K G Terbrugge

Mahidol University, Krung Thep, Bangkok, Thailand

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Publications (151)424.11 Total impact

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    ABSTRACT: To report the epidemiological features, clinical presentation, angiographic characteristics and therapeutic options, success and complication rates in patients with dural carotid cavernous fistulas (dural CCFs).
    European radiology. 07/2014;
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    ABSTRACT: As a result of the rarity of spinal cord arteriovenous malformations (AVM), there are only a few series available that describe clinical features, outcome after treatment, and natural history of these lesions. In this article, we aim to describe our experience with both nidus- and fistulous-type spinal cord AVMs.
    07/2014;
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    ABSTRACT: The purpose of this study was to determine the accuracy and utility of contrast-enhanced MR angiography (CE-MRA) in spinal dural arteriovenous fistulas (SDAVF).
    European radiology. 07/2014;
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    ABSTRACT: To describe pregnancy outcomes in women with hereditary hemorrhagic telangiectasia (HHT). This was a retrospective descriptive study of women with HHT (18-55 years of age) from the Toronto HHT Database using a telephone questionnaire regarding pregnancy, delivery, and neonatal outcomes. A total of 244 pregnancies were reported in 87 women with HHT. Miscarriages occurred in 20%. Hereditary hemorrhagic telangiectasia-related complications included minor hemoptysis during two pregnancies (1.1%) and hemothorax during four pregnancies (2.1%). One patient presenting with a hemothorax had presented during a previous pregnancy with a transient ischemic attack, most likely resulting from paradoxical emboli. One patient presented with an intracranial hemorrhage, and one patient presented with heart failure. These complications occurred in women previously unscreened and untreated for arteriovenous malformations. Other complications not clearly related to HHT were deep vein thrombosis (n=1), pulmonary embolism (n=1), myocardial infarction (n=1), and myocardial ischemia (n=1). Women noticed an increased frequency of epistaxis and development of new telangiectases during pregnancy. Epidural or spinal anesthesia was performed in 92 of 185 deliveries (50%) without complications. None of these women had undergone screening for spinal arteriovenous malformation before anesthesia. Women with HHT who have not been screened for arteriovenous malformations are at risk for serious pregnancy complications. LEVEL OF EVIDENCE:: III.
    Obstetrics and Gynecology 02/2014; · 4.80 Impact Factor
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    ABSTRACT: Unfortunately, two of the authors names, Dae Chul Suh and Michael Soderman, were incorrectly listed as Dae Sul Chuh instead of Dae Chul Suh and Michael Soderman instead of Michael Söderman in the original publication of this paper.
    Interventional Neuroradiology 12/2013; 19(4):519. · 0.77 Impact Factor
  • The Canadian journal of neurological sciences. Le journal canadien des sciences neurologiques 11/2013; 40(6):807-813. · 1.33 Impact Factor
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    ABSTRACT: Despite improvements of embolization agents and techniques, endovascular treatment of spinal dural arterovenous fistula (SDAVF) is still limited by inconsistent success. The aim of embolization is to occlude initial portion of the draining vein by liquid embolic materials. This study investigates factors that contribute to the success of embolization treatments among SDAVF patients. We performed a retrospective analysis on consecutive SDAVF patients who received N-butyl cyanoacrylate (NBCA) glue embolization between January 1992 and June 2012. Univariable and multivariable logistic regression analyses were performed to calculate the probability of successful draining vein occlusion for variable procedure-related factors. We attempted endovascular approach as the first intention treatment in 66 out of 90 consecutive patients. Among them, a total of 43 NBCA glue injections were performed in 40 patients. Successful embolization was achieved in 24 patients (60 %). In multivariable analyses, antegrade flow during microcatheter test injection (OR 13.2, 95 % CI 1.7 to 105.4) and use of glue concentration ≥30 % (OR 0.1, 95 % CI 0.01 to 0.8) were detected as significant positive and negative predictors of successful venous penetration, respectively. With persistent antegrade flow, the success rates using a glue mixture of more than 30 % dropped significantly from 85.0 to 42.9 % (p = 0.049). If contrast stagnated during microcatheter injections, success rates were low regardless of glue concentrations. Presence of antegrade flow toward the draining vein and injection of NBCA glue less than 30 % are associated with higher chance of draining vein penetration and, therefore, successful endovascular SDAVF obliteration.
