RPS 1111 - Neuro interventions and beyond

Author Block: A. Bani Sadr, J. Fournel, M. Hermier, N. Nighoghossian, Y. Berthezene; Lyon/FR
Purpose: Despite successful thrombectomy, most stroke patients experience infarct growth which negatively affect functional outcomes. Advances in oxygen metabolism mapping on admission dynamic-susceptibility contrast MRI have shown promise in assessing the viability of diffusion-weighted imaging (DWI) lesions. We aimed to assess the utility of oxygen metabolism mapping at the voxel scale in determining the fate of diffusion-mismatch regions following successful thrombectomy.
Methods or Background: We conducted a retrospective analysis of the HIBISCUS-STROKE cohort (NCT: 03149705), a single-center, observational study enrolling patients treated with thrombectomy between 2016 and 2022. Admission DSC-MRI was used to generate time-to-maximum (Tmax), cerebral blood volume (CBV), cerebral metabolic rate of oxygen (CMRO2), and oxygen extraction fraction (OEF) maps. In patients with successful reperfusion (modified Thrombolysis in Cerebral Infarction [mTICI] score ≥2B), Tmax ≥6s voxels excluding DWI abnormalities were analyzed on day 6 T2-fluid attenuated inversion recovery MRI. Semi-quantitative measurements of CMRO2, CBV, and OEF were extracted from regions identified as either necrotic or salvaged at follow-up.
Results or Findings: Among the 321 patients enrolled, 134 (41.7%) met inclusion criteria (median age 71.0 years; 58.2% male; median NIHSS score 15.0). In the training cohort, ROC analysis identified optimal thresholds for predicting necrosis: CBV (0.99), CMRO2 (0.64), and OEF (1.59). In the validation cohort, CMRO2 achieved an area under the curve (AUC) of 73.6% (95% confidence interval [CI]: 65.0–82.1), significantly outperforming CBV (AUC: 63.5%, 95% CI: 53.8–73.1; P=0.003) and OEF (AUC: 55.0%, 95% CI: 45.2–64.7; P=0.0005). Multivariable logistic regression revealed that CMRO2 <0.64 was independently associated with necrosis in diffusion-perfusion mismatch regions (OR: 6.0, 95% CI: 3.2–11.6, P<0.0001).
Conclusion: In acute stroke patients achieving successful thrombectomy, a CMRO2 < 0.64 in regions of diffusion-perfusion mismatch.
Limitations: DSC-MRI dervied oxygen metabolism mapping is not yet validated against PET
Funding for this study: This work was supported by the RHU MARVELOUS (ANR-16-RHUS-0009) of Université de Lyon, within the program “Investissements d'Avenir” operated by the French National Research Agency.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: The local ethics committee (Institutional Review Board No: 00009118) approved this study, and all participants or their relatives gave provided informed consent.

Author Block: R. Bruen¹, H. Briody¹, S. Singh¹, N. Healy², M. T. Crockett¹, J. Müller¹, S. O' Reilly¹, J. Thornton¹, P. Nicholson¹; ¹Dublin 9/IE, ²Dublin/IE
Purpose: Mechanical thrombectomy (MT) has revolutionized acute ischemic stroke care, demonstrating superior functional outcomes compared to intravenous t-PA alone. A substantial minority of patients fail to achieve successful recanalization. This study analyses the causes of unsuccessful MT in a large tertiary referral centre over an 11-year period.
Methods or Background: We retrospectively reviewed a prospective stroke registry at our institution, identifying all patients with acute ischemic stroke who underwent MT between January 2012-2023. Unsuccessful MT was defined as a post-interventional modified Thrombolysis in Cerebral Infarction (mTICI) score < 2b. We collected demographic data, NIHSS, ASPECTS, occlusion location, pre-MT alteplase administration and specific reasons for MT failure, categorizing them into three groups: Target not reached, Target reached but recanalization failed, and non-technical reasons.
Results or Findings: Of 2620 MT procedures performed, 259 (9.9%) were unsuccessful. The median patient age was 75 years (IQR 65-83), 48% (n=124) were female and the median NIHSS score was 16 (IQR 10-19). Occlusions were located in the anterior circulation in 98% of cases, with a median ASPECTS of 9. In Category 1 (n=48, 19%), non-reaching of the target was attributed to cervical artery tortuosity (n=23, 48%), challenging aortic arch anatomy (n=7, 14.6%) and inability to traverse a cervical occlusion (n=18, 37.5%). Category 2 failures were the most common (n=146, 56%) and were caused by unsuccessful microcatheter advancement beyond the occlusion (n=8, 5.4%), stent retriever and aspiration catheter failed recanalization (n=39, 26.7%), and spontaneous/iatrogenic re-occlusion (n=99, 67.8%). Category 3 (non-technical failures; n=62, 24%) were less common and were mainly due to patient neurological decline.
Conclusion: Unsuccessful mechanical thrombectomy was encountered in 9.9% of cases in our cohort. The most common reason was spontaneous/iatrogenic re-occlusion.
Limitations: Study was performed in a single site tertiary referral centre.
Funding for this study: None
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information: Retrospective data. No ethics required.

