Abstract
ObjectiveTo quantify radiation exposure (RE) of endovascular stroke treatment (EST) in the anterior circulation per thrombectomy attempt and determine causes for interventions associated with high RE.MethodsA retrospective single-center study of an institutional review board−approved stroke database of patients receiving EST for large vessel occlusions in the anterior circulation between January 2013 and April 2018 to evaluate reference levels (RL) per thrombectomy attempt. ESTs with RE above the RL were analyzed to determine causes for high RE.ResultsOverall, n = 544 patients (occlusion location, M1 and M2 segments of the middle cerebral artery 53.5% and 27.2%, carotid artery 17.6%; successful recanalization rate 85.7%) were analyzed. In the overall population, DAP (in Gy cm2, median (IQR)) was 113.7 (68.9–181.7) with a median fluoroscopy time of 31 min (IQR, 17–53) and a median of 2 (IQR, 1–4) thrombectomy attempts. RE increased significantly with every thrombectomy attempt (DAP1, 68.7 (51.2–106.8); DAP2, 106.4 (84.8–115.6); p value1vs2, < 0.001; DAP3, 130.2 (89.1–183.6); p value2vs3, 0.044; DAP4, 169.9 (128.4–224.1); p value3vs4, 0.001; and DAP5, 227.6 (146.3–294.6); p value4vs5, 0.019). Procedures exceeding the 90th percentile of the attempt-dependent radiation exposure level were associated with procedural complications (n = 17/52, 29.8%) or a difficult vascular access (n = 8/52, 14%).ConclusionsRadiation exposure in endovascular stroke treatment is depending on the number of thrombectomy attempts. Radiation exposure doubles when three attempts and triples when five attempts are necessary compared with single-maneuver interventions. Procedural complications and difficult vascular access were associated with a high radiation exposure in this collective.Key Points• Radiation exposure of endovascular stroke treatment (EST) is dependent on the number of thrombectomy attempts.• Reference levels as means for quality control in hospitals performing endovascular stroke treatment should be defined by the number of thrombectomy attempts—we suggest 107 Gy cm2, 156 Gy cm2, 184 Gy cm2, 244 Gy cm2, and 295 Gy cm2for 1 to 5 maneuvers, respectively, for EST of the anterior circulation• Cases with high rates of radiation exposure are associated with periprocedural complications and difficult anatomical access as a probable cause for a high radiation exposure.
Highlights
MethodsIntroductionRadiation exposure by ionizing radiation is a key concern in modern diagnostic radiology with a high physician and patient awareness mainly due to potential relative cancer risk for both parties [1, 2]
Reference levels as means for quality control in hospitals performing endovascular stroke treatment should be defined by the number of thrombectomy attempts—we suggest 107 Gy cm2, 156 Gy cm2, 184 Gy cm2, 244 Gy cm2, and 295 Gy cm2 for 1 to 5 maneuvers, respectively, for EST of the anterior circulation
We report radiation exposure during EST in the anterior circulation and derive reference levels depending on the number of thrombectomy attempts for 1 to 5 ESTattempts from the so far largest single-center patient cohort (n = 544)
Summary
IntroductionRadiation exposure by ionizing radiation is a key concern in modern diagnostic radiology with a high physician and patient awareness mainly due to potential relative cancer risk for both parties [1, 2]. As the radiological and neuroradiological CT imaging increased in the last decades, a great effort is made by CT manufacturers, technicians, and physicians to lower radiation exposure [3, 4]. In the 1990s, the term dose reference level (DRL) emerged to control radiation exposure in radiological departments. DRLs showed to effectively control and reduce the radiation exposure for diagnostic imaging [5]. The number of EST procedures is increasing worldwide [7, 8]. With increasing numbers of neurointerventional procedures, the interest in tracking and controlling radiation exposure during neuro-interventions is growing [9, 10]. Following the 7-metric managing approach of the society of vascular and interventional neurology, which includes the control of radiation exposure as the seventh metric, is discussed [11]
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