    Neuroradiology 10/2013; · 2.70 Impact Factor
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    ABSTRACT: Interventional Neuroradiology (INR) is not bound by the classical limits of a speciality, and is not restricted by standard formats of teaching and education. Open and naturally linked towards neurosciences, INR has become a unique source of novel ideas for research, development and progress allowing new and improved approaches to challenging pathologies resulting in better anatomo-clinical results. Opening INR to Neurosciences is the best way to keep it alive and growing. Anchored in Neuroradiology, at the crossroad of neurosciences, INR will further participate to progress and innovation as it has often been in the past.
    Interventional Neuroradiology 09/2013; 19(3):263-70. · 0.77 Impact Factor
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    ABSTRACT: Object The authors describe the clinical presentation, imaging features, and management of patients presenting with filum terminale arteriovenous fistulas (FTAVFs) and the role of transarterial treatment in their management. Methods The authors retrospectively reviewed data obtained in 10 patients with FTAVFs diagnosed between January 1990 and December 2011. Results Most patients (70%) were male, and the age of the population ranged from 31 to 72 years (mean 58.2 years). Clinical presentation was progressive paraparesis and sensory loss in the lower extremities in 9 cases, back pain in 7, radicular pain in 3, bowel/bladder disturbance in 5, and impotence in 1. The duration of symptoms varied between 2 and 24 months. Initial MRI studies showed intramedullary increased T2 signal, swollen cord, and dilated perimedullary veins in all patients. One patient had syringomyelia, presumably caused by venous hypertension transmitted by the perimedullary venous system. Embolization was attempted in 7 patients and was curative in 6 patients. Surgery was performed in the other 4 patients in whom embolization was unsuccessful or deemed not feasible. There was no treatment-related complication in either group. Symptoms, venous congestion in the cord, and syringomyelia improved on follow-up in all patients. Conclusions Embolization should be considered the treatment of choice for FTAVFs and can effectively treat the majority of patients presenting with an FTAVF. In a smaller group of patients in whom the angioarchitecture is unfavorable, open surgery is recommended.
    Journal of neurosurgery. Spine 05/2013; · 1.61 Impact Factor
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    ABSTRACT: BACKGROUND: Neuroprotection with NA-1 (Tat-NR2B9c), an inhibitor of postsynaptic density-95 protein, has been shown in a primate model of stroke. We assessed whether NA-1 could reduce ischaemic brain damage in human beings. METHODS: For this double-blind, randomised, controlled study, we enrolled patients aged 18 years or older who had a ruptured or unruptured intracranial aneurysm amenable to endovascular repair from 14 hospitals in Canada and the USA. We used a computer-generated randomisation sequence to allocate patients to receive an intravenous infusion of either NA-1 or saline control at the end of their endovascular procedure (1:1; stratified by site, age, and aneurysm status). Both patients and investigators were masked to treatment allocation. The primary outcome was safety and primary clinical outcomes were the number and volume of new ischaemic strokes defined by MRI at 12-95 h after infusion. We used a modified intention-to-treat (mITT) analysis. This trial is registered with ClinicalTrials.gov, number NCT00728182. FINDINGS: Between Sept 16, 2008, and March 30, 2011, we randomly allocated 197 patients to treatment-12 individuals did not receive treatment because they were found to be ineligible after randomisation, so the mITT population consisted of 185 individuals, 92 in the NA-1 group and 93 in the placebo group. Two minor adverse events were adjudged to be associated with NA-1; no serious adverse events were attributable to NA-1. We recorded no difference between groups in the volume of lesions by either diffusion-weighted MRI (adjusted p value=0·120) or fluid-attenuated inversion recovery MRI (adjusted p value=0·236). Patients in the NA-1 group sustained fewer ischaemic infarcts than did patients in the placebo group, as gauged by diffusion-weighted MRI (adjusted incidence rate ratio 0·53, 95% CI 0·38-0·74) and fluid-attenuated inversion recovery MRI (0·59, 0·42-0·83). INTERPRETATION: Our findings suggest that neuroprotection in human ischaemic stroke is possible and that it should be investigated in larger trials. FUNDING: NoNO Inc and Arbor Vita Corp.