Author Block: S. Singh, P. Rohan, C. Leneghan, R. Bruen, M. T. Crockett, A. O'Hare, S. Power, J. Thornton, P. Nicholson; Dublin/IE
Purpose: To compare patient characteristics and outcomes following endovascular thrombectomy (EVT) for ischemic stroke between patients experiencing in-hospital stroke (IHS) and out-of-hospital stroke (OHS).
Methods or Background: A single-center, retrospective observational cohort study was conducted using data from the institutional EVT database at Beaumont Hospital. Patients were categorized as IHS or OHS, and their baseline characteristics and outcomes were compared.
Results or Findings: Of 2619 patients undergoing EVT, 383 (14.6%) experienced IHS (median age 72 years, 57% male) and 2235 (85.4%) experienced OHS (median age 72 years, 54% male). OHS patients had higher pre-stroke modified Rankin Scale (mRS) scores (p<0.0001) and were significantly more likely to receive intravenous thrombolysis (p<0.0001). IHS patients had higher median National Institutes of Health Stroke Scale (NIHSS) scores at day 1 (11 vs. 8, p=0.14) and day 5 (6 vs. 4, p=0.0586), although these differences were not statistically significant. IHS patients also had higher mRS scores at day 30 (p<0.0001) and day 90 (p<0.0001). OHS patients tended to have better Thrombolysis in Cerebral Infarction (TICI) scores post-revascularization (p=0.0535). Treatment was faster in the IHS group: onset to groin puncture (210 vs. 308 minutes, p<0.0001), onset to first reperfusion (243 vs. 341 minutes, p<0.0001). There was no significant difference in groin puncture to first reperfusion time (23 vs. 21 minutes, p=0.1367). IHS patients had a longer median EVT procedure time (37 vs. 32 minutes, p=0.0363).
Conclusion: Despite shorter time intervals to intervention, patients with IHS experienced worse functional outcomes after EVT compared to patients with OHS.
Limitations: N/A
Funding for this study: N/A
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: Approved by the local ethics committee at Beaumont Hospital, Dublin, Ireland

Author Block: A. Tsaoulia, M. Mantatzis, L. Kougias, A. Stoforiadi, P. K. Prassopoulos; Thessaloniki/GR
Purpose: The standard of care for patients with large vessel occlusion (LVO) is mechanical thrombectomy, with or without preceding thrombolysis. Patients with a large infarction core have a higher risk of reperfusion edema or hemorrhage. Alberta stroke program early computed tomography (ASPECTS) score is widely used to evaluate the extent of acute ischemic stroke at the middle cerebral artery territory. An extention of it is CTA-SI ASPECTS (CTAsp), which shows the collateral circulation and discriminates hypoperfused areas. However, it is not established whether this hypoperfusion depicts core or penumbra and if CTAsp is more accurate for patient selection. We aim to find a possible correlation between CTAsp and infarct core
Methods or Background: We analyzed the initial CT/CTAs of seven patients with LVO that had complete first pass recanalization and the CTAsp scores were calculated. All CT/CTAs were performed on a 16-slice SIEMENS Emotion-16. A non-contrast CT scan was obtained after thrombectomy, 24 and 48 hours later. These scans were performed on a 128-slice GE OPTIMA. Ten ROIS were applied in each hemisphere in areas defined by ASPECTS, to find density differences.
Results or Findings: The patients were divided into two groups based on CTAsp scores; 3 patients had a score of 6-7 and 4 with a score of 8-10. In two patients a discrepancy between ASPECTS and CTAsp was found. The final infarct core was associated with CTAsp in 6/7 patients, while in one, the hypodense area in CTAsp was normalized in follow up.
Conclusion: CTAsp proves to be helpful for attempting to predict which patients will have a good outcome after endovascular treatment.
Limitations: Small number of cases-preliminary results
Funding for this study: None
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information: The study is based on an imaging score from emergency obtained CT scans.

