Wide neck intracranial aneurysms are often difficult to treat with coiling alone, and sophisticated techniques such as balloon-assisted coiling, stent-assisted coiling, flow-diversion, or ...intrasaccular flow-disruption are sometimes required.
This technical note reports the endovascular treatment of a recurrent middle cerebral bifurcation aneurysm by remodeling technique followed by flow-diverter (Silk Vista Baby) deployment through a remodeling balloon (double lumen balloon Eclipse 2L).
•The number of mechanical thrombectomies has increased a sevenfold since 2012 in France.•The mean number of interventional neuroradiologist per center performing mechanical thrombectomy increased ...from 2.9±0.9 to 3.7±1.85.•Majority of interventional neuroradiologist use combined (stent and distal aspiration) approach (54.5%), and the use of balloon guide catheter is not standard, with a third of them never using it.•The majority of centers performing mechanical thrombectomy would require at least one more interventional neuroradiologist to stabilize team and insure continuity of care.
Mechanical thrombectomy (MT) has dramatically changed the landscape of stroke care as well as stroke care organization. Public health institutions are faced with the challenge of swiftly providing equal access to this high technical level procedure with rapidly broadening indications, and constantly developing techniques. The aim of this study was to present a current nationwide overview of technical MT practices in France as well as local organizations.
Thrombectomy capable French stroke centers, and physicians performing MT were invited to participate to a nationwide survey, disseminated through an existing trainee-led research network (the JENI-RC) under the aegis of the French Society of Neuroradiology. The survey was composed of 64 questions to collect both individual practices and general center-based information.
All French centers (100%) answered the survey, and 74% (110/148) of active interventional neuroradiologists (INR) performing MT completed individual questionnaires. The mean number of INR per center performing MT was 3.7±1.85, and 85% of the centers were organized for 24/7 continuity of care. MRI was the most commonly used imaging modality for stroke diagnosis and patients’ selection, and perfusion imaging was routinely available in 85% of the centers. Half of centers performed yearly between 100 and 200 MT. Anesthesiologic, and technical considerations are also developed in the manuscript.
This nationwide survey highlights the impressive response to the challenge of reorganization of stroke care with regards to mechanical thrombectomy in France. Technical and management disparities remain. Most centers remain understaffed to properly function in the long term, but the inflow of INT trainees is substantial.
IMPORTANCE: The positive treatment effect of endovascular therapy (EVT) is assumed to be caused by the preservation of brain tissue. It remains unclear to what extent the treatment-related reduction ...in follow-up infarct volume (FIV) explains the improved functional outcome after EVT in patients with acute ischemic stroke. OBJECTIVE: To study whether FIV mediates the relationship between EVT and functional outcome in patients with acute ischemic stroke. DESIGN, SETTING, AND PARTICIPANTS: Patient data from 7 randomized multicenter trials were pooled. These trials were conducted between December 2010 and April 2015 and included 1764 patients randomly assigned to receive either EVT or standard care (control). Follow-up infarct volume was assessed on computed tomography or magnetic resonance imaging after stroke onset. Mediation analysis was performed to examine the potential causal chain in which FIV may mediate the relationship between EVT and functional outcome. A total of 1690 patients met the inclusion criteria. Twenty-five additional patients were excluded, resulting in a total of 1665 patients, including 821 (49.3%) in the EVT group and 844 (50.7%) in the control group. Data were analyzed from January to June 2017. MAIN OUTCOME AND MEASURE: The 90-day functional outcome via the modified Rankin Scale (mRS). RESULTS: Among 1665 patients, the median (interquartile range IQR) age was 68 (57-76) years, and 781 (46.9%) were female. The median (IQR) time to FIV measurement was 30 (24-237) hours. The median (IQR) FIV was 41 (14-120) mL. Patients in the EVT group had significantly smaller FIVs compared with patients in the control group (median IQR FIV, 33 11-99 vs 51 18-134 mL; P = .007) and lower mRS scores at 90 days (median IQR score, 3 1-4 vs 4 2-5). Follow-up infarct volume was a predictor of functional outcome (adjusted common odds ratio, 0.46; 95% CI, 0.39-0.54; P < .001). Follow-up infarct volume partially mediated the relationship between treatment type with mRS score, as EVT was still significantly associated with functional outcome after adjustment for FIV (adjusted common odds ratio, 2.22; 95% CI, 1.52-3.21; P < .001). Treatment-reduced FIV explained 12% (95% CI, 1-19) of the relationship between EVT and functional outcome. CONCLUSIONS AND RELEVANCE: In this analysis, follow-up infarct volume predicted functional outcome; however, a reduced infarct volume after treatment with EVT only explained 12% of the treatment benefit. Follow-up infarct volume as measured on computed tomography and magnetic resonance imaging is not a valid proxy for estimating treatment effect in phase II and III trials of acute ischemic stroke.
