes after EVT. TL patients with prior IVT had more complete recanalization and mRS 0-2 and IVT was found to be a predictor of good outcome after EVT., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Purpose: Rigorous and regular evaluation of defined quality indicators is crucial for further improvement of both technical and clinical results after mechanical thrombectomy (MT) for acute ischemic stroke (AIS). Following the recent international multi-society consensus quality indicators, we aimed to assess trend in these indicators on national level., Material and Methods: The prospective multicenter study (METRICS) was conducted in Czech Republic (CR) in year 2019. All participating centers collected technical and clinical data including defined quality indicators and results were subsequently compared with those from year 2016., Results: In the 2019, 1375 MT were performed in the CR and 1178 (86%) patients (50.3% males, mean age 70.5 ± 13.0 years) were analyzed. Recanalization (TICI 2b-3) was achieved in 83.7% of patients and 46.2% of patients had good 3-month clinical outcome. Following time intervals were shortened in comparison to 2016: "hospital arrival - GP" (77 vs. 53 min; p<0.0001), "hospital arrival - maximal achieved recanalization" (122 vs. 93 min; p<0.0001), and "stroke onset - maximal achieved recanalization" (240 vs. 229 min; p p<0.0001). More patients with tandem occlusion were treated in 2019 (7.8 vs. 16.5%; p<0.0001) and more secondary transports were in 2019 (31.3 vs. 37.8%; p=0.002). No difference was found in 3-month clinical outcome and in the rate of periprocedural complications. Results of the METRICS study met all criteria of multi-society consensus quality indicators., Conclusion: Nationwide comparison between 2016 and 2019 showed improvement in the key time intervals, but without better overall clinical outcomes after MT., Competing Interests: Conflict of Interest The authors declare that they have no conflict of interest., (Copyright © 2022 Elsevier Inc. All rights reserved.)

BACKGROUND In dialysis patients with exhausted usual central venous access sites, the translumbar hemodialysis catheter (TLC) provides a viable option for dialysis access. The technical success of catheter insertion, associated complications, and long-term patency of TLC were evaluated in this study. MATERIAL AND METHODS This retrospective study included 37 patients with occluded central thoracic veins in whom 39 TLC implantation procedures were performed and 196 patients with internal jugular vein hemodialysis catheters (JVC). TLC implantation was performed as a hybrid procedure with computed tomography (CT)-navigated translumbar inferior vena cava cannulation and subsequent fluoroscopy-guided hemodialysis catheter placement. RESULTS The rates of technical success of the implantations and minor periprocedural complications were 97.4% and 10.3% in the TLC group and 98.6% and 4.2% in the JVC group, respectively. The median follow-up in the TLC and JVC groups was 673 days and 310 days, respectively. The primary-assisted patency at the 1-year and 3-year follow-up was 88.7% and 72.0% in the TLC group and 81.6% and 67.0% in the JVC group, respectively, with no statistically significant difference between the 2 groups. The incidence rate of infection-related and patency-related complications calculated for 1000 catheter-days was 0.15 and 0.11 in the TLC group and 0.33 and 0.25 in the JVC group, respectively. CONCLUSIONS The CT-guided implantation of the TLC is a useful option to create dialysis access with a low complication rate and satisfactory long-term patency in patients without usual venous access.

