Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress 2023 EHA Congress 2023 ASCO Annual Meeting
Clinical Collections
Advances in Alzheimer’s

Keynote webinar | Spotlight on sleep in brain health

LIVE: Thursday 2nd May 2024, 18:00-19:30 (CEST)

Quality sleep is essential for health. But what happens to our brains when sleep patterns are disturbed? Join our experts to explore the interplay between sleep disruption and neurological diseases, and the questions that you need to be asking your patients to help you prevent the harmful effects of sleep deprivation.
ADVANCED SEARCH
Log in
Top
Clinical Neuroradiology
Published in: Clinical Neuroradiology 3/2023

Open Access 01-06-2023 | Carotid Stenosis | Original Article

Radiation Dose and Fluoroscopy Time of Extracranial Carotid Artery Stenting

Elective vs. Emergency Treatment Including Combined Mechanical Thrombectomy in Tandem Occlusion

Authors: Robert Forbrig, Yigit Ozpeynirci, Thomas David Fischer, Christoph G. Trumm, Thomas Liebig, Robert Stahl

Published in: Clinical Neuroradiology | Issue 3/2023

Login to get access

Abstract

Purpose

Fluoroscopically guided endovascular carotid artery stenting (CAS) of extracranial carotid stenosis (ECS) is a reasonable alternative to carotid endarterectomy in selected patients. Diagnostic reference levels (DRL) for this common neurointervention have not yet been defined and respective literature data are sparse. We provide detailed dosimetrics for useful expansion of the DRL catalogue.

Methods

A retrospective single-center study of patients undergoing CAS between 2013 and 2021. We analyzed dose area product (DAP) and fluoroscopy time considering the following parameters: indications for CAS, semielective/elective versus emergency including additional mechanical thrombectomy (MT) in extracranial/intracranial tandem occlusion, etiology of ECS (atherosclerotic vs. radiation-induced), periprocedural features, e.g., number of applied stents, percutaneous transluminal angioplasty (PTA) and MT maneuvers, and dose protocol. Local DRL was defined as 75% percentile of the DAP distribution.

Results

A total of 102 patients were included (semielective/elective CAS n = 75, emergency CAS n = 8, CAS + MT n = 19). Total median DAP was 78.2 Gy cm2 (DRL 117 Gy cm2). Lowest and highest median dosimetry values were documented for semielective/elective CAS and CAS + MT (DAP 49.1 vs. 146.8 Gy cm2, fluoroscopy time 27.1 vs. 43.8 min; p < 0.005), respectively. Dosimetrics were significantly lower in patients undergoing 0–1 PTA maneuvers compared to ≥ 2 maneuvers (p < 0.05). Etiology of ECS, number of stents and MT maneuvers had no significant impact on dosimetry values (p > 0.05). A low-dose protocol yielded a 33% reduction of DAP.

