Introduction: Unruptured intracranial aneurysms (UIA) have a high prevalence (3.2%) and are increasingly diagnosed with modern imaging tools. The main risk of UIA is their rupture associated with ...intracranial bleeding with often severe clinical consequences.
Areas covered: This review discusses the management strategy of UIAs, based on the large series of the literature (ISUIA, ATENA, UCAS, ...), knowing that no randomized controlled trial is available to compare different strategies. The different endovascular treatments are described.
Expert commentary: Due to the relatively scarce data regarding the risk of rupture of UIAs, the strategy of management is often difficult to define. It has to be multidisciplinary and has to take into account several factors related to the patient and the aneurysm. Beside the surgical approach, several endovascular tools are available to treat UIAs, that includes standard coiling, balloon-assisted coiling, stent-assisted coiling, flow diversion, and flow disruption.
•Smoking is more frequent in patients with ruptured aneurysms.•Elevated blood pressure is more frequent in patients with ruptured aneurysms.•Aneurysm characteristics associated with rupture are size, ...location, and neck size.
Identifying patients with intracranial aneurysms (IA) who have a high risk of rupture is critical to determine optimal management. ARETA (Analysis of Recanalization after Endovascular Treatment of intracranial Aneurysm) is a prospective, multicenter study, dedicated to evaluating endovascular treatment of IA. We aimed to identify factors associated with ruptured status, using this very large series of patients with ruptured and unruptured aneurysms.
Several analyses were conducted in the ARETA population: univariate and multivariate analyses in the whole population of patients and aneurysms to determine patient and aneurysm factors associated with aneurysm rupture, as well as a matched pair analysis (based on aneurysm size) conducted in the subgroup of patients with only one aneurysm to analyze the patient and aneurysm factors simultaneously.
From December 2013 to May 2015, 1289 patients with 1761 aneurysms were included in ARETA. The multivariate analysis identified four patient factors: elevated blood pressure (EBP), no familial history, single IA, and active smoking, and four aneurysm factors: size≥5mm, narrow neck, irregular shape, and ACA/Acom location, associated with rupture status. In the matched pair analysis, five risk factors of rupture were identified: no familial history of aneurysm, narrow neck, active smoking, ACA/Acom location, and irregular shape.
The most important patient factors associated with IA rupture are smoking and EBP. Given that size is a well-identified aneurysm factor, narrow neck also seems to be associated with aneurysm rupture. Further studies are needed to confirm this factor and determine underlying mechanisms. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01942512.
Introduction
The study attempts to identify notable factors predicting poor outcome, death, and intracranial hemorrhage in patients with acute ischemic stroke undergoing mechanical thrombectomy with ...stent retriever. These data could be useful to improve the selection of patients for thrombectomy.
Methods
Patients with acute ischemic stroke treated with the Solitaire FR device were retrospectively analyzed from a prospectively collected database. We assessed the effect of selected demographic characteristics, clinical and imaging factors on poor outcome at 3 months (modified Rankin score 3–6), mortality at 3 months, and hemorrhage at day 1 (symptomatic and asymptomatic).
Results
From May 2010 to April 2012, 59 consecutive patients with an acute ischemic stroke underwent mechanical thrombectomy. At 3 months, 57.6 % of the patients were functionally independent (modified Rankin Scale 0–2) and mortality was 20.4 %. Multivariate analyses revealed that a thrombus length > 14 mm (
p
= 0.02; OR 7.55; 95 % CI 1.35–42.31) and longer endovascular procedure duration (
p
= 0.01; OR 1.04; 95 % CI 1.01–1.07) were independently associated with poor outcome. A higher baseline Alberta Stroke Program Early CT (ASPECT) score (
p
= 0.04; OR 0.79 per point; 95 % CI 0.63–0.99) and successful recanalization (
p
= 0.02; OR 0.07; 95 % CI 0.01–0.72) were independent predictors of good functional outcome. Baseline ASPECT score (
p
< 0.01; OR 0.65; 95 % CI 0.54–0.78) independently predicted symptomatic intracranial hemorrhage at day 1.
Conclusion
Absolute baseline ASPECT score reflects early symptomatic hemorrhage risk and functional outcome at 3 months. Thrombus length measured on MRI play an important role on functional outcome at 3 months after thrombectomy. Further analyses are needed to determine its importance in the selection of patients for mechanical thrombectomy.