Author Block: D. Weiß, M. Vach, V. L. Ivan, S. Muhammad, B. Hofmann, M. Neyazi, B. Turowski, M. Kaschner; Düsseldorf/DE
Purpose: Flow-diversion has become a key treatment option for complex intracranial aneurysms. Recent advancements include coated flow-diverters (FD), designed to potentially reduce the need for dual antiplatelet therapy thereby removing the associated secondary risks, while maintaining patency and low complication rates. Comparing coated and uncoated FDs may offer insights into long-term outcomes and treatment optimization.
Methods or Background: In this retrospective single-center study, we investigated the data of 21 consecutive patients with cerebral aneurysms, treated between 2021 and 2023 with the coated Derivo 2heal Embolization Device (D2H) and the uncoated Derivo Embolization Device (DED) (both Acandis, Pforzheim, Germany). We described the procedure and analyzed clinical and radiological data, along with long-term outcomes after 18 months of follow-up.
Results or Findings: Nine patients (42.9%) had incidental, while 12 (57.1%) had symptomatic aneurysms, including ten with WFNS IV subarachnoid hemorrhages. Aneurysm locations included mostly the internal carotid (n=9) and the vertebral artery (n=7). All FDs were successfully deployed: 11 patients received the coated device and 10 the uncoated device. After 18 months, 73.3% patients had favorable outcomes (mRS 0-2). One coated FD occluded asymptomatically after six months, and one uncoated FD occluded immediately but could be recanalized.
Conclusion: We observed favorable occlusion rates for both coated and uncoated FDs. The role of dual antiplatelet therapy remains debated. Large multicenter studies are essential to evaluate the patency of coated compared to uncoated FDs and determine whether they can reduce thrombogenicity, potentially allowing for less or no antiplatelet therapy in emergencies.
Limitations: Unequal distribution of emergency and elective treatments. Limited by both the number of patients. The study does not address whether monotherapy would be sufficient for drug-coated stents.
Funding for this study: None
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: Local ethics committee of medical faculty

Author Block: D. Xie, Z. Lai, H. Ma, R. Xu, J. Wu, J. Zhao; Guangzhou/CN
Purpose: To assess the feasibility and effect of CT black blood technique in the post-treatment follow-up of intracranial aneurysms treated with flow-diverting stents.
Methods or Background: A retrospective analysis was conducted on 18 patients who underwent treatment with flow-diverting stents for intracranial aneurysms and subsequently underwent digital subtraction angiography (DSA) follow-up. All patients underwent CT angiography (CTA) examination before DSA. The contrast-enhancement boost technique was employed to process CTA images to obtain CT black blood images. Two radiologists independently rated the image quality and diagnostic confidence for stent-related stenosis on both conventional CTA and CT black blood images using a 4-point scale. The performance of conventional CTA and CT black blood in diagnosing stent-related stenosis was compared, and the examination time and radiation dose of CTA and DSA were recorded and compared.
Results or Findings: Subjective ratings of image quality and diagnostic confidence for stent-related stenosis were significantly higher for CT black blood images compared to conventional CTA images (3.94±0.23 vs. 3.06±0.62 and 3.89±0.31 vs. 2.83±0.6, respectively; all p＜0.01). DSA detected 2 cases of distal stenosis and 5 cases of overall stenosis within the stent. Compared to conventional CTA (sensitivity: 100%, specificity: 36.4%, accuracy: 61.1%), CT black blood demonstrated significantly improved performance in detecting stent-related stenosis, with diagnostic sensitivity, specificity, and accuracy all reaching 100%, and perfect inter-observer agreement (k=1.0). Regarding radiation dose, the average radiation dose for conventional CTA was (67.85±8.31) mGy, whereas the radiation dose required for DSA significantly increased to (516.81±193.83) mGy (p＜0.001). The examination times for CT and DSA were (3.53±0.74) minutes and (9.57±8.26) minutes, respectively(p＜0.01).
Conclusion: The CT black blood technique shows potential as the preferred method for post-treatment follow-up of intracranial aneurysms treated with flow-diverting stents.
Limitations: Sample size was relatively small.
Funding for this study: None
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: None

