[Show abstract][Hide abstract] ABSTRACT: Background and purpose:
Mechanical thrombectomy is beneficial for patients with acute ischemic stroke and a proximal anterior occlusion, but it is unclear if these results can be extrapolated to patients with an M2 occlusion. The purpose of this study was to examine the technical aspects, safety, and outcomes of mechanical thrombectomy with a stent retriever in patients with an isolated M2 occlusion who were included in 3 large multicenter prospective studies.
Materials and methods:
We included patients from the Solitaire Flow Restoration Thrombectomy for Acute Revascularization (STAR), Solitaire With the Intention For Thrombectomy (SWIFT), and Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment (SWIFT PRIME) studies, 3 large multicenter prospective studies on thrombectomy for ischemic stroke. We compared outcomes and technical details of patients with an M2 with those with an M1 occlusion. All patients were treated with a stent retriever. Imaging data and outcomes were scored by an independent core laboratory. Successful reperfusion was defined as modified Thrombolysis in Cerebral Infarction score of 2b/3.
We included 50 patients with an M2 and 249 patients with an M1 occlusion. Patients with an M2 occlusion were older (mean age, 71 versus 67 years; P = .04) and had a lower NIHSS score (median, 13 versus 17; P < .001) compared with those with an M1 occlusion. Procedural time was nonsignificantly shorter in patients with an M2 occlusion (median, 29 versus 35 minutes; P = .41). The average number of passes with a stent retriever was also nonsignificantly lower in patients with an M2 occlusion (mean, 1.4 versus 1.7; P = .07). There were no significant differences in successful reperfusion (85% versus 82%, P = .82), symptomatic intracerebral hemorrhages (2% versus 2%, P = 1.0), device-related serious adverse events (6% versus 4%, P = .46), or modified Rankin Scale score 0-2 at follow-up (60% versus 56%, P = .64).
Endovascular reperfusion therapy appears to be feasible in selected patients with ischemic stroke and an M2 occlusion.
American Journal of Neuroradiology 11/2015; DOI:10.3174/ajnr.A4591 · 3.59 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background and purpose:
Standard selection criteria for revascularization therapy usually exclude patients with unclear-onset stroke. Our aim was to evaluate the efficacy and safety of revascularization therapy in patients with unclear-onset stroke in the anterior circulation and to identify the predictive factors for favorable clinical outcome.
Materials and methods:
We retrospectively analyzed 41 consecutive patients presenting with acute stroke with unknown time of onset treated by intravenous thrombolysis and/or mechanical thrombectomy. Only patients without well-developed fluid-attenuated inversion recovery changes of acute diffusion lesions on MR imaging were enrolled. Twenty-one patients were treated by intravenous thrombolysis; 19 received, simultaneously, intravenous thrombolysis and mechanical thrombectomy (as a bridging therapy); and 1 patient, endovascular therapy alone. Clinical outcome was evaluated at 90 days by using the mRS. Mortality and symptomatic intracranial hemorrhage were also reported.
Median patient age was 72 years (range, 17-89 years). Mean initial NIHSS score was 14.5 ± 5.7. Successful recanalization (TICI 2b-3) was assessed in 61% of patients presenting with an arterial occlusion, symptomatic intracranial hemorrhage occurred in 2 patients (4.9%), and 3 (7.3%) patients died. After 90 days, favorable outcome (mRS 0-2) was observed in 25 (61%) patients. Following multivariate analysis, initial NIHSS score (OR, 1.43; 95% CI, 1.13-1.82; P = .003) and bridging therapy (OR, 37.92; 95% CI, 2.43-591.35; P = .009) were independently associated with a favorable outcome at 3 months.
The study demonstrates the safety and good clinical outcome of acute recanalization therapy in patients with acute stroke in the anterior circulation and an unknown time of onset and a DWI/FLAIR mismatch on imaging. Moreover, bridging therapy versus intravenous thrombolysis alone was independently associated with favorable outcome at 3 months.
