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Background: Endovascular treatment (ET) is standard of care in patients with acute ischemic stroke due to large vessel occlusion, but data on ET in young patients remain limited. Aim: We aim to compare outcomes for young stroke patients undergoing ET in a matched cohort. Methods: We analyzed patients from an observational multicenter cohort with acute ischemic stroke and ET, the German Stroke Registry—Endovascular Treatment trial. Baseline characteristics, procedural parameters, and functional outcome at 90 days were compared between young (Results: Out of 6628 acute ischemic stroke patients treated with ET, 363 (5.5%) were young. Young patients differed with regard to prognostic outcome characteristics. Specifically, National Institutes of Health Stroke Scale (NIHSS) at admission was lower (median 13, interquartile range (IQR) 8–17 vs. 15, IQR 9–19, p Conclusion: Young stroke patients undergoing ET have better outcomes compared to older patients, even when matched for prestroke condition, comorbidities, and stroke severity. Hence, more liberal guidelines to perform ET for younger patients may have to be established by future studies.

Objective Arterial spin labeling blood perfusion signal relies on the difference between a label and a control image. Background suppression pulses are commonly used to improve the contrast, yet these are based on estimates of tissue relaxation times. The aim of this study is to improve the perfusion contrast by individualizing the timing of these background suppression pulses by means of T1 mapping. Methods The optimized timing of the background suppression pulses is obtained by rapid T1 mapping employing the variable flip angle technique. Ten healthy volunteers were included in this study. To compare the results, visual grading and the Wilcoxon signed-rank test was used comparing three categories of image quality. Results The readers confirmed that the images of the proposed method generally show a higher signal-to-background ratio and cortical structures are better visible. Noise was mostly comparable to the standard method. Relative blood flow was statistically significant higher in the modified method. Conclusion The individually optimized background suppression pulses improve the image appearance and allow for a better visualization of cortical structures. The proposed technique however prolongs scan time, which can be seen as negative result, yet needs to be further evaluated. Key Points • Background suppression timing in ASL can vary. • Both the label and control condition can be modified for T1 mapping. • Adapting the pulse timing improves the signal-to-background ratio.

Purpose Grey matter (GM) atrophy due to neuronal loss is a striking feature of patients with CLN3 disease. A precise and quantitative description of disease progression is needed in order to establish an evaluation tool for current and future experimental treatments. In order to develop a quantitative marker to measure brain volume outcome, we analysed the longitudinal volumetric development of GM, white matter (WM) and lateral ventricles and correlated those with the clinical course. Methods One hundred twenty-two MRI scans of 35 patients (21 females; 14 males; age 15.3 ± 4.8 years) with genetically confirmed CLN3 disease were performed. A three-dimensional T1-weighted sequence was acquired with whole brain coverage. Volumetric segmentation of the brain was performed with the FreeSurfer image analysis suite. The clinical severity was assessed by the Hamburg jNCL score, a disease-specific scoring system. Results The volumes of supratentorial cortical GM and supratentorial WM, cerebellar GM, basal ganglia/thalamus and hippocampus significantly (r = − 0.86 to − 0.69, p r = 0.68, p r = − 0.56, p = 0.0001). Supratentorial cortical GM volume showed the steepest (4.6% (± 0.2%)) and most uniform decrease with strongest correlation with age (r = − 0.86, p r = 0.85, p = Conclusion Supratentorial cortical GM volume is a sensitive parameter for assessment of disease progression even in early and late disease stages and represents a potential reliable outcome measure for evaluation of experimental therapies.

Embolization of the middle meningeal artery has gained substantial interest as a therapy for chronic subdural hematomas. For the results of the currently running chronic subdural hematoma trials to inform clinical practice, sufficient accuracy and matching definitions are necessary. We summarized the current practice in chronic subdural hematoma evaluation and derived suggestions on reporting standards using the {Nested} Knowledge AutoLit living review platform. On the basis of the most commonly reported data elements, we suggested a set of standardized image-based study end points for chronic subdural hematoma evaluation for future trials. The measurement methods and reporting standards as proposed in this article have been derived from published best practices and are endorsed by the European Society of Minimally Invasive Neurological Therapy's research committee. The standardization of radiologic outcome measures and measurement techniques in chronic subdural hematoma embolization trials would increase the impact and implication of each trial as well as facilitate data pooling for increased statistical power and, therefore, translation to clinical practice.