    The Lancet Neurology 10/2012; 11(11):942-950. · 23.92 Impact Factor
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    ABSTRACT: Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant genetic disease with a wide spectrum of vascular malformations (VMs) involving multiple organs. Nine to 16% of patients with HHT harbor brain arteriovenous malformations (AVMs), which can cause intracranial hemorrhage (ICH). Our objective was to study clinical manifestations of brain AVMs in patients with HHT and correlate these with the specific gene mutated. We reviewed records of 171 patients with HHT and brain AVMs. A history of ICH was found in 27% (41/152) patients, with a mean age of 26 ± 18 range, (0-68) years. All of patients with ICH were neurologically asymptomatic prior to ICH. Multiple brain AVMs were found in 23% (170/39) of patients on initial examination. Genetic test results were available in 109 (64%) patients. Mutations in ENG, ACVRL1, and SMAD4 were present in 75 (69%), 18 (17%), and 2 (2%), respectively. A history of ICH was reported in 24% of patients with an ENG mutation and 27% of patients with an ACVRL1 mutation, with a mean age of 26 ± 16 (range, 2-50) and 18 ± 21 (0-48) years, respectively. No statistically significant differences in age at first brain AVM diagnosis, prevalence of ICH history, age at ICH, or other manifestations of brain AVMs were observed among gene groups. In conclusion, no evidence for differences in brain AVM characteristics was observed among HHT gene groups, although we cannot exclude clinically important differences. Larger studies are needed to further guide brain AVM screening decisions in patients with HHT. © 2012 Wiley Periodicals, Inc.
    American Journal of Medical Genetics Part A 09/2012; 158A(11):2829-34. · 2.30 Impact Factor
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    ABSTRACT: BACKGROUND:: Radiosurgery as a potential treatment modality for brain arteriovenous malformations (AVM) has 60-90% obliteration rates. OBJECTIVE:: To test whether AVM angioarchitecture determines obliteration rate following radiosurgery. METHODS:: Retrospective analysis of 139 patients with AVM who underwent radiosurgery. Multiple angioarchitectural characteristics were reviewed on conventional angiogram on the day of radiosurgery: enlargement of feeding arteries, flow-related or intranidal aneurysms, perinidal angiogenesis, arteriovenous transit time, nidus type, venous ectasia, focal pouches, venous rerouting, and presence of a pseudeophlebitic pattern. The radiation plan was reviewed for nidus-volume and eloquence of AVM location. A chart review was performed to determine clinical presentation and previous treatment. Outcome was dichotomized into complete/incomplete obliteration and various statistics were performed, examining whether outcome status was associated with the investigated factors. RESULTS:: Marginal dose ranged from 15-25Gy (mean 18.8Gy), with lower doses prescribed in eloquent locations. AVM sizes ranged from 0.08-21cc (Mean: 3.78+/-4.19). Complete AVM obliteration was achieved in 92 patients (66%) and was related to these independent factors: noneloquent location (OR 3.20), size (OR 0.88), low flow (OR 3.47), no or mild arterial enlargement (OR 3.32), and absence of perinidal angiogenesis (OR 2.61). Concerning the three latter angioarchitectural characteristics, if no or only a single factor was present in an individual patient (n=92 patients), obliteration was observed in 74 (=80%); if two or three factors were present (n= 47), obliteration was observed in 18 patients (=38%) (OR 6.62). CONCLUSION:: Angioarchitectural factors that indicate high flow are associated with lower rate of AVM obliteration following radiosurgery.