American Journal of Neuroradiology 11/2015; DOI:10.3174/ajnr.A4574 · 3.59 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Non-traumatic cavernous internal carotid artery (ICA) aneurysms are rare, and favour the occurrence of massive recurrent epistaxis, which is associated with a high mortality rate. We report the case of a 67-year-old woman presenting a ruptured ICA aneurysm extending into the sphenoid sinus, revealed by epistaxis. Selective coil embolization of the aneurysm was performed. Flow-diverter stents were deployed in order to utterly exclude the aneurysm and prevent revascularization. Anti-platelet treatment was provided to lower the risk of in-stent thrombosis. A left frontal hematoma associated with a subarachnoid haemorrhage occurred at day 2. Outcome was favourable with no neurological sequelae, and no clinical recurrence of epistaxis occurred. A 4 months follow-up digital subtraction angiography showed a complete exclusion of the aneurysm. In addition, a magnetic resonance cerebral angiography at 16 months showed stable results. Thus, this two-stage endovascular procedure has proven its effectiveness in preventing epistaxis recurrence while preserving the ICA patency.
[Show abstract][Hide abstract] ABSTRACT: Objective:
Within the context of a prospective randomized trial (SWIFT PRIME), we assessed whether early imaging of stroke patients, primary with CT perfusion, can estimate the size of the irreversibly injured ischemic core and the volume of critically hypoperfused tissue. We also evaluated the accuracy of ischemic core and hypoperfusion volumes for predicting infarct volume in patients with the target mismatch profile.
Baseline ischemic core and hypoperfusion volumes were assessed prior to randomized treatment with IV tPA-alone vs. IV tPA + endovascular therapy (Solitaire stent-retriever) using RAPID automated post-processing software. Reperfusion was assessed with angiographic TICI scores at the end of the procedure (endovascular group) and Tmax >6s volumes at 27-hours (both groups). Infarct volume was assessed at 27-hours on non-contrast CT or MRI.
151 patients with baseline imaging with CT perfusion (79%) or multimodal MRI (21%) were included. The median baseline ischemic core volume was 6 ml (IQR 0-16). Ischemic core volumes correlated with 27-hour infarct volumes in patients who achieved reperfusion (r = 0.58, P <0.0001). In patients who did not reperfuse (<10% reperfusion), baseline Tmax>6s lesion volumes correlated with 27-hour infarct volume (r=0.78; P=0.005). In Target mismatch patients, the union of baseline core and early follow-up Tmax>6s volume (i.e. predicted infarct volume) correlated with the 27-hour infarct volume (r=0.73; P<0.0001); the median absolute difference between the observed and predicted volume was 13 ml.
Ischemic core and hypoperfusion volumes, obtained primarily from CT perfusion scans, predict 27-hour infarct volume in acute stroke patients who were treated with reperfusion therapies. This article is protected by copyright. All rights reserved.
Annals of Neurology 10/2015; DOI:10.1002/ana.24543 · 9.98 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Changes in working memory are sensitive indicators of both normal and pathological brain aging and associated disability. The present study aims to further understanding of working memory in normal aging using a large cohort of healthy elderly in order to examine three separate phases of information processing in relation to changes in task load activation. Using covariance analysis, increasing and decreasing neural activation was observed on fMRI in response to a delayed item recognition task in 337 cognitively healthy elderly persons as part of the CRESCENDO (Cognitive REServe and Clinical ENDOphenotypes) study. During three phases of the task (stimulation, retention, probe), increased activation was observed with increasing task load in bilateral regions of the prefrontal cortex, parietal lobule, cingulate gyrus, insula and in deep grey matter nuclei, suggesting an involvement of central executive and salience networks. Decreased activation associated with increasing task load was observed during the stimulation phase, in bilateral temporal cortex, parietal lobule, cingulate gyrus and prefrontal cortex. This spatial distribution of decreased activation is suggestive of the default mode network. These findings support the hypothesis of an increased activation in salience and central executive networks and a decreased activation in default mode network concomitant to increasing task load.
Neurobiology of Learning and Memory 10/2015; 125. DOI:10.1016/j.nlm.2015.10.002 · 3.65 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Suicidal vulnerability has been related to impaired value-based decision-making and increased sensitivity to social threat, mediated by the prefrontal cortex. Using functional magnetic resonance imaging, we aimed at replicating these previous findings by measuring brain activation during the Iowa Gambling Task and an emotional faces viewing task. Participants comprised 15 euthymic suicide attempters (history of depression and suicidal behavior) who were compared with 23 euthymic patient controls (history of depression without suicidal history) and 35 healthy controls. The following five model-based regions of interest were investigated: the orbitofrontal cortex (OFC), ventrolateral prefrontal cortex (VLPFC), anterior cingulate cortex (ACC), medial (MPFC) and dorsal prefrontal cortex (DPFC). Suicide attempters relative to patient controls showed (1) increased response to angry vs. neutral faces in the left OFC and the VLPFC, as previously reported; (2) increased response to wins vs. losses in the right OFC, DPFC and ACC; (3) decreased response to risky vs. safe choices in the left DPFC; and (4) decreased response to sad vs. neutral faces in the right ACC. This study links impaired valuation processing (here for signals of social threat, sadness and reward) to prefrontal cortex dysfunction in suicide attempters. These long-term deficits may underlie the impaired decision-making and social difficulties found in suicide attempters.