BACKGROUND We investigated the properties and effects of 5 mechanical thrombectomy procedures in patients with acute ischemic stroke. The relationships between the type of procedure, the time required, the success of recanalization, and the clinical outcome were analyzed. MATERIAL AND METHODS This prospective comparative analysis included 500 patients with acute ischemic stroke and large-vessel occlusion. We compared contact aspiration thrombectomy (ADAPT, n=100), stent retriever first line (SRFL, n=196), the Solumbra technique (n=64), mechanical thrombectomy plus stent implantation (n=81), and a combined procedure (n=59). RESULTS ADAPT provided shorter procedure (P<0.001) and recanalization times (P<0.001) than the other techniques. Better clinical outcome was achieved for ischemia in the anterior circulation than ischemia in the posterior fossa (P<0.001). Compared to the other techniques, patients treated with ADAPT procedure had increased odds of achieving better mTICI scores (P=0.002) and clinical outcome (NIHSS) after 7 days (P=0.003); patients treated with SRFL had increased odds of achieving better long-term clinical status (3M-mRS=0-2; P=0.040). Patients with SRFL and intravenous thrombolysis (IVT) had increased odds of better clinical status (3M-mRS=0-2; P=0.031) and decreased odds of death (P=0.005) compared to patients with SRFL without IVT. The other treatment approaches had no additional effect of IVT. Patients with SRFL with a mothership transfer had increased odds of achieving favorable clinical outcome (3M-mRS) compared to SRFL with the drip-and-ship transfer paradigm (P=0.015). CONCLUSIONS Our results showed that ADAPT and SRFL provided significantly better outcomes compared to the other examined techniques. A mothership transfer and IVT administration contributed to the success of the SRFL approach.

BACKGROUND The aim of the study was to investigate the role of von Willebrand factor (vWF), the vWF-cleaving protease, ADAMTS13, the composition of thrombus, and patient outcome following mechanical cerebral artery thrombectomy in patients with acute ischemic stroke. MATERIAL AND METHODS A prospective cohort study included 131 patients with ischemic stroke (<6 hours) with or without intravenous thrombolysis. Interventional procedure parameters, hemocoagulation markers, vWF, ADAMTS13, and histological examination of the extracted thrombi were performed. The National Institutes of Health Stroke Scale (NIHSS) score was used on hospital admission, after 24 hours, at day 7; the three-month modified Rankin Scale score was used. RESULTS Mechanical thrombectomy resulted in a Treatment in Cerebral Ischemia (TICI) score of 2-3, with recanalization in 89% of patients. Intravenous thrombolysis was used in 101 (78%). Patients with and without intravenous thrombolysis therapy had a good clinical outcome (score 0-2) in 47% of cases (P=0.459) using the three-month modified Rankin Scale. Patients with a National Institutes of Health Stroke Scale (NIHSS) score ≥15 had significantly increased vWF levels (P=0.003), and a significantly increased vWF: ADAMTS13 ratio (P=0.038) on hospital admission. Significant correlation coefficients were found for plasma vWF and thrombo-embolus vWF (r=0.32), platelet (r=0.24), and fibrin (r=0.26) levels. In the removed thrombus, vWF levels were significantly correlated with platelet count (r=0.53), CD31-positive cells (r=0.38), and fibrin (r=0.48). CONCLUSIONS In patients with acute ischemic stroke, mechanical cerebral artery thrombectomy resulted in a good clinical outcome in 47% of cases, with and without intravenous thrombolysis therapy.

Aim: To evaluate liver tumor motion and how well reference measurement predicts motion during treatment., Material and Methods: This retrospective study included 20 patients with colorectal cancer that had metastasized to the liver who were treated with stereotactic ablative radiotherapy. An online respiratory tumor tracking system was used. Tumor motion amplitudes in the superior-inferior (SI), latero-lateral (LL), and anterior-posterior (AP) directions were collected to generate patient-specific margins. Reference margins were generated as the mean motion and 95th percentile of motion from measurements recorded for different lengths of time (1, 3, and 5 min). We analyzed the predictability of tumor motion in each axis, based on the reference measurement and intra-/interfraction motions., Results: About 96,000 amplitudes were analyzed. The mean tumor motions were 9.9 ± 4.2 mm, 2.6 ± 0.8 mm, and 4.5 ± 1.8 mm in the SI, LL, and AP directions, respectively. The intrafraction variations were 3.5 ± 1.8 mm, 0.63 ± 0.35 mm, and 1.4 ± 0.65 mm for the SI, LL, and AP directions, respectively. The interfraction motion variations were 1.32 ± 0.79 mm, 0.31 ± 0.23 mm, and 0.68 ± 0.62 mm for the SI, LL, and AP directions, respectively. The Pearson's correlation coefficients for margins based on the reference measurement (mean motion or 95th percentile) and margins covering 95% of the motion during the whole treatment were 0.8-0.91, 0.57-0.7, and 0.77-0.82 in the SI, LL, and AP directions, respectively., Conclusion: Liver tumor motion in the SI direction can be adequately represented by the mean tumor motion amplitude generated from a single 1 min reference measurement. Longer reference measurements did not improve results for patients who were well-educated about the importance of regular breathing. Although the study was based on tumor tracking data, the results are useful for ITV delineation when tumor tracking is not available.