    Neurosurgery 08/2012; · 2.53 Impact Factor
  • The Canadian journal of neurological sciences. Le journal canadien des sciences neurologiques 07/2012; 39(4):531-2. · 1.33 Impact Factor
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    ABSTRACT: BACKGROUND AND PURPOSE:Flow-diverting stents are increasingly being used for the treatment of complex intracranial aneurysms, but the indications for their use in lieu of traditional endovascular PVO have yet to be precisely defined. The purpose of this study was to review the clinical and imaging outcomes of patients with intracranial aneurysms treated by PVO.MATERIALS AND METHODS:A total of 28 patients with intracranial aneurysms, treated by PVO between July 1992 and December 2009, were reviewed. Aneurysms arising from peripheral arteries were excluded. Clinical and imaging data were retrospectively analyzed from a prospectively maintained data base.RESULTS:There were 28 patients with 28 aneurysms treated by PVO. Aneurysms of the anterior circulation presenting with mass effect (n = 11) or discovered incidentally (n = 1), and dissecting-type VB aneurysms presenting with subarachnoid hemorrhage (n = 6) faired the best with high obliteration rates (83.3% and 83.6%, respectively) and no permanent major ischemic complications. In contrast, VB aneurysms presenting with mass effect (n = 7) demonstrated the lowest obliteration rate (57.1%), the highest rate of permanent major ischemic complications (28.6%), and a high mortality rate (28.6%).CONCLUSIONS:PVO is a safe and effective treatment for complex intracranial aneurysms of the carotid artery and dissecting-type VB aneurysms presenting with SAH. In contrast, PVO for aneurysms of the VB circulation presenting with mass effect is less efficacious and associated with significant morbidity and mortality. It is hoped that flow diverters may represent a better treatment technique for these most difficult-to-treat lesions.
    American Journal of Neuroradiology 05/2012; · 3.17 Impact Factor
  • Kenichi Sato, Karel G Terbrugge, Timo Krings
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    ABSTRACT: Spinal dural arteriovenous fistulas (SDAVFs) consist of a shunt with converging feeding vessels arising from radiculomeningeal arteries and draining retrogradely via a radicular vein into the perimedullary veins, thereby causing progressive myelopathy due to venous hypertension in the spinal cord. The purpose of this study was to evaluate the hypothesis that the obstruction of radicular venous outlets could be an additional factor inducing symptomatic venous hypertension due to a decreased outflow in SDAVFs. The authors compared the clinical and imaging findings in patients with asymptomatic SDAVFs identified incidentally at the upper thoracic region with the findings in symptomatic patients who harbored SDAVFs at the same level. All symptomatic patients presented with medullary dysfunction. The mean age of patients with asymptomatic SDAVF was 51.5 years, approximately 10 years younger than the patients with symptomatic SDAVF (64.1 years old). Despite the existence of dilated perimedullary vessels in the dorsal side of the spinal cord in all patients, the spinal cord edema seen in symptomatic patients was not detected on the MR images obtained in patients with asymptomatic SDAVF. The spinal angiograms of the asymptomatic patients distinctively demonstrated early radicular venous outflow from affected perimedullary veins to the extradural venous plexus as a potential alternate route for the venous hypertension to be released. Obstruction of the radicular venous outflow could be an important factor in inducing spinal congestive edema due to venous hypertension, as well as subsequent clinical symptoms of SDAVFs.