Background and Purpose— Stroke etiology drives thrombus composition. We thus hypothesized that endovascular treatment shows different efficacy in cardioembolic versus noncardioembolic large-vessel occlusions (LVOs). Methods— Procedural characteristics, grade of reperfusion, and functional outcome at discharge and 90 days were compared between patients with cardioembolic versus noncardioembolic LVO from the GSR-ET (German Stroke Registry–Endovascular Treatment; n=2589). To determine associations with functional outcome, adjusted odds ratios and 95% CIs were calculated using ordinal multivariable logistic regression models adjusting for potential baseline confounder variables. Results— Endovascular treatment of cardioembolic LVO had a higher rate of successful reperfusion (85.6% versus 81.0%; P =0.002) and a higher rate of complete reperfusion after a single thrombectomy pass (45.7% versus 38.1%; P Conclusions— These results provide evidence for higher efficacy of endovascular treatment in cardioembolic LVO compared with noncardioembolic LVO.

Der wissenschaftliche Nachweis der hohen Wirksamkeit der endovaskularen Schlaganfallbehandlung bei proximalem Gefasverschluss („large vessel occlusion“, LVO) hat dazu gefuhrt, dass diese Therapie als Goldstandard bei Schlaganfallpatienten akzeptiert ist. In dieser Ubersicht soll der Versuch unternommen werden, die verschiedenen Organisationsmodelle fur die Thrombektomie vorzustellen und zu analysieren, welches Modell unter welchen Umstanden zu bevorzugen ist. In einer Analyse der jungeren wissenschaftlichen Literatur werden die Modelle zur Optimierung des Patiententransportes („drip and ship“ und „mothership“) sowie der Optimierung der Verfugbarkeit von Interventionalisten („drip and drive“ und „remote mentoring“) vorgestellt und gegeneinander abgewogen. Zudem werden Uberlegungen zu Thrombektomieraten und Pravalenz von LVOs und der Modellierung von Organisationsmodellen angestellt. Ist der Ort des Schlaganfallpatienten genauso weit oder naher an einem „comprehensive stroke center“ (CSC) gelegen wie ein „primary stroke center“ (PSC), sollte der Patient per „mothership“ direkt zum CSC zu transportiert werden. Ist hingegen ein PSC naher am Ort des Schlaganfalls als ein CSC und liegt die Zeit nach Symptombeginn im Lysezeitfenster hangt diese Entscheidung von vielen Variablen ab. Basierend auf der nicht eindeutigen Datenlage kann derzeit keine Empfehlung fur ein allgemein uberlegeneres Organisationsmodell gegeben werden.

Arterial spin labeling blood perfusion signal relies on the difference between a label and a control image. Background suppression pulses are commonly used to improve the contrast, yet these are based on estimates of tissue relaxation times. The aim of this study is to improve the perfusion contrast by individualizing the timing of these background suppression pulses by means of T1 mapping.The optimized timing of the background suppression pulses is obtained by rapid T1 mapping employing the variable flip angle technique. Ten healthy volunteers were included in this study. To compare the results, visual grading and the Wilcoxon signed-rank test was used comparing three categories of image quality.The readers confirmed that the images of the proposed method generally show a higher signal-to-background ratio and cortical structures are better visible. Noise was mostly comparable to the standard method. Relative blood flow was statistically significant higher in the modified method.The individually optimized background suppression pulses improve the image appearance and allow for a better visualization of cortical structures. The proposed technique however prolongs scan time, which can be seen as negative result, yet needs to be further evaluated.• Background suppression timing in ASL can vary. • Both the label and control condition can be modified for T1 mapping. • Adapting the pulse timing improves the signal-to-background ratio.