Follow-up of intracranial aneurysms treated by flow diverter with MRI is complicated by imaging artifacts produced by these devices. This study compares the diagnostic accuracy of three-dimensional ...time-of-flight MR angiography (3D-TOF-MRA) and contrast-enhanced MRA (CE-MRA) at 3 T for the evaluation of aneurysm occlusion and parent artery patency after flow diversion treatment, with digital subtraction angiography (DSA) as the gold standard.
Patients treated with flow diverters between January 2009 and January 2013 followed by MRA at 3 T (3D-TOF-MRA and CE-MRA) and DSA within a 48 h period were included in a prospective single-center study. Aneurysm occlusion was assessed with full and simplified Montreal scales and parent artery patency with three-grade and two-grade scales.
Twenty-two patients harboring 23 treated aneurysms were included. Interobserver agreement using simplified scales for occlusion (Montreal) and parent artery patency were higher for DSA (0.88 and 0.61) and CE-MRA (0.74 and 0.55) than for 3D-TOF-MRA (0.51 and 0.02). Intermodality agreement was higher for CE-MRA (0.88 and 0.32) than for 3D-TOF-MRA (0.59 and 0.11). CE-MRA yielded better accuracy than 3D-TOF-MRA for aneurysm remnant detection (sensitivity 83% vs 50%; specificity 100% vs 100%) and for the status of the parent artery (specificity 63% vs 32%; sensitivity 100% vs 100%).
At 3 T, CE-MRA is superior to 3D-TOF-MRA for the evaluation of aneurysm occlusion and parent artery patency after flow diversion treatment. However, intraluminal evaluation remains difficult with MRA regardless of the sequence used.
The Brush Sign (BrS) is a radiological biomarker (MRI) showing signal decrease of subependymal and deep medullary veins on paramagnetic-sensitive magnetic resonance sequences. Previous studies have ...shown controversial results regarding the prognostic value of BrS. We aimed to assess whether BrS on T2*-weighted sequences could predict functional prognosis in patients treated with mechanical thrombectomy (MT).
We included all consecutive patients with large artery occlusion related stroke in anterior circulation treated with MT between February 2020 and August 2022 at Reims University Hospital. Multivariable logistic regression models were used to investigate factors associated with BrS and its impact on outcomes.
Of the 327 included patients, 124 (37,9%) had a BrS on baseline MRI. Mean age was 72 ± 16 years and 184 (56,2 %) were female. In univariate analysis, BrS was associated with a younger age (67 vs 74; p<0.001), a higher NIHSS score (16(10–20) vs 13(8–19); p = 0.047) history of diabetes (15.3% vs 26.1 %; p = 0.022) and a shorter onset to MRI time (145.5 (111.3–188.5) vs 162 (126–220) p = 0.008). In multivariate analyses, patients with a BrS were younger (OR:0.970 (0.951 – 0.989)), tend to have a higher NIHSS score at baseline (OR:1.046 (1.000 – 1.094) and were less likely to have diabetes (OR: 0.433; 0.214–0.879). The presence of BrS was independently associated with functional independence (OR: 2.234(1.158–4,505) at 3 months but not with mortality nor with symptomatic intracerebral hemorrhage.
BrS on pre-treatment imaging could be considered as a biomarker of physiological adaptation to cerebral ischemia, allowing prolonged viability of brain tissue and might participate in the therapeutic decision.
Summary Background and purpose Data about non-invasive follow-up of aneurysm after stent-assisted coiling is scarce. We aimed to compare time-of-flight (TOF) magnetic resonance angiography (MRA) ...(3D-TOF-MRA) and contrast-enhanced MRA (CE-MRA) at 3-Tesla, with digital subtraction angiography (DSA) for evaluating aneurysm occlusion and parent artery patency after stent-assisted coiling. Materials and methods In this retrospective single-center study, patients were included if they had an intracranial aneurysm treated by stent-assisted coiling between March 2008 and June 2015, followed with both MRA sequences (3D-TOF-MRA and CE-MRA) at 3-Tesla and DSA, performed in an interval < 48 hours. Results Thirty-five aneurysms were included. Regarding aneurysm occlusion evaluation, agreement with DSA was better for CE-MRA (K = 0.53) than 3D-TOF-MRA (K = 0.28). Diagnostic accuracies for aneurysm remnant depiction were similar for 3D-TOF-MRA and CE-MRA ( P = 1). Both 3D-TOF-MRA (K = 0.05) and CE-MRA (K = −0.04) were unable to detect pathological vessel compared to DSA, without difference in accuracy ( P = 0.68). For parent artery occlusion detection, agreement with DSA was substantial for 3D-TOF-MRA (K = 0.64) and moderate for CE-MRA (K = 0.45), with similar good diagnostic accuracies ( P = 1). Conclusion After stent-assisted coiling treatment, 3D-TOF-MRA and CE-MRA demonstrated good accuracy to detect aneurysm remnant (but tended to overestimation). Although CE-MRA agreement with DSA was better, there was no statistical difference between 3D-TOF-MRA and CE-MRA accuracies. Both MRAs were unable to provide a precise evaluation of in-stent status but could detect parent vessel occlusion.