Background: To evaluate pancreatic tumor motion and its dynamics during respiration., Methods and Materials: This retrospective study includes 20 patients with unresectable pancreatic cancer who were treated with stereotactic ablative radiotherapy. An online respiratory tumor tracking system was used. Periodical maximum and minimum tumor positions with respiration in superior-inferior (SI), latero-lateral (LL), and anterior-posterior (AP) directions were collected for tumor motion evaluation. The predictability of tumor motion in each axis, based on reference measurement, was analyzed., Results: The use of a 20-mm and 5-mm constant margins for SI and LL/AP directions, avoids target underdosage, without the need for reference measurement. Pearson's correlation coefficient indicated only a modest correlation between reference and subsequent measurements in the SI direction (r = 0.50) and no correlation in LL (r = 0.17) and AP (r = 0.35) directions. When margins based on the reference measurement of respiratory tumor motion are used, then 30% of patients have a risk zone of underdosage >3 mm (in average). ITV (internal target volume) optimization based on the reference measurement is possible, but allows only modest margin reduction (approximately from 20 mm to 16-17 mm) in SI direction and no reduction in AP and LL directions., Conclusion: Our results support the use of 20-mm margin in the SI direction and 5-mm margins in the LL and AP directions to account for respiratory motion without reference measurement. Single measurement of tumor motion allows only modest margin reduction. Further margin reduction is only possible when there is on-line tumor motion control according to internal markers.

Background and Purpose: Sonolysis is a new therapeutic procedure for arterial recanalization. The aim of this study was to confirm the safety and efficacy of endovascular sonolysis by using the EkoSonic Endovascular System in subjects with acute ischemic stroke., Materials and Methods: Patients with acute ischemic stroke with occlusion of the middle cerebral artery or basilar artery were enrolled consecutively in this prospective study. The control group (44 MCA and 12 BA occlusions) was selected from historical controls. EkoSonic Endovascular System was started within 8 hours after stroke onset. The NIHSS score at hospital admission, after 24 hours, and at 7 days; arterial recanalization; early neurologic improvement; symptomatic intracerebral hemorrhage; and favorable 3-month clinical outcome defined as a modified Rankin Scale score of 0-2 were evaluated by statistical means., Results: Fourteen patients (10 men; mean age, 65.1 ± 11.2 years; median NIHSS score, 16.5) underwent EkoSonic endovascular sonolysis. Arterial recanalization after endovascular treatment was achieved in 6 of 7 (85.7%) patients with MCA occlusion (4 complete recanalizations) and in all 7 (100%) patients with BA occlusion (6 complete recanalizations). No (0%) symptomatic intracerebral hemorrhage or periprocedural complications occurred. Seven (50%) patients were independent at 3 months (median mRS score, 2). Early neurologic improvement and favorable clinical outcome were significantly more frequent in patients with MCA occlusion undergoing EkoSonic endovascular sonolysis than in controls (100% and 71.4% versus 4.6% and 13.6% of patients; P = .0001 and P = .003, respectively). Three-month mortality was significantly lower in patients with BA occlusion undergoing EkoSonic endovascular sonolysis than in controls (0% versus 66.7% patients, P = .013)., Conclusions: In this small study, EkoSonic endovascular sonolysis allowed safe and potentially effective revascularization in patients experiencing acute ischemic stroke.