[Show abstract][Hide abstract] ABSTRACT: OBJECT WEB is an innovative intrasaccular treatment for intracranial aneurysms. Preliminary series have shown good safety and efficacy. The WEB Clinical Assessment of Intrasaccular Aneurysm Therapy (WEBCAST) trial is a prospective European trial evaluating the safety and efficacy of WEB in wide-neck bifurcation aneurysms. METHODS Patients with wide-neck bifurcation aneurysms for which WEB treatment was indicated were included in this multicentergood clinical practices study. Clinical data including adverse events and clinical status at 1 and 6 months were collected and independently analyzed by a medical monitor. Six-month follow-up digital subtraction angiography was also performed and independently analyzed by a core laboratory. Success was defined at 6 months as complete occlusion or stable neck remnant, no worsening in angiographic appearance from postprocedure, and no retreatment performed or planned. RESULTS Ten European neurointerventional centers enrolled 51 patients with 51 aneurysms. Treatment with WEB was achieved in 48 of 51 aneurysms (94.1%). Adjunctive implants (coils/stents) were used in 4 of 48 aneurysms (8.3%). Thromboembolic events were observed in 9 of 51 patients (17.6%), resulting in a permanent deficit (modified Rankin Scale [mRS] Score 1) in 1 patient (2.0%). Intraoperative rupture was not observed. Morbidity (mRS score > 2) and mortality were 2.0% (1 of 51 patients, related to rupture status on entry to study) and 0.0% at 1 month, respectively. Success was achieved at 6 months in 85.4% of patients treated with WEB: 23 of 41 patients (56.1%) had complete occlusion, 12 of 41 (29.3%) had a neck remnant, and 6 of 41 (14.6%) had an aneurysm remnant. CONCLUSIONS The WEBCAST study showed good procedural and short-term safety of aneurysm treatment with WEB and good 6-month anatomical results.
Journal of Neurosurgery 09/2015; DOI:10.3171/2015.2.JNS142634 · 3.74 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective: We endeavored to develop an unruptured intracranial aneurysm (UIA) treatment score
(UIATS) model that includes and quantifies key factors involved in clinical decision-making in the
management of UIAs and to assess agreement for this model among specialists in UIA management
Methods: An international multidisciplinary (neurosurgery, neuroradiology, neurology, clinical epidemiology)
group of 69 specialists was convened to develop and validate the UIATS model using a Delphi
consensus. For internal (39 panel members involved in identification of relevant features) and external
validation (30 independent external reviewers), 30 selected UIA cases were used to analyze agreement
with UIATS management recommendations based on a 5-point Likert scale (5 indicating strong
agreement). Interrater agreement (IRA) was assessed with standardized coefficients of dispersion (vr*)
(vr* 5 0 indicating excellent agreement and vr* 5 1 indicating poor agreement).
Results: The UIATS accounts for 29 key factors in UIA management. Agreement with UIATS (mean
Likert scores) was 4.2 (95% confidence interval [CI] 4.1–4.3) per reviewer for both reviewer cohorts;
agreement per case was 4.3 (95% CI 4.1–4.4) for panel members and 4.5 (95% CI 4.3–4.6) for
external reviewers (p 5 0.017). Mean Likert scores were 4.2 (95% CI 4.1–4.3) for interventional
reviewers (n 5 56) and 4.1 (95% CI 3.9–4.4) for noninterventional reviewers (n 5 12) (p 5 0.290).
Overall IRA (vr*) for both cohorts was 0.026 (95% CI 0.019–0.033).