Endovascular procedures are paramount in the treatment of cerebrovascular diseases, e.g. thrombectomy for stroke. The continuous further development of the devices used for these procedures (e.g. catheters and stents) requires permanent learning by the treating physician.Technical support options for new neuroendovascular procedures.Integration of streaming technologies into the training concept for neuroradiologists.The transmission of angiographic images to a remote computer workstation in real time is possible independent of location by means of specific streaming technology. This approach enables a neuroendovascular specialist to advise geographically distant interventionalists when performing catheter interventions of the brain, to oversee the handling of the materials used and to instruct them if necessary (remote proctoring).Especially during emergency interventions and during travel restrictions, patient safety can be increased by connecting to another neuroendovascular specialist via live streaming.HINTERGRUND: Endovaskuläre Verfahren haben einen festen Platz bei der Behandlung von Hirngefäßerkrankungen, z. B. die Thrombektomie beim Schlaganfall. Die ständige Weiterentwicklung der hierbei verwendeten Materialien (z. B. Katheter und Stents) fordert von den behandelnden Ärzten ein permanentes Lernen.Technische Hilfsmöglichkeiten zur Unterstützung bei neuen neuroendovaskulären Verfahren.Integration von Streamingtechnologien in das Ausbildungskonzept von Neuroradiologen.Die Übertragung angiographischer Aufnahmen auf einen entfernten Computerarbeitsplatz in Echtzeit ist mittels spezifischer Streamingtechnologie ortsunabhängig möglich. Hierdurch kann ein neuroendovaskulärer Spezialist geographisch entfernte Interventionalisten bei der Durchführung eines Kathetereingriffes am Gehirn beraten, die Handhabung der verwendeten Materialien überblicken und bei Bedarf anleiten (Remote-Proctoring).Insbesondere bei Notfalleingriffen und während Reisebeschränkungen kann durch Zuschaltung eines weiteren neuroendovaskulären Spezialisten per Livestreaming die Patientensicherheit erhöht werden.

This experiment was designed to evaluate the effects of steam addition to the conditioner on moisture content throughout the pelleting process and subsequent effects on pellet quality. Treatments consisted of diets pelleted with no steam and steam added to achieve conditioning temperatures of 62.8 and 87.8°C. Conditioner retention time was set at 30 sec and diets were pelleted with a 6.4×63.5 mm pellet die. Pellet samples were collected and immediately placed in an experimental counter-flow cooler for 15 min. All treatments were replicated at 3 separate time points to provide 3 replicates per treatment. Mash (M), conditioned mash (CM), hot pellets (HP), and cooled pellet (CP) samples were collected for moisture content analysis and CP for pellet durability index (PDI). Data were analyzed with pelleting run as the experimental unit and time period as the blocking factor. Moisture samples were analyzed as a 3×4 factorial of steam-conditioning and sample location. There was a steam-conditioning×sample interaction (P< 0.01) for moisture. Mash samples for all treatments were similar (13.3%; 36.2°C). For the no steam treatment, there was no difference in moisture content for the M, CM, and HP; however, moisture decreased in CP, with samples having 13.4, 13.1, 12.9, and 12.0% moisture, respectively. For the 62.7°C treatment, there was an increase in moisture from M to CM, followed by a decrease in both HP and CP, with samples having 13.2, 15.3, 14.9, and 12.7% moisture, respectively. For the 87.8°C treatment, moisture increased from M to CM, and decreased in HP and CP with samples having 13.3, 17.3, 16.3, and 13.4% moisture, respectively. Increasing conditioning temperature from no steam to 87.8°C increased (P< 0.01) PDI from 3.3, 59.1, to 91.1%, respectively. In conclusion, increasing feed temperature from 36.2 to 87.8°C via steam addition increased condition mash moisture content by 4.2% resulting in improved pellet quality.

The objective of this study was to determine effects of pelleting on the standardized ileal digestibility (SID) of amino acids (AA) in diets with or without increased concentrations of free AA and reducing sugars (RS). Eight individually housed, ileal cannulated barrows (initially 69.2 kg) were allotted to a replicated 8×8 Latin square with 8 diets and eight 7-d periods with ileal digesta collected on d 6 and 7. Treatments were arranged in a 2×2×2 factorial with main effects of diet form (mash vs. pellet), crystalline AA (low vs. high), or reducing sugars (low vs. high) provided by dried distillers grains with solubles and bakery meal. Diets were pelleted to achieve a hot pellet temperature of 85 to 88°C. Data were analyzed as a completely randomized Latin square using the GLIMMIX procedure of SAS. A feed form×RS interaction (P < 0.026) for SID of tryptophan was observed. Feeding pelleted low RS diets improved SID of tryptophan compared with mash high and low RS diets, and pelleted high RS diets. For main effects of feed form, the SID of total AA, CP, and indispensable AA increased (P < 0.042) in pigs fed pelleted diets compared with mash diets. For main effects of crystalline AA, pigs fed high crystalline AA had increased (P = 0.007) SID of tryptophan and decreased (P = 0.050) SID of histidine compared with those fed low crystalline AA diets. For main effects of RS diets, pigs fed high RS diets had decreased (P < 0.05) SID of total AA, CP and indispensable AA. In conclusion, pelleting diets with increased crystalline AA or RS did not affect the improvement in AA digestibility from pelleting. Pelleting diets improved AA digestibility. Diets formulated with high crystalline AA had increased SID of tryptophan. Formulating diets with high RS resulted in decreased AA digestibility compared with corn-soybean meal-based diets.