BACKGROUND AND PURPOSE—Here, we assessed how sustained is reversal of the acute diffusion lesion (RAD) observed 24 hours after intravenous thrombolysis, and the relationships between RAD fate and ...early neurological improvement.
METHODS—We analyzed 155 consecutive patients thrombolyzed intravenously 152 minutes (median) after stroke onset and who underwent 3 MR sessions1 before and 2 after treatment (median times from onset, 25.6 and 54.3 hours, respectively). Using voxel-based analysis of diffusion-weighted imaging (DWI)1, DWI2, and DWI3 lesions on coregistered image data sets, we assessed the outcome of RAD voxels (hyperintense on DWI1 but not on DWI2) as transient or sustained on DWI3, and their relationships with early neurological improvement, defined as ΔNational Institutes of Health Stroke Scale ≥8 or National Institutes of Health Stroke Scale ≤1 at 24 hours. Tmax and apparent diffusion coefficient values were compared between sustained and transient RAD voxels.
RESULTS—The median (interquartile range) baseline National Institutes of Health Stroke Scale and DWI1 lesion volume were 11 (7–18) mL and 15.6 (6.0–50.9) mL, respectively. The median (interquartile range) RAD volume on DWI2 was 2.8 (1.1–6.6) mL, of which 70% was sustained on DWI3. Sixteen (10.3%) patients had sustained RAD ≥10 mL. As compared with transient RAD voxels, sustained RAD voxels had nonsignificantly higher baseline apparent diffusion coefficient values (median interquartile range, 793 717–887 versus 777 705–869×10 mm·s, respectively; P=0.08) and significantly better perfusion (Tmax, mean±SD, 6.3±3.2 versus 7.8±4.0 s; P<0.001). At variance with transient RAD, the volume of sustained RAD was associated with early neurological improvement in multivariate analysis (odds ratio, 1.08; 95% confidence interval, 1.01–1.17, per 1-mL increase; P=0.03).
CONCLUSIONS—After thrombolysis, over two-thirds of the DWI lesion reversal captured on 24-hour follow-up MR is sustained. Sustained DWI lesion reversal volume is a strong imaging correlate of early neurological improvement.
Summary Background The goal of the present study was to determine whether the presence or absence of parenchymal FLAIR hyperintensity alone, before thrombolysis, might be a predictive factor of ...ischemic stroke outcomes after the acute phase of stroke and at 3 months. Materials and methods We retrospectively included 84 patients with an ischemic stroke between November 2007 and March 2012, who underwent 3 T MRI, were treated by thrombolysis, and had medical follow-up at 3 months. Two readers analyzed parenchymal FLAIR visibility. Logistic regressions were performed for NIHSS difference (NIHSS at admission – NIHSS at the end of hospitalization) and for 3 months modified Ranking Score (mRS). Predictive values of positive parenchymal FLAIR for identifying poor outcome at discharge and at 3 months were estimated. Results Parenchymal FLAIR positivity was not predictive of NIHSS difference but it predicted poor outcome at 3 months (sensitivity: 0.49 0.37–0.60, specificity: 0.69 0.46–0.91, positive predictive value: 0.87 0.76–0.98 and negative predictive value: 0.24 0.12–0.36). Conclusions At 3 Tesla, the presence of a parenchymal hyperintense FLAIR signal before thrombolysis is predictive of a poor clinical outcome at 3 months.