    Journal of neurosurgery. Spine 03/2012; 16(5):441-6. · 1.61 Impact Factor
  • The Canadian journal of neurological sciences. Le journal canadien des sciences neurologiques 03/2012; 39(2):239-41. · 1.33 Impact Factor
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    ABSTRACT: INTRODUCTION: Unexplained post-procedural events such as cerebral edema, inflammation, aseptic meningitis and hydrocephalus have been reported following unruptured cerebral aneurysm coiling. However, understanding of the etiology for these occurrences is limited due to their rare occurrence. A multicenter registry was developed to investigate further the occurrence of these events. METHOD: This registry consisted of a retrospective analysis of unruptured aneurysms treated with hydrocoil that evolved to develop focal cerebral edema, inflammation, aseptic meningitis, or ventricular enlargement/hydrocephalus following uncomplicated coil embolization. Data points included pre, intra, and postoperative imaging, patient demographics, aneurysm demographics, procedural details such as coils used, medications administered, and intraprocedural complications, and all post-procedure follow-up including clinical status of the patients and all adverse events. RESULTS: Twenty-five patients (26 aneurysm coiling procedures) were found at 12 centers over an 8-year period. The mean aneurysm size was 13.7 mm. The average time from treatment to onset of symptoms was 8.5 months (2 weeks to 30 months, median 6 months). Delayed hydrocephalus was the most common clinical presentation. Six of the 25 patients were asymptomatic and did not require treatment. CONCLUSION: Patients undergoing endovascular coiling may be at risk of developing delayed complications, which may or may not be symptomatic. This risk appeared low and was restricted mostly to larger aneurysms. These events can be difficult to detect due to delayed presentation.
    Journal of neurointerventional surgery 02/2012; · 1.38 Impact Factor
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    ABSTRACT: The purpose of this study was to quantitatively estimate the relationship between multiplicity of brain arteriovenous malformations (bAVMs) and the diagnosis of hereditary hemorrhagic telangiectasia (HHT). We combined databases from 2 large North American bAVM referral centers, including demographics, clinical presentation, and angiographic characteristics, and compared patients with HHT with non-HHT patients. Logistic regression analysis was performed to quantify the association between bAVM multiplicity and odds of HHT diagnosis. Sensitivity, specificity, positive and negative predictive value, and positive and negative likelihood ratios were calculated to determine accuracy of bAVM multiplicity for screening HHT. Prevalence of HHT was 2.8% in the combined group. bAVM multiplicity was present in 39% of patients with HHT and was highly associated with diagnosis of HHT in univariate (OR, 83; 95% CI, 40-173; P<0.0001) and multivariable (OR, 86; 95% CI, 38-195; P<0.001) models adjusting for age at presentation (P=0.013), symptomatic presentation (P=0.029), and cohort site (P=0.021). bAVM multiplicity alone was associated with high specificity (99.2%; 95% CI, 98.7%-99.6%) and negative predictive value (98.3%; 95% CI, 97.6%-98.8%) and low sensitivity (39.3%; 95% CI, 26.5%-53.2%) and positive predictive value (59.5%; 95% CI, 42.1%-75.2%). Positive and negative likelihood ratio was 51 and 0.61, respectively, for diagnosis of HHT. HHT bAVMs were also more often smaller in size (<3 cm), noneloquent in location, and associated with superficial venous drainage compared with non-HHT bAVMs. Multiplicity of bAVMs is highly predictive of the diagnosis of HHT. The presence of multiple bAVMs should alert the clinician to the high probability of HHT and lead to comprehensive investigation for this diagnosis.
    Stroke 01/2012; 43(1):72-8. · 6.16 Impact Factor
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    ABSTRACT: Prospective differentiation between reversible cerebral vasoconstriction syndrome and central nervous system vasculitis can be challenging. We hypothesized that high-resolution vessel wall MRI would demonstrate arterial wall enhancement in central nervous system vasculitis but not in reversible cerebral vasoconstriction syndrome. We identified all patients with multifocal segmental narrowing of large intracranial arteries who had high-resolution vessel wall MRI and follow-up angiography at our institute over a 4-year period and performed a detailed chart review. Three patients lacked arterial wall enhancement, and these all had reversal of arterial narrowing within 3 months. Four patients demonstrated arterial wall enhancement, and these had persistent or progressive arterial narrowing at a median follow-up of 17 months (range, 6-36 months) with final diagnoses of central nervous system vasculitis (3) and cocaine vasculopathy (1). Preliminary results suggest that high-resolution contrast-enhanced vessel wall MRI may enable differentiation between reversible cerebral vasoconstriction syndrome and central nervous system vasculitis.