Background: Thrombus embolization during endovascular treatment (EVT) occurs in up to 9% of cases, making secondary medium-vessel occlusions (MeVOs) of particular interest to neurointerventionalists. We sought to gain insight into the current EVT approaches for secondary MeVO stroke in an international case-based survey as there are currently no clear recommendations for EVT in these patients. Methods: Participants were presented with three secondary MeVO cases, each consisting of three case-vignettes with changes in patient neurological status (improvement, no change, unable to assess). Clustered multivariable logistic regression analyses were used to assess factors influencing the decision to treat. Results: 366 physicians from 44 countries took part. The majority (54.1%) were in favor of EVT. Participants were more likely to treat occlusions in the anterior M2/3 (74.3%; risk ratio [RR]2.62, 95%CI:2.27-3.03) or A3 (59.7%; RR2.11, 95%CI:1.83-2.42) segment, compared to the M3/4 segment (28.3%;reference). Physicians were less likely to pursue EVT in patients with neurological improvement (49.9% versus 57.0%; RR0.88, 95%CI:0.83-0.92). Interventionalists and more experienced physicians were more likely to treat secondary MeVOs. Conclusions: Physician’s willingness to treat secondary MeVOs endovascularly is limited and varies per occlusion location and change in neurological status. More evidence on the safety and efficacy of EVT for secondary MeVO stroke is needed.

Background: There are no recommendations regarding endovascular treatment (EVT) for patients with acute ischemic stroke (AIS) due to primary medium vessel occlusion (MeVO). The aim of this study was to examine the willingness to perform EVT among stroke physicians in patients with mild, yet personally-disabling deficits due to MeVO. Methods: In an international survey consisting of 4 cases of primary MeVOs, participants were asked whether the presence of personally-disabling deficits would influence their decision-making for EVT despite the patients having low NIHSS scores. Decision rates were calculated based on physician characteristics. Clustered univariable logistic regression was performed. Results: 366 participants from 44 countries provided 2562 answers. 56.9% opted to perform EVT in scenarios in which the deficit was relevant to the patient’s profession versus 41.0% in which no information regarding patient profession was provided (RR1.39, p60 years (RR1.61, 95%CI:1.23-2.10), with more neurointervention experience (RR1.60, 95%CI:1.24-2.06), and who personally performed >100 EVTs per year (RR1.63, 95%CI:1.22-2.17). Conclusions: The presence of a patient-relevant deficit in low NIHSS AIS due to MeVO is an important factor for EVT decision-making. This may have relevance for the conduct and interpretation of low NIHSS EVT randomized trials.

The scientific evidence of the high efficacy of endovascular stroke treatment in large vessel occlusion (LVO) led to this treatment being accepted as the gold standard in these patients.This review article presents the various organizational models for thrombectomy and analyzes which model is preferred under which circumstances.In an analysis of the recent scientific literature the models for optimizing patient transport (drip and ship or mothership) and optimizing the availability of interventionalists (drip and drive or remote mentoring) are presented and compared. In addition, considerations are made on thrombectomy rates and the prevalence of LVOs and the construction of organizational models.If the location of the stroke patient is just as far from or closer to a comprehensive stroke center (CSC) than a primary stroke center (PSC), the patient should be transported directly to the CSC by mothership. If, on the other hand, a PSC is closer to the stroke site than a CSC and the time after the onset of symptoms lies within the lysis time window, this decision depends on many variables.Based on the unambiguous data situation, no recommendations can currently be made for a generally superior organizational model.