Follow-up infarct volume (FIV) has been recommended as an early indicator of treatment efficacy in patients with acute ischemic stroke. Questions remain about the optimal imaging approach for FIV ...measurement.
To examine the association of FIV with 90-day modified Rankin Scale (mRS) score and investigate its dependency on acquisition time and modality.
Data of seven trials were pooled. FIV was assessed on follow-up (12 hours to 2 weeks) CT or MRI. Infarct location was defined as laterality and involvement of the Alberta Stroke Program Early CT Score regions. Relative quality and strength of multivariable regression models of the association between FIV and functional outcome were assessed. Dependency of imaging modality and acquisition time (≤48 hours vs >48 hours) was evaluated.
Of 1665 included patients, 83% were imaged with CT. Median FIV was 41 mL (IQR 14-120). A large FIV was associated with worse functional outcome (OR=0.88(95% CI 0.87 to 0.89) per 10 mL) in adjusted analysis. A model including FIV, location, and hemorrhage type best predicted mRS score. FIV of ≥133 mL was highly specific for unfavorable outcome. FIV was equally strongly associated with mRS score for assessment on CT and MRI, even though large differences in volume were present (48 mL (IQR 15-131) vs 22 mL (IQR 8-71), respectively). Associations of both early and late FIV assessments with outcome were similar in strength (ρ=0.60(95% CI 0.56 to 0.64) and ρ=0.55(95% CI 0.50 to 0.60), respectively).
In patients with an acute ischemic stroke due to a proximal intracranial occlusion of the anterior circulation, FIV is a strong independent predictor of functional outcome and can be assessed before 48 hours, oneither CT or MRI.
The clinical benefit of mechanical thrombectomy(MT) for stroke patients with tandem occlusion is similar to that of isolated intracranial occlusions. However, the management of cervical internal ...carotid artery(ICA) occlusion during the MT, particularly in the setting of carotid dissection, remains controversial. We aimed to investigate the clinical impact of cervical ICA patency at day 1 on 3-month functional outcome.
We collected data from the Endovascular Treatment in Ischemic Stroke, a prospective national registry in 30 French centers performing MT between January 2015 and January 2022. Inclusion criteria were consecutive tandem occlusions related to cervical ICA dissection treated with MT. Tandem occlusions of other etiology, isolated cervical ICA occlusions without intracranial thrombus and patients without day-1 ICA imaging were excluded. Primary endpoint was the 3-month functional outcome. Secondary endpoints included intracranial hemorrhage(ICH), excellent outcome, mortality and early neurological improvement. A sensitivity analysis was performed in patients with intracranial favorable recanalization after MT.
During the study period, 137 patients were included of which 89(65%) presented ICA patency at day 1. The odds of favorable outcome did not significantly differ between patients with patent and occluded ICA at day 1(68.7 vs 59.1%;aOR=1.30;95%CI 0.56-3.00,p=0.54). Excellent outcome, early neurological improvement, mortality and ICH were also comparable between groups. Sensitivity analysis showed similar results.
ICA patency at day 1 in patients with tandem occlusions related to dissection did not seem to influence functional outcome. Endovascular recanalization of the cervical ICA including stenting might not be systematically required in this setting.