Author Block: I. Požar¹, F. F. Bajrović², L. Umek², K. Šurlan Popović²; ¹Izola/SI, ²Ljubljana/SI
Purpose: This study aimed to evaluate the predictive value of automatically assessed collateral circulation (CC) and infarct core for functional outcome in acute ischemic stroke (AIS) patients treated with endovascular thrombectomy (EVT).
Methods or Background: We conducted a retrospective cohort study of 208 patients with anterior large vessel occlusion treated with EVT. Two AI-powered software were used to automatically assess CC and infarct core. Comparative analyses included patient demographics, clinical and imaging data, and functional outcome. Univariate and multivariable logistic regression analyses were conducted to predict the 90-day functional outcome. A favorable outcome was defined as a modified Rankin scale (mRS) score≤2.
Results or Findings: Among the 208 patients, 114 (54.8%) were women and 94 were men, with a mean age of 71.4±13.3 years. Patients with higher collateral score (CS) exhibited lower infarct core volumes (p<0.001) and better mRS score at 90 days (p=0.008). Among patients with a favorable outcome, the mean infarct core volume was lower compared to those with poor outcomes (5 mL vs. 8.6 mL, p=0.003). In univariate logistic regression, both infarct core (OR 0.94, p=0.005) and CC (OR 1.84, p=0.014) were predictors of favorable outcome. However, in multivariable models, only infarct core remained a significant independent predictor [AORs of 0.95 (p=0.021) and 0.96 (p=0.039)].
Conclusion: Automatically assessed infarct core is a robust predictor of functional outcome in AIS patients post-EVT, while CC's predictive value diminishes when adjusted for infarct core. These findings support the integration of AI-powered evaluations in clinical settings to improve prognosis and treatment strategies for AIS.
Limitations: Our study's limitations include using a 40-slice CT scanner, which affects data acquisition speed, particularly in perfusion; non-blinded assessments potentially introducing bias; and reliance on a single CS evaluation, which could lead to inaccurate data.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: The study was approved by the National Medical Ethics Committee of the Republic of Slovenia (No. 0120-377/2019/4).

Author Block: M. Guettier, H. Biegalski, R. Lopes, J. Dumont, W. Gorwood, H. Henon, N. Bricout, G. Kuchcinski, M. Bretzner; Lille/FR
Purpose: Relative brain age (RBA) is a novel MRI-derived biomarker that quantifies brain health relative to other patients within a cohort. It has previously been associated with poorer outcomes in untreated ischemic stroke patients. However, its impact on poststroke outcomes in patients treated with mechanical thrombectomy (MT) remains unclear.We investigated the clinical determinants of RBA and its association with poststroke outcomes in patients treated with MT
Methods or Background: We conducted a retrospective analysis of clinical and imaging data from stroke patients admitted to Lille University Hospital for anterior circulation MT between 2015 and 2020. Admission axial T2 FLAIR MRI images were used to obtain brain parcellation data. A modified brain age prediction pipeline was applied to estimate brain age and derive RBA. Linear regression was used to identify cardiovascular risk factors associated with higher RBA, while logistic regression was employed to assess the impact of RBA on post-stroke outcomes.
Results or Findings: A total of 1,296 patients were included, with a mean age of 70 years; 54% were women. Patients with a history of diabetes mellitus and smoking had significantly higher RBA, indicating older-appearing brains (p=0.001 and p=0.010, respectively). Univariate analysis showed that patients with higher RBA, reflecting poorer brain health, were less likely to achieve favorable functional outcomes after stroke (p=0.027). In multivariate analysis, several factors, including age, RBA, admission NIHSS score, intravenous thrombolysis, successful MT, glycemia, time from imaging to MT, and MT duration, were significantly associated with post-stroke outcomes (adjusted odds ratios: 0.48, 0.80, 0.48, 2.04, 5.72, 0.75, 0.81, and 0.69, respectively).
Conclusion: Our study highlights the influence of smoking and diabetes on brain aging and the detrimental effects of poor brain health on post-stroke outcomes, building on decades of clinical knowledge.
Limitations: Retrospective data
Funding for this study: This study has been funded by the ESR/EIBIR 2022 Seed Grant.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: The ethical committee (Comité de protection des personnes Nord-Ouest IV) classified the study as observational on March 9, 2010, and the committee protecting personal information of the patient approved the study by December 21, 2010 (n°10.677). Anonymized data supporting the findings of this study are available from the corresponding author upon reasonable request.