Conclusion

This CAS study suggests novel local DRLs for both elective and emergency cases with or without intracranial MT. A dedicated low-dose protocol was suitable for substantial reduction of radiation dose.
Literature
1.
Brott TG, Hobson RW 2nd, Howard G, Roubin GS, Clark WM, Brooks W, Mackey A, Hill MD, Leimgruber PP, Sheffet AJ, Howard VJ, Moore WS, Voeks JH, Hopkins LN, Cutlip DE, Cohen DJ, Popma JJ, Ferguson RD, Cohen SN, Blackshear JL, Silver FL, Mohr JP, Lal BK, Meschia JF. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med. 2010;363:11–23.CrossRefPubMedPubMedCentral
2.
Eckstein HH, Kühnl A, Berkefeld J, Lawall H, Storck M, Sander D. Diagnosis, treatment and follow-up in extracranial carotid stenosis. Dtsch Arztebl Int. 2020;117:801–7.PubMedPubMedCentral
3.
Eckstein HH, Ringleb P, Allenberg JR, Berger J, Fraedrich G, Hacke W, Hennerici M, Stingele R, Fiehler J, Zeumer H, Jansen O. Results of the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE) study to treat symptomatic stenoses at 2 years: a multinational, prospective, randomised trial. Lancet Neurol. 2008;7:893–902.CrossRefPubMed
4.
Müller MD, Lyrer PA, Brown MM, Bonati LH. Carotid artery stenting versus endarterectomy for treatment of carotid artery stenosis. Stroke. 2021;52:e3–e5.CrossRefPubMed
5.
6.
7.
Willinsky RA, Taylor SM, TerBrugge K, Farb RI, Tomlinson G, Montanera W. Neurologic complications of cerebral angiography: prospective analysis of 2,899 procedures and review of the literature. Radiology. 2003;227:522–8.CrossRefPubMed
8.
Acton H, James K, Kavanagh RG, O’Tuathaigh C, Moloney D, Wyse G, Fanning N, Maher M, O’Connor OJ. Monitoring neurointerventional radiation doses using dose-tracking software: implications for the establishment of local diagnostic reference levels. Eur Radiol. 2018;28:3669–75.CrossRefPubMed
9.
Aroua A, Rickli H, Stauffer JC, Schnyder P, Trueb PR, Valley JF, Vock P, Verdun FR. How to set up and apply reference levels in fluoroscopy at a national level. Eur Radiol. 2007;17:1621–33.CrossRefPubMed
10.
D’Ercole L, Thyrion FZ, Bocchiola M, Mantovani L, Klersy C. Proposed local diagnostic reference levels in angiography and interventional neuroradiology and a preliminary analysis according to the complexity of the procedures. Phys Med. 2012;28:61–70.CrossRefPubMed
11.
Farah J, Rouchaud A, Henry T, Regen C, Mihalea C, Moret J, Spelle L. Dose reference levels and clinical determinants in stroke neuroradiology interventions. Eur Radiol. 2019;29:645–53.CrossRefPubMed
12.
Forbrig R, Ozpeynirci Y, Grasser M, Dorn F, Liebig T, Trumm CG. Radiation dose and fluoroscopy time of modern endovascular treatment techniques in patients with saccular unruptured intracranial aneurysms. Eur Radiol. 2020;30:4504–13.CrossRefPubMedPubMedCentral
13.
Guenego A, Mosimann PJ, Pereira VM, Nicholson P, Zuber K, Lotterie JA, Dobrocky T, Marcellus DG, Olivot JM, Piotin M, Gralla J, Fahed R, Wintermark M, Heit JJ, Cognard C. 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. 2019;29:3506–15.CrossRefPubMed
14.
Hassan AE, Amelot S. Radiation exposure during neurointerventional procedures in modern biplane angiographic systems: a single-site experience. Interv Neurol. 2017;6:105–16.CrossRefPubMedPubMedCentral
15.
Kien N, Rehel JL, Etard C, Aubert B. Dose patient en neuroradiologie interventionnelle: bilan d’une enquête multicentrique [Patient dose during interventional neuroradiology procedures: Results from a multi-center study]. J Radiol. 2011;92:1101–12.CrossRefPubMed
16.
Söderman M, Mauti M, Boon S, Omar A, Marteinsdóttir M, Andersson T, Holmin S, Hoornaert B. Radiation dose in neuroangiography using image noise reduction technology: a population study based on 614 patients. Neuroradiology. 2013;55:1365–72.CrossRefPubMedPubMedCentral
17.
van der Marel K, Vedantham S, van der Bom IM, Howk M, Narain T, Ty K, Karellas A, Gounis MJ, Puri AS, Wakhloo AK. Reduced patient radiation exposure during neurodiagnostic and Interventional X‑Ray angiography with a new imaging platform. AJNR Am J Neuroradiol. 2017;38:442–9.CrossRefPubMedPubMedCentral
18.