Background Because of recent advances in best medical treatment (BMT), it is currently unclear whether any additional surgical or endovascular interventions confer additional benefit, in terms of preventing late ipsilateral carotid territory ischemic stroke in asymptomatic patients with significant carotid stenoses. The aim was to compare the stroke-preventive effects of BMT alone, with that of BMT in combination with carotid endarterectomy (CEA) or carotid artery stenting (CAS) in patients with high grade asymptomatic extracranial carotid artery stenosis. Methods SPACE-2 was planned as a three-armed, randomized controlled trial (BMT alone vs. CEA plus BMT vs. CAS plus BMT, ISRCTN 78592017). However, because of slow patient recruitment, the three-arm study design was amended (July 2013) to become two parallel randomized studies (BMT alone vs. CEA plus BMT, and BMT alone vs. CAS plus BMT). Results The change in study design did not lead to any significant increase in patient recruitment, and trial recruitment ceased after recruiting 513 patients over a 5 year period (CEA vs. BMT ( n = 203); CAS vs. BMT ( n = 197), and BMT alone ( n = 113)). The 30 day rate of death/stroke was 1.97% for patients undergoing CEA, and 2.54% for patients undergoing CAS. No strokes or deaths occurred in the first 30 days after randomization in patients randomized to BMT. There were several potential reasons for the low recruitment rates into SPACE-2, including the ability for referring doctors to refer their patients directly for CEA or CAS outwith the trial, an inability to convince patients (who had come "mentally prepared" that an intervention was necessary) to accept BMT, and other economic constraints. Conclusions Because of slow recruitment rates, SPACE-2 had to be stopped after randomizing only 513 patients. The German Research Foundation will provide continued funding to enable follow up of all recruited patients, and it is also planned to include these data in any future meta-analysis prepared by the Carotid Stenosis Trialists Collaboration.

Neue Studienergebnisse weisen auf einen Zusammenhang zwischen wiederholten kontrastmittel-unterstutzen MRT-Untersuchungen und Ablagerung gadoliniumhaltiger Kontrastmittel im zentralen Nervensystem hin. Ein wesentlicher Faktor hierbei stellt moglicherweise die zum Einsatz kommende Kontrastmittelsubstanzklasse (linear bzw. makrozyklisch) dar. Uber die letzten Jahrzehnte hat sich die MRT als ein unverzichtbarer Bestandteil in der Diagnostik, aber auch in der Verlaufsbeurteilung unterschiedlicher Erkrankungen etabliert. Dies gilt im besonderen Mase fur chronische Erkrankungen, wie die Multiple Sklerose. Wiederholte MRT-Untersuchungen spielen hier insbesondere durch die zunehmenden Therapieoptionen eine wesentliche Rolle im Verlauf der Erkrankung. Im vorliegenden Artikel werden die derzeit vorhandenen Studienergebnisse uber die Ablagerung gadoliniumhaltiger Kontrastmittel zusammengefasst und im Hinblick auf mogliche Konsequenzen fur den Einsatz der MRT im Rahmen der Diagnose und insbesondere der Verlaufsbeurteilung der Multiplen Sklerose diskutiert.

Supplemental Material for Angioplasty in asymptomatic carotid artery stenosis vs. endarterectomy compared to best medical treatment: One-year interim results of SPACE-2 by T Reiff, HH Eckstein, U Mansmann, O Jansen, G Fraedrich, H Mudra, D Böckler, M Böhm, H Brückmann, ES Debus, J Fiehler, W Lang, K Mathias, EB Ringelstein, J Schmidli, R Stingele, R Zahn, T Zeller, A Hetzel, U Bodechtel, A Binder, J Glahn, W Hacke and PA Ringleb in International Journal of Stroke