Hintergrund: Ein Nachteil der endovaskularen Behandlung (EVT) von intrakraniellen Aneurysmen (IA) ist eine mogliche Rekanalisation, uber deren Risikofaktoren bis heute keine systematische Analyse an ...einer grossen Patientenzahl durchgefuhrt wurde. Zielsetzung: ARETA (clinicaltrials.gov NCT01942512) ist eine multizentrisch- prospektive studie, deren Ziele es sind * die Rate der Aneurysmarekanalisation nach EVT, im Zusammenhang mit der verwendeten Technik, systematisch zu analysieren * Faktoren, die das Risiko der Rekanalisation beeinflussen abzugrenzen * Moglichkeiten zu bestimmen, die Rate an Aneurysmarekanalisationen zu reduzieren. Methodik: Patienten mit unrupturierten oder rupturierten IA, die mittels EVT zwischen 12/2013 und 05/2015 in 16 teilnehmenden Zentren behandelt wurden, wurden in die studie eingeschlossen. Ergebnisse: 1345 Patienten (Frauen: 66,6%; mittleres Alter: 54,5 Jahre) wurden eingeschlossen. Tabakkonsum wurde bei 60,3% und erhohter Blutdruck bei 35% der Patienten angegeben. 50,3% der IA waren initial rupturiert. Folgende Lokalisationen der behandelten IA wurden beobachtet: AcomA (38,0%), supraclinoidale AQ (26,1%), McA (22,4%), vertebrobasilares system (6,9%), cavernosale AcI (6,7%). EVT erfolgte mittels Coils (+/- Remodeling) in 87%. Selbstexpandierende Stents wurden in 5,2%, intrasacculare Devices in 4,2%, Flow Diverter in 2,8% und andere Techniken in 0,8% verwendet. Die Analyse der peri- und postprozeduralen Komplikationen sowie die Auswertung der DSA-Daten (Core Lab: PW, LS) lauft derzeit. Aktuelle Ergebnisse werden prasentiert. Fazit: ARETA ist die bis jetzt grosste Studie, die pradiktive Faktoren der Aneurysmarekanalisation nach EVT von IA systematisch untersucht.
Whether thrombectomy alone is equally as effective as intravenous alteplase plus thrombectomy remains controversial. We aimed to determine whether thrombectomy alone would be non-inferior to ...intravenous alteplase plus thrombectomy in patients presenting with acute ischaemic stroke.
In this multicentre, randomised, open-label, blinded-outcome trial in Europe and Canada, we recruited patients with stroke due to large vessel occlusion confirmed with CT or magnetic resonance angiography admitted to endovascular centres. Patients were randomly assigned (1:1) via a centralised web server using a deterministic minimisation method to receive stent-retriever thrombectomy alone or intravenous alteplase plus stent-retriever thrombectomy. In both groups, thrombectomy was initiated as fast as possible with any commercially available Solitaire stent-retriever revascularisation device (Medtronic, Irvine, CA, USA). In the combined treatment group, intravenous alteplase (0·9 mg/kg bodyweight, maximum dose 90 mg per patient) was administered as early as possible after randomisation for 60 min with 10% of the calculated dose given as an initial bolus. Personnel assessing the primary outcome were masked to group allocation; patients and treating physicians were not. The primary binary outcome was a score of 2 or less on the modified Rankin scale at 90 days. We assessed the non-inferiority of thrombectomy alone versus intravenous alteplase plus thrombectomy in all randomly assigned and consenting patients using the one-sided lower 95% confidence limit of the Mantel-Haenszel risk difference, with a prespecified non-inferiority margin of 12%. The main safety endpoint was symptomatic intracranial haemorrhage assessed in all randomly assigned and consenting participants. This trial is registered with ClinicalTrials.gov, NCT03192332, and is closed to new participants.
Between Nov 29, 2017, and May 7, 2021, 5215 patients were screened and 423 were randomly assigned, of whom 408 (201 thrombectomy alone, 207 intravenous alteplase plus thrombectomy) were included in the primary efficacy analysis. A modified Rankin scale score of 0-2 at 90 days was reached by 114 (57%) of 201 patients assigned to thrombectomy alone and 135 (65%) of 207 patients assigned to intravenous alteplase plus thrombectomy (adjusted risk difference -7·3%, 95% CI -16·6 to 2·1, lower limit of one-sided 95% CI -15·1%, crossing the non-inferiority margin of -12%). Symptomatic intracranial haemorrhage occurred in five (2%) of 201 patients undergoing thrombectomy alone and seven (3%) of 202 patients receiving intravenous alteplase plus thrombectomy (risk difference -1·0%, 95% CI -4·8 to 2·7). Successful reperfusion was less common in patients assigned to thrombectomy alone (182 91% of 201 vs 199 96% of 207, risk difference -5·1%, 95% CI -10·2 to 0·0, p=0·047).
Thrombectomy alone was not shown to be non-inferior to intravenous alteplase plus thrombectomy and resulted in decreased reperfusion rates. These results do not support omitting intravenous alteplase before thrombectomy in eligible patients.
Medtronic and University Hospital Bern.
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