Shimizu T, Toyota S, Nakagawa K, Murakami T, Kumagai T, Mori K, Taki T. Reduction of radiation exposure using low pulse rate fluoroscopy during neuroendovascular surgery. Interv Neuroradiol. 2021;27:314–20.CrossRefPubMed
19.
Stanišić MG, Majewska N, Makałowski M, Juszkat R, Błaszak M, Majewski W. Patient radiation exposure during carotid artery stenting. Vascular. 2015;23:154–60.CrossRefPubMed
20.
Majewska N, Blaszak MA, Juszkat R, Frankiewicz M, Makalowski M, Majewski W. Patients’ radiation doses during the implantation of stents in carotid, renal, iliac, femoral and popliteal arteries. Eur J Vasc Endovasc Surg. 2011;41:372–7.CrossRefPubMed
21.
Swerdlow NJ, Jones DW, Pothof AB, O’Donnell TFX, Liang P, Li C, Wyers MC, Schermerhorn ML. Three-dimensional image fusion is associated with lower radiation exposure and shorter time to carotid cannulation during carotid artery stenting. J Vasc Surg. 2019;69:1111–20.CrossRefPubMed
22.
D’Ercole L, Quaretti P, Cionfoli N, Klersy C, Bocchiola M, Rodolico G, Azzaretti A, Lisciandro F, Cascella T, Zappoli Thyrion F. Patient dose during carotid artery stenting with embolic-protection devices: evaluation with radiochromic films and related diagnostic reference levels according to factors influencing the procedure. Cardiovasc Intervent Radiol. 2013;36:320–9.CrossRefPubMed
23.
Castaño C, Dorado L, Guerrero C, Millán M, Gomis M, Perez de la Ossa N, Castellanos M, García MR, Domenech S, Dávalos A. Mechanical thrombectomy with the Solitaire AB device in large artery occlusions of the anterior circulation: a pilot study. Stroke. 2010;41:1836–40.CrossRefPubMed
24.
Zaidat OO, Yoo AJ, Khatri P, Tomsick TA, von Kummer R, Saver JL, Marks MP, Prabhakaran S, Kallmes DF, Fitzsimmons BF, Mocco J, Wardlaw JM, Barnwell SL, Jovin TG, Linfante I, Siddiqui AH, Alexander MJ, Hirsch JA, Wintermark M, Albers G, Woo HH, Heck DV, Lev M, Aviv R, Hacke W, Warach S, Broderick J, Derdeyn CP, Furlan A, Nogueira RG, Yavagal DR, Goyal M, Demchuk AM, Bendszus M, Liebeskind DS. Recommendations on angiographic revascularization grading standards for acute ischemic stroke: a consensus statement. Stroke. 2013;44:2650–63.CrossRefPubMedPubMedCentral
25.
Miller DL, Balter S, Cole PE, Lu HT, Schueler BA, Geisinger M, Berenstein A, Albert R, Georgia JD, Noonan PT, Cardella JF, St George J, Russell EJ, Malisch TW, Vogelzang RL, Miller GL 3rd, Anderson J. Radiation doses in interventional radiology procedures: the RAD-IR study: part I: overall measures of dose. J Vasc Interv Radiol. 2003;14:711–27.CrossRefPubMed
26.
Vañó E, Miller DL, Martin CJ, Rehani MM, Kang K, Rosenstein M, Ortiz-López P, Mattsson S, Padovani R, Rogers A. Authors on behalf of ICRP. ICRP publication 135: diagnostic reference levels in medical imaging. Ann ICRP. 2017;46:1–144.CrossRefPubMed
27.
28.
29.
30.
Werncke T, Kemling M, Tashenov S, Hinrichs JB, Meine TC, Maschke SK, Kyriakou Y, Wacker FK, Meyer BC. Comparison of a contrast-to-noise ratio-driven exposure control and a regular detector dose-driven exposure control in abdominal imaging in a clinical angiography system. Med Phys. 2021;48:7641–56.CrossRefPubMed
Metadata
Title
Radiation Dose and Fluoroscopy Time of Extracranial Carotid Artery Stenting
Elective vs. Emergency Treatment Including Combined Mechanical Thrombectomy in Tandem Occlusion
Authors
Robert Forbrig
Yigit Ozpeynirci
Thomas David Fischer
Christoph G. Trumm
Thomas Liebig
Robert Stahl
Publication date
01-06-2023
Publisher
Springer Berlin Heidelberg
Published in
Clinical Neuroradiology / Issue 3/2023
Print ISSN: 1869-1439
Electronic ISSN: 1869-1447
DOI
https://doi.org/10.1007/s00062-023-01288-w

Other articles of this Issue 3/2023

Clinical Neuroradiology 3/2023 Go to the issue

Clinical Case

Freiburg Neuropathology Case Conference

Original Article

Preoperative Embolization of Meningiomas Facilitates Reduced Surgical Complications and Improved Clinical Outcomes

Editorial

Farewell to Companions

Original Article

Dual-Energy Computed Tomography in Stroke Imaging

Original Article

Location-specific ASPECTS does not improve Outcome Prediction in Large Vessel Occlusion compared to Cumulative ASPECTS

Original Article

Prone Dynamic CT Myelography in Spontaneous Intracranial Hypotension