Introduction The intrasaccular flow diversion device WEB is a system used in the treatment of wide necked bifurcation aneurysm. The large number of clinical studies conducted have included mainly unruptured aneurysms. The CLARYS study has been set up to evaluate the efficacy and the safety of the WEB system used to treat bifurcation ruptured aneurysms. Materials and methods The CLARYS study is a prospective, multicenter evaluation conducted in 13 interventional neuroradiological departments in France and Germany. The study design meets the Good Clinical Practice (GCP) standards with data collected in an eDC 100% monitored and endpoints independently evaluated. The primary endpoint is defined as the re-bleeding rate at 1 month post procedure. The secondary endpoints are the rate of adverse events related to the device, the procedure or the disease, the neurological evaluation at 1 month and 1 year based on mRS, the occlusion at 1 year based on the WEB Occlusion Scale (WOS) and the procedure and fluoroscopy time. Results From February 2016 to September 2017, 60 patients (women: 31, 51.7%; mean age: 54.5±1.49 years) with 60 aneurysms were included in the study. The aneurysms locations were at the anterior communicating artery (26/60, 43.3%), the middle cerebral artery bifurcation (23/60, 38.3%), the basilar apex (7/60, 11.7%), the anterior cerebral artery (2/60, 3.3%), the internal carotid artery terminus (1/60, 1.7%) and the posterior communicating artery (1/60, 1.7%). The WEB device was successfully implanted in 56/60 cases (95.0%) The adverse events reported by the sites and adjudicated by the Clinical Event Adjudicator (CEA) were described based on timeline occurrence (per procedure or post procedure), category of events, clinical impact and relationship to device, procedure or disease. The primary endpoint will be presented as well as the morbidity and mortality at 1 month. The 12 months data are under collection so will not be available. Conclusion The study results at 1 month will be presented to address the rate of re bleeding and the safety of the device used in the treatment of ruptured bifurcation aneurysm, following clinical evaluation conducted according to study GCP. Disclosures D. Herbreteau: 2; C; MicroVention. A. Narata: None. R. Bibi: None. L. Ikka: None. C. Mihalea: None. J. Caroff: None. J. Moret: 2; C; MicroVention, Medtronic, Balt. 4; C; Sensome. X. Barreau: None. J. Ferre: None. J. Gauvrit: None. H. Raoult: None. J. Fiehler: 1; C; German Ministry of Science and Education (BMBF), German Ministry of Economy and Innovation (BMWi), German Research Foundation (DFG), European Union (EU), Hamburgische Investitions-und Forderbank (IFB), Medtronic, MicroVention, Philips, Stryker. 2; C; Acandis, Boehringer Ingelheim, Cerenovus, Covidien, Medtronic, Medina, MicroVention, Penumbra, Route 92, Stryker. J. Buhk: 2; C; Sequent, MicroVention. V. Costalat: 2; C; Medtronic, Stryker, Balt, Cerenovus, MicroVention. A. Januel: None. C. Cognard: 2; C; Stryker, MicroVention, Medtronic, Cerenovus. T. Liebig:None. M. Bester: None. H. Desal: None. B. Daumas-Duport: None. R. Bourcier: None. M. Mohlenbruch: None. J. Berkefeld: 2; C; Sequent/MicroVention. R. Du Mesnil de Rochemont: 2; C; Sequent. W. Weber: 2; C; Phenox, MicroVention, Medtronic, Penumbra, Stryker. S. Velasco:None. A. Biondi: None. J. Byrne: 2; C; Oxford Endovascular Ltd. L. Pierot: 2; C; Balt, Cerus Endovascular, MicroVention/Sequent, Phenox, Vesalio, Penumbra.

Recently, five independent randomized controlled clinical trials demonstrated the efficacy and safety of endovascular stroke treatment in stroke patients with occlusion of proximal intracranial arteries. The five trials MR CLEAN, ESCAPE, EXTEND-IA, SWIFT-PRIME and REVASCAT randomized a total of 1287 stroke patients to either standard treatment, which in the majority of patients consisted of intravenous thrombolysis within 4.5 h of symptom onset or additional endovascular stroke treatment. In all the studies endovascular treatment resulted in a better clinical outcome with an odds ratio for a better clinical outcome 90 days after stroke ranging between 1.7 and 3.1 and an absolute increase in the proportion of patients with functionally independent outcome between 14% and 31%. The overwhelming benefit of endovascular treatment mainly results from mechanical thrombectomy using stent retriever devices and starting endovascular treatment within 6 h of symptom onset in stroke patients.