Author Block: N. Tan, X. Zhou; Kunming/CN
Purpose: To analyze the incidence and anatomic distribution of acute cerebral embolism and identify associated risk factors in patients undergoing interventional cardiac catheterization.
Methods or Background: We conducted a prospective study of patients from two cohorts between January 2023 and April 2024. Diffusion-weighted magnetic resonance imaging (DW-MRI) was used to detect silent brain infarcts (SBIs) preoperatively and within 48 hours postoperatively. For transcatheter aortic valve implantation (TAVI) patients, a cerebral embolic protection device (CEPD, model CEP016F) was randomly employed to minimize the risk of small emboli entering the cerebral vasculature. In atrial fibrillation ablation procedures, some patients underwent Vein of Marshall Ethanol Infusion (VOMEt) to decrease the recurrence of atrial fibrillation and prevent the formation of new embolic events. Independent risk factors were identified through multivariate logistic regression analysis.
Results or Findings: Silent brain infarcts were detected in 34 of 48 patients (70.8%) within 48 hours postoperatively. Among the patients who used CEPDs (n = 12), 7 (56.8%) found SBIs. Patients who used CEPDs showed a trend toward smaller infarct volumes ( 5.32 cm³ vs. 8.11 cm³; P = 0.07). In patients who underwent VOMEt procedures (n = 20), 13 (65.0%) developed SBIs; however, neither the incidence nor the volume of SBIs showed significant differences compared to those who did not undergo VOMEt. Multivariate logistic regression analysis identified operation time as an independent positive predictor of SBIs (odds ratios, 6.190 and 13.564; both P < .001).
Conclusion: Silent brain infarcts were detected in 70.8% of patients undergoing interventional cardiac catheterization, predominantly affecting the parietal lobes. These findings highlight the importance of procedural optimization to reduce cerebral embolic risk.
Limitations: The study was with a relatively small simple size, and conducted at a single center.
Funding for this study: No
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: Kunming Yan’an Hospital Ethics Committee

Author Block: P. Reidler, O. Öcal, J. Ricke, D. Puhr-Westerheide, M. P. Fabritius; Munich/DE
Purpose: Contrast staining (CS) signifies prolonged tissue absorption of iodinated contrast media following endovascular therapy (EVT) for large vessel occlusion stroke, indicating blood-brain barrier disruption. With EVT becoming the standard for treating basilar artery occlusion (BAO) stroke, our study aimed to determine the prognostic significance of post-interventional CS in BAO stroke cases.
Methods or Background: We included BAO patients who received postinterventional noncontrast CT within 24h after EVT. Expert radiologists confirmed the presence of CS on CT and its volume was quantified. Functional outcomes were assessed on the modified Rankin (mRS) scale at 90 days and unfavorable outcome was defined as mRS ≥4. A multivariable LASSO-penalized logistic regression analysis was used to determine association of CS and other clinical and imaging parameters with functional outcome.
Results or Findings: 42 patients fulfilled the inclusion criteria (15 female, 35,7%). CS on postinterventional CT was present in 18 patients (42.9%) with a median [interquartile range / IQR] volume of 7.9 mL [3.7-14.6]. Patients with CS had a worse outcome with higher mRS after 90 days (median [IQR]: 6 [4-6] vs. 2 [1-4], p<0.001). Multivariable LASSO analysis revealed significant and strongest association of CS with clinical outcome.
Conclusion: CS on postinterventional CT after EVT for BAO is an independent predictor of unfavorable functional outcome, outperforming other pre- and post-interventional imaging parameters.
Limitations: Retrospective, small sample size
Funding for this study: None
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: LMU Munich