Purpose: To compare safety and utility of intraarterial revascularization with use of stents to no revascularization in patients who either failed to respond to intravenous thrombolysis (IVT) or have contraindications to IVT., Materials and Methods: The case-control study was approved by local ethics committees; all patients signed informed consent. One hundred thirty-one patients (74 men; mean age, 65.9 years ± 12.3; range, 25-86 years) with acute ischemic stroke (AIS) due to middle cerebral artery (MCA) occlusion were enrolled; 75 underwent IVT. No further recanalization therapy was performed in 26 (35%) IVT-treated patients with MCA recanalization (group 1). Patients with IVT failure after 60 minutes were allocated to endovascular treatment (group 2A) or no further therapy (group 2B). Patients with contraindication to IVT were allocated to endovascular treatment within 8 hours since AIS onset (group 3A) or to no recanalization therapy (group 3B). Neurologic deficit at admission, MCA recanalization, symptomatic intracerebral hemorrhage (SICH), and 3-month clinical outcome were evaluated. Favorable clinical outcome was defined as modified Rankin scale score 0-2 at 3 months after stroke onset. Two-sided Mann-Whitney U test, independent samples t test, Fisher exact test, multivariate logistic regression analysis of baseline variables, and complete MCA recanalization for the prediction of favorable clinical outcome were used for statistical evaluation., Results: Median National Institutes of Health Stroke Scale score at admission was 13.5, 16.0, 15.5, 15.0, and 16.0 in groups 1, 2A, 2B, 3A, and 3B, respectively (P > .05); SICH occurred in one of 26 (3.8%), one of 23 (4.3%), one of 26 (3.8%), one of 31 (3.2%), and one of 25 (4.0%) patients, respectively (P > .05). MCA recanalization after endovascular treatment was achieved in 50 of 54 (92.6%) patients. Favorable outcome was significantly different between groups 2A and 2B (10 of 23 [43.5%] and four of 26 [15.4%], respectively; P = .03) and groups 3A and 3B (14 of 31 [45.2%] and two of 25 [8.0%], respectively; P = .004) and was dependent on MCA recanalization (odds ratio, 5.55; P = .006)., Conclusion: In this controlled trial, intraarterial revascularization with stents was an effective and safe-effective treatment option in patients with acute MCA occlusion with contraindication to IVT or after IVT failure.

Decompressive surgery <48 h from stroke onset reduces the prevalence of mortality and morbidity from malignant supratentorial infarction. We investigated if utilization of decompressive surgery changed in the Czech Republic (CZ) after the release of new guidelines regarding treatment of malignant brain infarction. The volume of decompressive surgery in 2009 in all centers in the CZ was assessed using the same methodology as in 2006. All neurosurgery departments in the CZ were asked to complete a questionnaire and asked to identify all cases of decompressive surgery for malignant brain infarction through a combination of discharge codes for "brain infarction" and "decompressive surgery" from electronic hospital charts. Data for 56 patients were obtained from 15 of the 16 neurosurgery departments in the CZ. The average age was 53 ± 13; number of males 20; median time to surgery was 48 h (range 24-62); median NIHSS score was 25 (IQR, 20-30); median infarct volume was 300 cm(3) [interquartile (IQR, 250-350)]; mean shift on CT was 10.6 ± 3.6 mm and size of hemicraniectomy was 125 cm(2) (IQR, 110-154). A favorable outcome was achieved in 45% of the patients. The number of procedures increased from 39 in 2,006 to 2,056 in 2009. Based on data from one stroke center, 10% suffered from malignant supratentorial infarction and 2.3% met the criteria for decompressive surgery. In 2009, as compared to 2006, the volume of decompressive surgery carried out moderately increased. However, procedures remained underutilized because only ~10% of those who needed decompressive surgery underwent surgery.