Der Begriff „evidenzbasierte Medizin“ (EbM) bezeichnet einen durch seine Methodik definierten Bereich der medizinischen Wissenschaft, der auf einer abstrakten Ebene mit der Bewertung sowie der Zusammenfassung von Studien und der Sicherheit von Aussagen, die auf der Qualitat der zugrunde liegenden Untersuchungen beruht. Das Spektrum reicht hierbei von randomisierten kontrollierten Studien bis zur Expertenmeinung. Die methodische Qualitat, aber auch die beobachtete Effektgrose konnen dazu fuhren, dass randomisierte kontrollierte Studien hinsichtlich der Vertrauenswurdigkeit heruntergestuft und Beobachtungsstudien heraufgestuft werden. Letztlich ist hinter EbM der Wunsch zu verstehen, Entscheidungen in der medizinischen Praxis zu unterstutzen, indem die Daten aus medizinischen Publikationen in einem systematischen, methodisch strengen Ansatz analysiert werden. Die EbM folgt allgemeinen gesellschaftlichen Trends zu mehr Transparenz und Formalisierung. Eine Ruckabwicklung ist nach Lage der Dinge vollig ausgeschlossen. Die EbM wird hingegen weiteren Einfluss auf unsere tagliche Praxis gewinnen, sei es durch die zunehmende Bedeutung von Leitlinien oder schlicht durch die Entscheidung uber die Kostenerstattung fur unsere Eingriffe. In der klinischen Anwendung am Patienten sollte evidenzbasierte Medizin klinische Expertise, Ergebnisse externer systematischer Forschung und Patientenpraferenz zu einer Entscheidungsfindung zusammenbringen. Nur qualitativ hochwertige Studien werden angemessen im EbM-Apparat in Forschung und Burokratie berucksichtigt. Wir haben die Aufgabe, solche Studien selbst zu initiieren und durchzufuhren. Zum Gluck stehen die Chancen heute so gunstig wie nie zuvor.

The indications for mechanical thrombectomy are based on a proximal vessel occlusion in the absence of extensive ischemic damage in the corresponding dependent vascular territory. The maximum extent of early ischemic edema for which endovascular treatment is still useful is not clear from the studies. A benefit of mechanical thrombectomy can be safely assumed with an ASPECT score of 6-10, possibly also with lower scores. A more complex imaging with assessment of the status of collateral vessels or perfusion abnormality is scientifically interesting but usually not necessary for clinical decision-making for endovascular stroke treatment within the first 6 h after symptom onset.

Objectives Several plaque and lesion characteristics have been associated with an increased risk for procedural stroke during or shortly after carotid artery stenting (CAS). While technical advancements in stent design and cerebral protection devices (CPD) may help reduce the procedural stroke risk, and anatomy remains important, tailoring stenting procedures according to plaque and lesion characteristics might be a useful strategy in reducing stroke associated with CAS. In this descriptive report of the ongoing Asymptomatic Carotid Surgery Trial-2 (ACST-2), it was assessed whether choice for stent and use or type of CPD was influenced by plaque and lesion characteristics. Materials and methods Trial patients who underwent CAS between 2008 and 2015 were included in this study. Chi-square statistics were used to study the effects of plaque echolucency, ipsilateral preocclusive disease (90–99%), and contralateral high-grade stenosis (>50%) or occlusion of the carotid artery on interventionalists' choice for stent and CPD. Differences in treatment preference between specialties were also analysed. Results In this study, 831 patients from 88 ACST-2 centres were included. Almost all procedures were performed by either interventional radiologists (50%) or vascular surgeons (45%). Plaque echolucency, ipsilateral preocclusive disease (90–99%), and significant contralateral stenosis (>50%) or occlusion did not affect the choice of stent or either the use of cerebral protection and type of CPD employed (i.e., filter/flow reversal). Vascular surgeons used a CPD significantly more often than interventional radiologists (98.6% vs. 76.3%; p < .001), but this choice did not appear to be dependent on patient characteristics. Conclusions In ACST-2, plaque characteristics and severity of stenosis did not primarily determine interventionalists' choice of stent or use or type of CPD, suggesting that other factors, such as vascular anatomy or personal and centre preference, may be more important. Stent and CPD use was highly heterogeneous among participating European centres.

Durch die Verbreitung von Schnittbildverfahren mit angiografischen Rekonstruktionen hat die Haufigkeit zugenommen, mit der Aneurysmen hirnversorgender Arterien diagnostiziert werden. Zudem werden Untersuchungen nicht selten von Personen gewunscht, bei deren Verwandten ein Aneurysma oder eine Subarachnoidalblutung diagnostiziert wurde. Der Umgang mit diesem Themen ist fur jeden Radiologen bedeutsam und wird hier anhand der neueren Literatur diskutiert. Die Pravalenz von Aneurysmen in der Normalbevolkerung betragt etwa 2 – 3 %, steigt mit einem Verwandten ersten Grades mit einem Aneurysma auf etwa 4 – 10 % und bei mindestens zwei Verwandten mit Aneurysma auf etwa 20 %. Das Rupturrisiko ist insgesamt bei durchschnittlich etwa 5 % in einem 5-Jahreszeitraum anzusiedeln, ist jedoch tatsachlich sehr variabel und abhangig von individuell zu diskutierenden Faktoren. Das Risiko einer endovaskularen Behandlung liegt nach Literaturdaten bei unter 5 %, wobei fur die Risikoabwagung immer die Ergebnisse des jeweiligen Behandlungszentrums herangezogen werden mussen. Die Notwendigkeit eines MRA-Screenings sollte in Kenntnis all dieser Daten individuell mit dem Patienten diskutiert werden.