Author Block: C. Leneghan¹, D. Leneghan², P. Nicholson¹, S. Singh¹, J. Thornton¹, M. T. Crockett¹, A. O'Hare¹, J. Müller¹, P. Fearon¹; ¹Dublin/IE, ²Lucerne/CH
Purpose: This study compares clinical presentations, outcomes, and procedural aspects of endovascular thrombectomy (EVT) in young adults (18-49 years) versus older adults (≥50 years) with acute ischemic stroke due to intracranial artery occlusion (IAO).
Methods or Background: We analysed data from a prospectively maintained registry of patients treated with EVT in a large tertiary referral centre between 2012 and 2022. Young (18-49) and older (≥50) patients were compared regarding baseline characteristics, 30- and 90-day modified Rankin Scale (mRS), 24-hour and 5-day NIHSS, reperfusion success (mTICI), post-EVT ASPECTS, and 90-day mortality.
Results or Findings: Of 2201 patients, 243 (11%) were young adults. Young patients presented with lower median pre-treatment ASPECTS (8 vs. 9, p=0.0008). Older patients had higher NIHSS at 24 hours (OR 1.63, 95% CI 1.07-2.46), but no difference was observed at 5 days. Functional dependence (mRS ≥3) was more frequent in older patients at 30 (OR 1.92, 95% CI 1.45-2.53) and 90 days (OR 2.22, 95% CI 1.66-2.97). Mortality at 90 days was lower in younger patients (OR 0.45, 95% CI 0.28-0.70).
Conclusion: Younger patients undergoing EVT for IAO have lower initial ASPECTS but demonstrate faster neurological recovery and improved functional outcomes compared to older patients. This suggests that aggressive EVT is warranted even in younger patients with lower ASPECTS.
Limitations: Retrospective design, single-centre study.
Funding for this study: No specific funding was received for this study.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: The study was approved by the local clinical audit committee.

Author Block: M. T. Contaldo, A. Cervo, A. Macera, C. Rollo, A. Vitiello, G. Pero, G. Schwarz, M. Sessa, M. Piano; Milan/IT
Purpose: Cerebral venous thrombosis (CVT) is a rare cause of stroke, that tends to affect young people and the role of endovascular treatment (EVT) remains debated. This study aims to evaluate the efficacy and safety of mechanical thrombectomy (MT) performed at our center for dural sinus thrombosis.
Methods or Background: Within a retrospective observational analysis conducted over a 6-year period, data from 62 patients referred to the stroke unit for CVT were analyzed. Among them, 32 patients, classified with severe CVT, underwent EVT. We assessed safety by examining intraprocedural and periprocedural adverse events (asymptomatic, mild, or severe). Clinical outcomes were evaluated at baseline and discharge. Efficacy was determined by analyzing the recanalization rate (complete, partial, or absent) at the end of the procedure.
Results or Findings: A total of 32 patients received EVT, accounting for 36 procedures. EVT with MT was performed within 6 hours from onset in 21 out of 32 cases. In most cases, MT was performed as primary treatment, alongside best medical therapy. An intravenous bolus of heparin was administered in the angio-suite to patients who had not yet received anticoagulants or thrombolytics.
Successful recanalization (complete or partial without cortical venous drainage delay) was achieved in 91.3% of procedures. CVT recurrence occurred in 3 out of 36 procedures. Mortality rate was 3.1%.
Conclusion: This is one of the largest series of patients treated with MT in combination with best medical therapy, underscoring the favorable safety and efficacy profile of EVT. MT could be a first-line option for multiple dural sinus thrombosis, rapid deterioration, venous hypertension, or anticoagulant failure.
Limitations: This study is a single center experience with no control-group and a retrospective design, with a heterogeneous case-by-case patient selection.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information: Not applicable