During the pandemy caused by novel influenza A virus (subgroup H1N1), a significant number of patients became critically ill from respiratory failure. In the most severe cases of primary pneumonia, patients develop refractory hypoxemic acute respiratory distress syndrome (ARDS) with typical computed tomographic findings of multi-lobar alveolar opacities and extremely reduced pulmonary airspace. To reduce the risk of injurious ventilation and promote survival, some authors recommend the use of extracorporeal membrane oxygenation (ECMO). Unfortunately, ECMO is expensive, associated with serious complications, and available at very few centers. Other therapeutic options are clearly needed. Here we report three patients with severe influenza pneumonia who recovered following treatment with porcine surfactant (Tab. 1, Fig. 3, Ref. 6). Full Text in free PDF www.bmj.sk.

Object: Decompressive surgery within 48 hours in patients younger than 60 years of age reduces mortality and morbidity from malignant supratentorial infarction. The goal of this study was to characterize the utilization of decompressive surgery in the Czech Republic in 2006., Methods: This nationwide study was undertaken from September to December 2007 using a questionnaire sent to all neurosurgery departments in the Czech Republic. Diagnosis of brain infarction and decompressive surgery was based on discharge codes. Patient data were retrieved from hospital charts. Favorable outcome was defined as a modified Rankin scale score ≤4 on the day of discharge from the hospital., Results: Data were obtained from 15 of the 16 neurosurgery departments in the Czech Republic (94%) and from 39 patients (11 female [28%]). The average patient age was 52 +/-14 years (11 patients > 60), median time to surgery was 48 hours (interquartile range [IQR] 26-67 hours; 15 patients > 48 hours), median National Institutes of Health Stroke Scale score was 22 (IQR 16-30), median infarct volume was 341 cm³ (IQR 243-375 cm³), mean shift from the midline was 9.9 +/- 4.1 mm, median duration of hospitalization was 19 days (IQR 13-30 days), and mean bone flap surface area was 75 cm² (IQR 70-97 cm²). A favorable outcome was achieved in 19 patients (49%). The median number of procedures per site in 2006 was 1.5 (range 0-13 procedures). Five sites (31%) serving one-third of the entire population did not perform any decompressive surgery. No variable was a significant predictor of outcome in a multiple regression model., Conclusions: In 2006 decompressive surgery was underutilized and occurred late in the clinical course in the Czech Republic. Revision of national guidelines is necessary to incorporate the latest data and ensure that the patients who can benefit most receive treatment.

Background: Marfan's syndrome is an inherited connective tissue disorder that affects many organ systems and has widespread phenotype expression. The diagnosis is therefore made by phenotype assessment. Dural ectasia has been classified as a major diagnostic criterium with a prevalence of over 90% in patients with Marfan's syndrome. The objective of this study determine the feasibility of performing CT angiographic examination of aorta and large vessels for dural ectasia grading in a single CT exam of patients with Marfan's syndrome., Patients and Methods: 7 examinations in Marfan patients were performed of which 6 were CTA. In all exams the aorta was evaluated and simultaneously the lumbosacral region of the spine was well delineated. We performed calculation of spinal canal (SCI) and dural sac (DSI) indices and also qualitative grading of dural sac involvement., Results: In 4 patients both SCI (> 4,50) and DSI (> 3,75) fulfil the diagnostic criteria of Marfan's syndrome. In 1 patient complete spondyloptosis was detected., Conclusions: Whole body CT examination is the perfect tool for both aorta and spinal canal evaluation. Despite differences in spinal canal grading methods in all of our patients significant changes of the spinal canal in the lumbosacral region were detected. Dural ectasia is easy to detect and quantify and may therefore be used as a sensitive and specific sign of Marfan's syndrome.