Conclusions: This novel UIA decision guidance study captures an excellent consensus among
highly informed individuals on UIA management, irrespective of their underlying specialty. Clinicians
can use the UIATS as a comprehensive mechanism for indicating how a large group of specialists
might manage an individual patient with a UIA. Neurology 2015;85:881–889.
[Show abstract][Hide abstract] ABSTRACT: Objective:
We endeavored to develop an unruptured intracranial aneurysm (UIA) treatment score (UIATS) model that includes and quantifies key factors involved in clinical decision-making in the management of UIAs and to assess agreement for this model among specialists in UIA management and research.
An international multidisciplinary (neurosurgery, neuroradiology, neurology, clinical epidemiology) group of 69 specialists was convened to develop and validate the UIATS model using a Delphi consensus. For internal (39 panel members involved in identification of relevant features) and external validation (30 independent external reviewers), 30 selected UIA cases were used to analyze agreement with UIATS management recommendations based on a 5-point Likert scale (5 indicating strong agreement). Interrater agreement (IRA) was assessed with standardized coefficients of dispersion (vr*) (vr* = 0 indicating excellent agreement and vr* = 1 indicating poor agreement).
The UIATS accounts for 29 key factors in UIA management. Agreement with UIATS (mean Likert scores) was 4.2 (95% confidence interval [CI] 4.1-4.3) per reviewer for both reviewer cohorts; agreement per case was 4.3 (95% CI 4.1-4.4) for panel members and 4.5 (95% CI 4.3-4.6) for external reviewers (p = 0.017). Mean Likert scores were 4.2 (95% CI 4.1-4.3) for interventional reviewers (n = 56) and 4.1 (95% CI 3.9-4.4) for noninterventional reviewers (n = 12) (p = 0.290). Overall IRA (vr*) for both cohorts was 0.026 (95% CI 0.019-0.033).
This novel UIA decision guidance study captures an excellent consensus among highly informed individuals on UIA management, irrespective of their underlying specialty. Clinicians can use the UIATS as a comprehensive mechanism for indicating how a large group of specialists might manage an individual patient with a UIA.
[Show abstract][Hide abstract] ABSTRACT: Little is known about the hemodynamic disturbances induced by the cerebral aneurysms in the parent artery and the effect of flow diverter stents (FDS) on these latter. A better understanding of the aneurysm-parent vessel complex relationship may aid our understanding of this disease and to optimize its treatment. The ability of volumetric flow rate (VFR) waveform to reflect the arterial compliance modifications is well known. By analyzing the VFR waveform and the pulsatility in the parent vessel, this study aimed to test the hypotheses that (1) intracranial aneurysms might disrupt the blood flow of the parent vessel and (2) the treatment by FDS might have measurable corrective effect on these changes. Ten patients followed for unruptured intracranial aneurysms treated by FDS and ten healthy volunteers as control group were included in this study. Two-dimensional quantitative phase-contrast magnetic resonance imaging (MRI) was performed on each patient on the ICA artery upstream and downstream to the aneurysm, and on each volunteer at similar locations. The aneurysms altered significantly the parent vessel pulsatility and this effect was correlated to their volume. The aneurysms treatment by FDS allowed for the restoration of a normally modulated flow and pulsatility correction in the parent vessel.Journal of Cerebral Blood Flow & Metabolism advance online publication, 12 August 2015; doi:10.1038/jcbfm.2015.176.
Journal of cerebral blood flow and metabolism: official journal of the International Society of Cerebral Blood Flow and Metabolism 08/2015; DOI:10.1038/jcbfm.2015.176 · 5.41 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Les complications des hémorragies méningées constituent l’élément majeur du pronostic vital et fonctionnel dans les suites d’une rupture anévrismale. Savoir les dépister est un enjeu primordial. Leur type varie au fur et à mesure du suivi opératoire. Le but de cet article est dans un premier temps de lister les principales complications des hémorragies sous-arachnoïdiennes en phase aiguë (resaignement, hydrocéphalie aiguë, lésions ischémiques aiguës, complications non neurologiques), subaiguë (vasospasme) et chronique (hydrocéphalie chronique et troubles cognitifs) et d’en donner leurs principales caractéristiques cliniques et radiologiques. Dans un deuxième temps, nous décrivons la stratégie de suivi à long terme des patients ayant présenté une hémorragie méningée traitée par voie endovasculaire ou chirurgicale ; ce suivi associe consultation clinique, IRM cérébrale et au moins un contrôle angiographique.