Intrasaccular flow disruption with WEB is a safe and efficacious technique that has significantly changed endovascular management of wide-neck bifurcation aneurysms (WNBAs). Use of stent in ...combination with WEB is occasionally required. We analyzed the frequency of use, indications, safety, and efficacy of the WEB-stent combination.
All aneurysms treated with WEB and stent were extracted from a prospectively maintained database. Patient and aneurysm characteristics, complications, and anatomical results were independently analyzed by a physician independent of the procedures.
From June 2011 to January 2020, 152 patients with 157 aneurysms were treated with WEB. Of these, 17/152 patients (11.2%) with 19/157 aneurysms (12.1%) were treated with WEB device and stent. Indications were very wide neck with a branch emerging from the neck in 1/19 (5.2%) aneurysms and WEB protrusion in 18/19 (94.7%). At 1 month, no morbimortality was reported. At 6 months, anatomical results were complete aneurysm occlusion in 15/17 aneurysms (88.2%), neck remnant in 1/17 (5.9%), and aneurysm remnant in 1/17 (5.9%). At 12 months, there was complete aneurysm occlusion in 13/14 aneurysms (92.9%) and neck remnant in 1/14 (7.1%).
Combining WEB and stent is a therapeutic strategy to manage WNBA. In our series, this combination was used in 11.2% of patients treated with WEB, resulting in no morbidity or mortality with a high efficacy at 6 and 12 months (complete aneurysm occlusion in 88.2% and 92.9%, respectively).
Objective
We aimed to determine in the “THRACE” trial, the clinical and MRI technical parameters associated with the two-layered susceptibility vessel sign (TL-SVS) and the overestimation ratio ...(overR).
Materials and methods
Patients with pre-treatment brain gradient echo (GRE) sequence and an etiological work-up were identified. Two readers reviewed TL-SVS, i.e., a SVS with a linear low-intense signal core surrounded by a higher intensity and measured the overR as the width of SVS divided by the width of the artery. Binomial and ordinal logistic regression respectively tested the association between TL-SVS and quartiles of overR with patient characteristics, cardioembolic stroke (CES), time from onset to imaging, and GRE sequence parameters (inter slice gap, slice thickness, echo time, flip angle, voxel size, and field strength).
Results
Among 258 included patients, 102 patients were examined by 3 Tesla MRI and 156 by 1.5 Tesla MRI. Intra- and inter-reader agreements for quartiles of overR and TL-SVS were good to excellent. The median overR was 1.59 (IQR, 1.30 to 1.86). TL-SVS was present in 101 patients (39.2%, 95%CI, 33.1 to 45.1%). In multivariate analysis, only CES was associated with overR quartiles (OR, 1.83; 95%CI, 1.11 to 2.99), and every 60 min increase from onset to MRI time was associated with TL-SVS (OR, 1.72; 95%CI, 1.10 to 2.67). MRI technical parameters were statistically associated with neither overR nor TL-SVS.
Conclusion
Independent of GRE sequence parameters, an increased overR was associated to CES, while the TL-SVS is independently related to a longer time from onset to MRI.
Key Points
• An imaging biomarker would be useful to predict the etiology of stroke in order to adapt secondary prevention of stroke.
• The two-layered susceptibility vessel sign and the overestimation ratio are paramagnetic effect derived markers that vary according to the MRI machines and sequence parameters.
• Independent of sequence parameters, an increased overestimation ratio was associated to cardioembolic stroke, while the two-layered susceptibility vessel sign is independently related to a longer time from onset to MRI.
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