Acute vertebrobasilar occlusions (VBO) are dramatic clinical events with a mortality of up to 90% under standard medical treatment. If VBO is suspected a diagnosis of the vessel status has to be achieved immediately. For this purpose CT/CTA and MRI/MRA are equivalent diagnostic tools in the emergency setting. In contrast to the anterior circulation, local endovascular treatment is the established therapy for the posterior circulation as an underlying arteriosclerotic stenosis remains in 50% of the cases after intravenous fibrinolysis. Nevertheless, systemic fibrinolysis is considered the preferred option in cases where a neurointerventional center cannot be reached within a reasonable time frame and the patient can subsequently be transported for local therapy of a residual stenosis in order to prevent reocclusion ("drip and ship"). Profound clinical and pathophysiological knowledge is the absolute prerequisite for the correct application of state-of-the-art neurointerventional therapy. This review paper focuses on the clinical and pathophysiological details that are crucial for decision-making.

Ischemic stroke is a leading cause of death and disability worldwide. Much of the long-term disability occurs in patients with Emergent Large Vessel Occlusion (ELVO). In fact, in these patients, occlusion of a major intracerebral artery results in a large area of brain injury often resulting in

Recently, five independent randomized controlled clinical trials demonstrated the efficacy and safety of endovascular stroke treatment in stroke patients with occlusion of proximal intracranial arteries. The five trials MR CLEAN, ESCAPE, EXTEND-IA, SWIFT-PRIME and REVASCAT randomized a total of 1287 stroke patients to either standard treatment, which in the majority of patients consisted of intravenous thrombolysis within 4.5 h of symptom onset or additional endovascular stroke treatment. In all the studies endovascular treatment resulted in a better clinical outcome with an odds ratio for a better clinical outcome 90 days after stroke ranging between 1.7 and 3.1 and an absolute increase in the proportion of patients with functionally independent outcome between 14% and 31%. The overwhelming benefit of endovascular treatment mainly results from mechanical thrombectomy using stent retriever devices and starting endovascular treatment within 6 h of symptom onset in stroke patients.

There is an ongoing discussion about reimbursement of stent-angioplasty for the treatment of intracranial stenoses in Germany. The discussion was initiated by the statutory health insurance companies after publication of the SAMMPRIS study results, which were in favor for medical management compared to stent-angioplasty with the Wingspan® stent system. A report (Rapid report N14-01) mainly based on SAMMPRIS was written by the German Institute for Quality and Efficiency in Health Care (IQWiG) and serves as a basis for the decision-making process. This report was previously commented by the medical societies involved. Limitations of the SAMMPRIS trial and vital indications for intracranial stenting were outlined in this comment (acute vessel occlusion, hemodynamic impairment, recurrent symptoms under medical treatment). Currently also emergency stent procedures are a matter of debate. In this context a second IQWiG report was commissioned (GA 15 - 02) addressing the results of the VISSIT trial, the transferability of the results of the first report to emergency treatments and the practice of emergency intracranial stent treatment in Germany. Regarding transferability of results the main conclusion was that there was no evidence that the results of the studies analyzed for the first report (mainly SAMMPRIS) could not be transferred to emergency treatments. From a medical professional and scientific standpoint it is inacceptable to compare outcomes of a secondary prophylactic treatment with emergency procedures. The analysis of emergency treatments in Germany based on retrospective case series with a cumulative number of 31 patients. Since most emergency procedures are performed in a clinical context and are not necessarily subject to scientific evaluation, this does not reflect current practice in Germany. The first part of this statement briefly outlines the design of SAMMPRIS and VISSIT and the interpretation of the trial results from a professional perspective. The current state of discussion regarding reimbursement of intracranial stenting is summarized. The second section contains a detailed comment on the current IQWiG report GA15-02 "Stents for the treatment of intracranial artery stenosis: VISSIT study and acute treatment in Germany".