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Proposed achievable levels of dose and impact of dose-reduction systems for thrombectomy in acute ischemic stroke: an international, multicentric, retrospective study in 1096 patients

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Abstract

Background

International dose reference levels are lacking for mechanical thrombectomy in acute ischemic stroke patients with large vessel occlusions. We studied whether radiation dose-reduction systems (RDS) could effectively reduce exposure and propose achievable levels.

Materials and methods

We retrospectively included consecutive patients treated with thrombectomy on a biplane angiography system (BP) in five international, high-volume centers between January 2014 and May 2017. Institutional Review Board approvals were obtained. Technical, procedural, and clinical characteristics were assessed. Efficacy, safety, radiation dose, and contrast load were compared between angiography systems with and without RDS. Multivariate analyses were adjusted according to Bonferroni’s correction. Proposed international achievable cutoff levels were set at the 75th percentile.

Results

Out of the 1096 thrombectomized patients, 520 (47%) were treated on a BP equipped with RDS. After multivariate analysis, RDS significantly reduced dose–area product (DAP) (91 vs 140 Gy cm2, relative effect 0.74 (CI 0.66; 0.83), 35% decrease, p < 0.001) and air kerma (0.46 vs 0.97 Gy, relative effect 0.63 (CI 0.56; 0.71), 53% decrease, p < 0.001) with 75th percentile levels of 148 Gy cm2 and 0.73 Gy, respectively. There was no difference in contrast load, rates of successful recanalization, complications, or clinical outcome.

Conclusion

Radiation dose-reduction systems can reduce DAP and air kerma by a third and a half, respectively, without affecting thrombectomy efficacy or safety. The respective thresholds of 148 Gy cm2 and 0.73 Gy represent achievable levels that may serve to optimize current and future radiation exposure in the setting of acute ischemic stroke treatment. As technology evolves, we expect these values to decrease.

Key Points

• Internationally validated achievable levels may help caregivers and health authorities better assess and reduce radiation exposure of both ischemic stroke patients and treating staff during thrombectomy procedures.

• Radiation dose-reduction systems can reduce DAP and air kerma by a third and a half, respectively, without affecting thrombectomy efficacy or safety in the setting of acute ischemic stroke due to large vessel occlusion.

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Abbreviations

AIS:

Acute ischemic stroke

BP:

Biplane angiosuite without radiation dose-reduction system

DAP:

Dose–area product

MCA:

Middle cerebral artery

mRS:

Modified Rankin Scale

MT:

Mechanical thrombectomy

mTICI:

Modified Thrombolysis In Cerebral Infarction

NIHSS:

National Institute of Health Stroke Scale

RDS:

Radiation dose-reduction system

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Acknowledgements

The authors acknowledge the professionalism, efficacy, and admirable work of both medical and non-medical workers in all five centers in radiology, neurology, and radiophysic departments which enabled this study.

Funding

The authors state that this work has not received any funding.

Author information

Author notes

  1. Adrien Guenego and Pascal J. Mosimann contributed equally to this work.

Authors and Affiliations

  1. Interventional Neuroradiology Department, Hôpital Pierre-Paul Riquet, Toulouse University Hospital, Place du Dr Baylac, TSA 40 031, 31059, Toulouse Cedex 9, France

    Adrien Guenego & Christophe Cognard

  2. Interventional and Diagnostic Neuroradiology, Bern, Switzerland

    Pascal J. Mosimann, Tomas Dobrocky & Jan Gralla

  3. Interventional and Diagnostic Neuroradiology, Toronto Western Hospital, Toronto, Canada

    Vitor Mendes Pereira & Patrick Nicholson

  4. Clinical Research Unit, Fondation Ophtalmologique Adolphe de Rothschild, Paris, France

    Kevin Zuber

  5. Stereotaxic Neurosurgery Department, Toulouse University Hospital, Toulouse, France

    Jean Albert Lotterie

  6. Interventional and Diagnostic Neuroradiology, Stanford Medical Center, Palo Alto, CA, USA

    David G. Marcellus, Max Wintermark & Jeremy J. Heit

  7. Vascular Neurology, Stroke Department, Toulouse University Hospital, Toulouse, France

    Jean Marc Olivot

  8. Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, France

    Michel Piotin & Robert Fahed

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Consortia

on behalf of the RADON Investigators

Contributions

RADON (RAdiation DOses in Neuro-thrombectomy) investigators:

Nestor Gonzalezi; Raphaël Blanch; Pasquale Mordasinib; Johannes Kaesmacherb; Eike Piechowiakb; Felix Ziboldb; Celina Ducrouxh; Fabrice Bonnevillea; Jean Darcourta; Ivan Vukasinovicj; Anne Christine Januela; Sylvie Monfraixk; Caterina Michelozzia; Philippe Talla; Mikael Mazighih; Blake W. Martinf; Elisa Guenegol; Fanny Carbilletm

(a)Interventional and Diagnostic Neuroradiology Department, Toulouse University Hospital, France

(b)Interventional and diagnostic Neuroradiology, Bern, Switzerland

(c)Interventional and Diagnostic Neuroradiology, Toronto Western Hospital, Toronto, Canada

(d)Clinical Research Unit, Fondation Ophtalmologique Adolphe de Rothschild, Paris, France

(e)Stereotaxic Neurosurgery Department, Toulouse University Hospital, France

(f)Interventional and Diagnostic Neuroradiology, Stanford Medical Center, CA, USA

(g)Vascular Neurology, Stroke Department, Toulouse University Hospital, France

(h)Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, France

(i)Neurosurgery and Interventional Neuroradiology Department, Cedars Sinai Hospital, USA

(j)Interventional Neuroradiology Department, Clinical Center of Serbia, Serbia

(k)Radiophysic Department, Toulouse University Hospital, France

(l)Anesthesiology Department, Toulouse University Hospital, France

(m)ALARA Expertise, Radiophysic Department, Strasbourg, France

Corresponding author

Correspondence to Adrien Guenego.

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Guarantor

The scientific guarantor of this publication is Prof. Christophe Cognard, MD.

Conflict of interest

The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

Statistics and biometry

One of the authors, Kevin Zuber, MSc, has significant statistical expertise.

Informed consent

Written informed consent was waived by the Institutional Review Board.

Ethical approval

Institutional Review Board approval was obtained.

Methodology

• retrospective

• observational

• multicenter study

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Guenego, A., Mosimann, P.J., Pereira, V.M. et al. Proposed achievable levels of dose and impact of dose-reduction systems for thrombectomy in acute ischemic stroke: an international, multicentric, retrospective study in 1096 patients. Eur Radiol 29, 3506–3515 (2019). https://doi.org/10.1007/s00330-019-06062-6

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