    Stroke 12/2011; 43(3):860-2. · 6.16 Impact Factor
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    ABSTRACT: An aneurysm is a focal dilatation of an arterial blood vessel. Luminal forces, such as high blood flow, shear stress and turbulence, are implicated in the pathogenesis of intracranial aneurysms, and luminal characteristics, such as sac size and morphology, are usually essential to the clinical decision-making process. Despite frequent clinical emphasis on the vessel lumen, however, the pathology underlying the formation, growth and rupture of an aneurysm mainly resides in the vessel wall. Research on the morphology and histopathology of the vessel wall reveals that intracranial aneurysms do not constitute a single disease, but are a shared manifestation of a wide range of diseases, each of which has a unique natural history and optimum therapy. This Review classifies intracranial aneurysms by vessel wall pathology, and demonstrates that understanding the morphology and pathology of this structure is important in determining the therapeutic approach. The article concludes that aneurysms represent a symptom of an underlying vascular disease rather than constituting a disease on their own.
    Nature Reviews Neurology 09/2011; 7(10):547-59. · 15.52 Impact Factor

Publication Stats

2k Citations
424.11 Total Impact Points

Institutions

  • 2013
    • Mahidol University
      Krung Thep, Bangkok, Thailand
    • Cathay General Hospital
      T’ai-pei, Taipei, Taiwan
  • 1992–2013
    • Toronto Western Hospital
      Toronto, Ontario, Canada
  • 2012
    • The University of Calgary
      • Hotchkiss Brain Institute
      Calgary, Alberta, Canada
    • St. Michael's Hospital
      Toronto, Ontario, Canada
    • Medical University of South Carolina
      • Department of Neurosciences (College of Medicine)
      Charleston, SC, United States
  • 1999–2012
    • University of Toronto
      • • Department of Medical Imaging
      • • Division of Neuroradiology
      • • Division of Neurosurgery
      • • Hospital for Sick Children
      Toronto, Ontario, Canada
  • 2011
    • Yonsei University Hospital
      Sŏul, Seoul, South Korea
  • 2010
    • Ramathibodi Hospital
      Krung Thep, Bangkok, Thailand
  • 2004–2010
    • Leiden University Medical Centre
      • Department of Radiology
      Leiden, South Holland, Netherlands
  • 2009
    • Gyeongsang National University
      • Department of Radiology
      Chinju, South Gyeongsang, South Korea
    • University of Groningen
      • Department of Neurosurgery
      Groningen, Province of Groningen, Netherlands
    • University of Lille Nord de France
      Lille, Nord-Pas-de-Calais, France
  • 2003–2009
    • Catholic University of Korea
      • Department of Radiology
      Sŏul, Seoul, South Korea
    • Queen Mary Hospital
      Hong Kong, Hong Kong
  • 2007
    • Shantou University
      Swatow, Guangdong, China
  • 2006
    • Sunnybrook Health Sciences Centre
      • Department of Radiation Oncology
      Toronto, Ontario, Canada
    • McMaster University
      • Division of Neurosurgery
      Hamilton, Ontario, Canada
  • 2005–2006
    • Tuen Mun Hospital
      • Department of Neurosurgery
      Hong Kong, Hong Kong
    • University of Nantes
      Naoned, Pays de la Loire, France
    • Buddhist Tzu Chi General Hospital
      T’ai-pei, Taipei, Taiwan
  • 2004–2006
    • University Health Network
      • Department of Medical Imaging
      Toronto, Ontario, Canada
  • 1989
    • SickKids
      Toronto, Ontario, Canada